Original Investigation |

Outcomes of Screening Mammography by Frequency, Breast Density, and Postmenopausal Hormone Therapy

Karla Kerlikowske, MD; Weiwei Zhu, MS; Rebecca A. Hubbard, PhD; Berta Geller, EdD; Kim Dittus, MD; Dejana Braithwaite, PhD; Karen J. Wernli, PhD; Diana L. Miglioretti, PhD; Ellen S. O’Meara, PhD; for the Breast Cancer Surveillance Consortium
JAMA Intern Med. 2013;173(9):807-816. doi:10.1001/jamainternmed.2013.307.
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Importance Controversy exists about the frequency women should undergo screening mammography and whether screening interval should vary according to risk factors beyond age.

Objective To compare the benefits and harms of screening mammography frequencies according to age, breast density, and postmenopausal hormone therapy (HT) use.

Design Prospective cohort.

Setting Data collected January 1994 to December 2008 from mammography facilities in community practice that participate in the Breast Cancer Surveillance Consortium (BCSC) mammography registries.

Participants Data were collected prospectively on 11 474 women with breast cancer and 922 624 without breast cancer who underwent mammography at facilities that participate in the BCSC.

Main Outcomes and Measures We used logistic regression to calculate the odds of advanced stage (IIb, III, or IV) and large tumors (>20 mm in diameter) and 10-year cumulative probability of a false-positive mammography result by screening frequency, age, breast density, and HT use. The main predictor was screening mammography interval.

Results Mammography biennially vs annually for women aged 50 to 74 years does not increase risk of tumors with advanced stage or large size regardless of women's breast density or HT use. Among women aged 40 to 49 years with extremely dense breasts, biennial mammography vs annual is associated with increased risk of advanced-stage cancer (odds ratio [OR], 1.89; 95% CI, 1.06-3.39) and large tumors (OR, 2.39; 95% CI, 1.37-4.18). Cumulative probability of a false-positive mammography result was high among women undergoing annual mammography with extremely dense breasts who were either aged 40 to 49 years (65.5%) or used estrogen plus progestogen (65.8%) and was lower among women aged 50 to 74 years who underwent biennial or triennial mammography with scattered fibroglandular densities (30.7% and 21.9%, respectively) or fatty breasts (17.4% and 12.1%, respectively).

Conclusions and Relevance Women aged 50 to 74 years, even those with high breast density or HT use, who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of false-positive results than those who undergo annual mammography. When deciding whether to undergo mammography, women aged 40 to 49 years who have extremely dense breasts should be informed that annual mammography may minimize their risk of advanced-stage disease but the cumulative risk of false-positive results is high.

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Figure 1. Study populations. BCSC indicates Breast Cancer Surveillance Consortium; and HT, hormone therapy. *Breast density reported by a subset of mammography facilities. †Of 15862 excluded, 24% have only 1 mammogram prior to cancer diagnosis and 76% are not in defined screening intervals.

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Figure 2. Overview of study design. Longer vs shorter screening interval may lead to advanced disease detected at the index examination (m1) owing to longer time for tumor growth since the previous screen (m), or advanced disease is detected clinically after m1 owing to the longer interval until the next screen. BrCa indicates breast cancer; a, screening interval; b, follow-up period for cancer ascertainment.




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