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Evidence Synthesis ______
_____
Number 74
Screening for Breast Cancer:
Systematic Evidence Review Update for the U. S.
Preventive Services Task Force
Prepared For:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
Contract Number 290-02-0024, Task Order Number 2
Prepared By:
Oregon Evidence-based Practice Center
Oregon Health & Science University
3181 SW Sam Jackson Park Rd.
Portland, Oregon 97239
Investigators:
Heidi D. Nelson MD, MPH
Kari Tyne, MD
Arpana Naik, MD
Christina Bougatsos, BS
Benjamin Chan, MS
Peggy Nygren, MA
Linda Humphrey MD, MPH
AHRQ Publication No. 10-05142-EF-1
November 2009
 
This report is based on research conducted by the Oregon Evidence-based Practice Center (EPC)
under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD
(Contract No. 290-02-0024). The investigators involved have declared no conflicts of interest
with objectively conducting this research. The findings and conclusions in this document are
those of the authors, who are responsible for its content, and do not necessarily represent the
views of AHRQ. No statement in this report should be construed as an official position of AHRQ
or of the U.S. Department of Health and Human Services.
The information in this report is intended to help clinicians, employers, policymakers, and others
make informed decisions about the provision of health care services. This report is intended as a
reference and not as a substitute for clinical judgment.
This report may be used, in whole or in part, as the basis for the development of clinical practice
guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage
policies. AHRQ or U.S. Department of Health and Human Services endorsement of such
derivative products may not be stated or implied.
Acknowledgements
This project was funded by AHRQ for the U.S. Preventive Services Task Force (USPSTF).
Additional support was provided by the Veteran’s Administration Women’s Health Fellowship
(Dr. Tyne) and the Oregon Health & Science University Department of Surgery in conjunction
with the Human Investigators Program (Dr. Naik). Data collection for some of this work was
supported by the NCI-funded Breast Cancer Surveillance Consortium (BCSC) cooperative
agreement (U01CA63740, U01CA86076, U01CA86082, U01CA63736, U01CA70013,
U01CA69976, U01CA63731, U01CA70040). The collection of cancer incidence data used in
this study was supported in part by several state public health departments and cancer registries
throughout the United States. A full description of these sources is available at
The authors acknowledge the contributions of the AHRQ Project Officer, Mary Barton, MD,
MPP, and USPSTF Leads Russ Harris, MD, MPH; Allen Dietrich, MD; Carol Loveland-Cherry,
PhD, RN; Judith Ockene, PhD, MEd; and Bernadette Melnyk, PhD, RN, CPNP/NPP. Andrew
Hamilton, MLS, MS, conducted the literature searches and Sarah Baird, MS, managed the
bibliography at the Oregon EPC. The authors thank the BCSC investigators, participating
mammography facilities, and radiologists for the data used in this project. A list of the BCSC
investigators and procedures for requesting BCSC data for research purposes are available at
http://breastscreening.cancer.gov/ . The authors also thank Patricia A. Carney, PhD; Steve Taplin,
MD; Sebastien Haneuse, PhD; and Rod Walker, MS, for their direct work with this project.
Suggested Citation: Nelson HD, Tyne K, Naik A, Bougatsos C, Chan B, Nygren P, Humphrey
L. Screening for Breast Cancer: Systematic Evidence Review Update for the U.S. Preventive
Services Task Force. Evidence Review Update No. 74. AHRQ Publication No. 10-05142-EF-1.
Rockville, MD: Agency for Healthcare Research and Quality; 2009.
Breast Cancer Screening
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Oregon Evidence-based Practice Center
Structured Abstract
Background: This systematic review is an update of new evidence since the 2002 U.S.
Preventive Services Task Force recommendation on breast cancer screening.
Purpose: To determine the effectiveness of mammography screening in decreasing breast cancer
mortality among average-risk women age 40-49 years and 70 years and older; the effectiveness
of clinical breast examination (CBE) and breast self examination (BSE) in decreasing breast
cancer mortality among women of any age; and harms of screening with mammography, CBE,
and BSE.
Data Sources: The Cochrane Central Register of Controlled Trials and Cochrane Database of
Systematic Reviews (through the fourth quarter of 2008), MEDLINE ® searches (January 2001 to
December 2008), reference lists, and Web of Science ® searches for published studies and Breast
Cancer Surveillance Consortium for screening mammography data.
Study Selection: Randomized, controlled trials with breast cancer mortality outcomes for
screening effectiveness, and studies of various designs and multiple data sources for harms.
Data Extraction: Relevant data were abstracted, and study quality was rated by using
established criteria.
Data Synthesis: Mammography screening reduces breast cancer mortality by 15% for women
age 39-49 (relative risk [RR] 0.85; 95% credible interval [CrI], 0.75-0.96; 8 trials). Results are
similar to those for women age 50-59 years (RR 0.86; 95% CrI, 0.75-0.99; 6 trials), but effects
are less than for women age 60-69 years (RR 0.68; 95% CrI, 0.54-0.87; 2 trials). Data are
lacking for women age 70 years and older. Radiation exposure from mammography is low.
