Fw: Do mammograms save lives?

[Guest guest]

From our good friend Zuckerman in Washington D.C.

----- Original Message ----- From: Zuckerman

Sent: Saturday, December 22, 2001 9:12 PM

Subject: Do mammograms save lives?

Hi everyone,

You may have heard the recent controversy about whether mammography is worthwhile. We reviewed the recent

report claiming that mammograms were not useful, and concluded that the recent report was flawed and that there is still clear evidence that mammograms result in earlier diagnoses AND save lives. Our article was published in the new issue of Lancet,

the prestigious British medical journal.

You will be amused to see our letter using spellings like "programme" -- that was the editors' work, not

our efforts to be cool. The tone is also very formal compared to our usual writing, but that's how they

write for this medical journal. (Also note that the footnotes don't work on this copy; the correct version will be

on our website, however).

Best wishes for the holidays!

Zuckerman, Ph.D.PresidentNational Center for Policy Research for Women & Families1444 Eye Street, NWWashington, DC 20005www.center4policy.org

Letter to the Editor

Lancet, Dec 22/29, 2001

Sir-

Olsen and Gotzsche’s review1 concurs with the findings of their earlier report2 that screening mammography programmes do not reduce breast cancer mortality and lead to more aggressive treatment. In a commentary, Horton agrees with their conclusion that screening mammography programs therefore are not justified.3 These conclusions could have a major impact on women’s healthcare and deserve careful scrutiny.

Our primary criticism is the notion that a screening programme can be justified only if it reduces mortality. Mortality is a very important outcome, and easily measured, and choosing an outcome parameter for ease of measurement is a common bias among clinical investigators. However, outcomes such as quality of life are also important to patients and could justify screening programmes. Unfortunately, such outcomes have been understudied in the assessment of breast-cancer screening. Rather than making assumptions about whether false positive tests and earlier detection of breast cancer improves or harms quality of life, objective measurement is needed of how mammography screening programmes affect quality of life, and whether certain types of patients will benefit more than others.

Olsen and Gotzsche conclude that screening mammography leads to overly aggressive treatment. If that is true, it is a condemnation of treatment practices, not of screening not the elimination of screening programs that provide earlier diagnoses. Our organization is one of many encouraging better education of patients and physicians to lower the prevalence of unnecessarily aggressive treatment. . The best solution to improving treatment is better technology, education, and training, along with improved communication between physicians and patients. These strategies deserve more attention from the medical community before a decision is made to eliminate screening programmes that lead to earlier diagnoses. There is no need to throw out the baby with the bath water.

We are also concerned with the meta-analysis itself. In six of seven randomized trials (including the extended Malmo trial4) analyzed by Olsen and Gotzsche, a reduction in breast cancer mortality was associated with the use of screening mammography. We recommend caution before rejecting these findings, which incorporated data from hundreds of thousands of patients, on the basis of one meta-analysis.

Meta-analysis requires many subjective decisions on the selection and weighting of variables. Each decision can introduce bias, no matter how systematic the decision-making process. A second set of investigators carefully analyzing the same data might reach very different conclusions. For example, many investigators did not agree with Olsen and Gotzsche’s decision to deem certain clinical trials unreliable on the basis of small baseline differences in mean age between screening and control groups.

Meta-analyses are considered an evolutionary improvement over the traditional review article, but their limitations must be acknowledged before they are used to formulate major health-policy decisions. The attention garnered by Olsen and Gotzsche illustrates the need to assess each meta-analysis thoroughly, as well as to reassess the proper role of meta-analyses.

Sincerely,

Jae Hong Lee, MD, MPH

Senior Medical Policy Analyst

Zuckerman, PhD

Executive Director