Patient adverse experiences are common and transient and do not affect screening practices.
Estimates of overdiagnosis vary from 1-10%. Younger women have more false-positive
mammography results and additional imaging but fewer biopsies than older women. Trials of
CBE are ongoing; trials of BSE showed no reductions in mortality but increases in benign biopsy
results.
Limitations: Studies of older women, digital mammography, and magnetic resonance imaging
are lacking.
Conclusions: Mammography screening reduces breast cancer mortality for women age 39-69
years; data are insufficient for women age 70 years and older. False-positive mammography
results and additional imaging are common. No benefit has been shown for CBE or BSE.
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Oregon Evidence-based Practice Center
Table of Contents
Chapter 1. Introduction ................................................................................................................1
Purpose of Review and Prior USPSTF Recommendation...........................................................1
Condition Definition ....................................................................................................................2
Prevalence and Burden of Disease...............................................................................................2
Etiology and Natural History .......................................................................................................3
Risk Factors .................................................................................................................................4
Current Clinical Practice..............................................................................................................5
Screening................................................................................................................................5
Diagnosis................................................................................................................................6
Treatment ...............................................................................................................................6
Screening Recommendations of Other Groups............................................................................7
Mammography .......................................................................................................................7
Clinical Breast Examination ..................................................................................................7
Breast Self Examination ........................................................................................................7
Chapter 2. Methods ......................................................................................................................8
Key Questions and Analytic Framework .....................................................................................8
Search Strategies..........................................................................................................................8
Study Selection ............................................................................................................................9
Data Abstraction and Quality Rating ...........................................................................................9
Meta-analysis of Mammography Trials.......................................................................................10
Analysis of Breast Cancer Surveillance Consortium Data ..........................................................10
External Review...........................................................................................................................11
Chapter 3. Results .......................................................................................................................11
Key Question 1a. Does screening with mammography (film and digital) or MRI decrease
breast cancer mortality among women age 40-49 years and 70 years and older? ....................11
Summary ................................................................................................................................11
Detailed Findings ...................................................................................................................12
Meta-analysis for women age 39-49 years ......................................................................13
Results for women age 70-74 years .................................................................................13
Comparisons with meta-analyses for women age 50-59 years and 60-69 years .............13
Key Question 1b. Does CBE screening decrease breast cancer mortality? Alone or with
mammography?.........................................................................................................................14
Summary ................................................................................................................................14
Detailed Findings ...................................................................................................................14
Key Question 1c. Does BSE practice decrease breast cancer mortality? ...................................16
Summary ................................................................................................................................16
Detailed Findings ...................................................................................................................16
Key Question 2a. What are the harms associated with screening with mammography (film
and digital) and MRI? ...............................................................................................................17
MRI and Digital Mammography ...........................................................................................17
Radiation Exposure................................................................................................................17
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Oregon Evidence-based Practice Center
Pain During Procedures .........................................................................................................18
Anxiety, Distress, and Other Psychological Responses.........................................................19
False-positive and False-negative Mammography Results, Additional Imaging, and
Biopsies..................................................................................................................................19
Overdiagnosis ........................................................................................................................20
Key Question 2b. What are the harms associated with CBE? ....................................................22
Key Question 2c. What are the harms associated with BSE?.....................................................22
Chapter 4. Discussion ..................................................................................................................23
Summary .....................................................................................................................................23
Limitations ...................................................................................................................................24
Future Research ...........................................................................................................................25
Conclusions..................................................................................................................................25
References ......................................................................................................................................26
Figures
Figure 1. Analytic Framework and Key Questions
Figure 2. Pooled Relative Risk for Breast Cancer Mortality from Mammography Screening
Trials for Women Age 39 to 49 Years
Figure 3. Number of Women Undergoing Routine Mammography to Diagnose 1 Case of
Invasive Cancer, DCIS, or Either in the Breast Cancer Surveillance Consortium
Figure 4. Number of Women Undergoing Additional Imaging and Number Undergoing
Biopsy to Diagnose 1 Case of Invasive Cancer the Breast Cancer Surveillance
Consortium
Tables
Table 1. Breast Cancer Screening Recommendations for Average-Risk Women
Table 2. Mammography Screening Trials Included in Meta-analyses
Table 3. Sensitivity Analysis: Meta-analysis of Screening Trials of Women Age 39 to 49
Years
Table 4. Summary of Screening Trials of Women Age 70 to 74 Years
Table 5. Pooled Relative Risk for Breast Cancer Mortality from Mammography Screening
Trials for All Ages
Table 6. Trials of Clinical Breast Examination and Breast Self Examination
Table 7. Age-specific Screening Results from the Breast Cancer Surveillance Consortium
Table 8. Studies of Breast Cancer Overdiagnosis
Table 9. Summary of Evidence
Appendices
Appendix A1. Acronyms and Abbreviations
Appendix B. Detailed Methods
Appendix B1. Literature Search Strategies
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