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Viewpoint | Less Is More

Lessons From the Swiss Medical Board Recommendation Against Mammography Screening Programs

Arnaud Chiolero, MD, PhD1; Nicolas Rodondi, MD, MAS2
[+] Author Affiliations
1Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
2Department of General Internal Medicine, Bern University Hospital, Bern, Switzerland
JAMA Intern Med. 2014;174(10):1541-1542. doi:10.1001/jamainternmed.2014.4197.
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When the US Preventive Services Task Force (USPSTF) in 2009 recommended against universal breast cancer screening with mammography in women aged 40 to 49 years, some scientists, radiologists, politicians, and patients strongly objected.1 The controversy has been called the “mammography wars.”2

The latest chapter in these wars comes from the Swiss Medical Board, which is mandated by the Conference of Health Ministers of the Swiss Cantons, the Swiss Medical Association, and the Swiss Academy of Medical Sciences to conduct health technology assessments. In a February 2014 report, the Swiss Medical Board stated that new systematic mammography screening programs should not be introduced, irrespective of the age of the women, and that existing programs should be discontinued.3,4 The board’s main argument was that the absolute reduction in breast cancer mortality was low and that the adverse consequences of the screening were substantial. The absolute risk reduction in breast cancer mortality has been estimated by the board at 0.16% for women screened during 6.2 years and followed-up over 13 years, based on the results of a recent Cochrane Review.5 The adverse consequences include false-positive test results, overdiagnosis and overtreatment of patients, and high costs, including the expense of follow-up testing and procedures.

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Mammograpy screening recommendations of Swiss Medical Board are based on assumptions
Posted on August 26, 2014
Dr. Matthias Perleth
Federal Joint Committee (G-BA), Germany
Conflict of Interest: None Declared
The viewpoint published by Chiolero & Rodondi on the recent account of the so-called Swiss Medical Board (SMB) on mammography screening sheds a light on the way how the Board came to its recommendations. In fact, the SMB simply repeats the analyses of many other working groups (e.g. the Cochrane Review[1], Dutch Health Council[2]) regarding the results of earlier randomised controlled trials (RCTs) but goes beyond this by carrying out a cost-effectiveness analysis. While the results of the RCTs are well known to everybody interested in the matter, the methodology behind the SMB's cost-effectiveness analysis seems to be less familiar, even to economists.Firstly, they simplify issues around breast cancer into four scenarios (1. women without breast cancer and negative screening mammography; 2. women with false-positive screening result; 3. women with true-positive screening results who are treated and are long-term survivors; 4. women dying of breast cancer) and for each scenario a model based on 10,000 women is created. It is unclear which type of model is constructed. For each scenario, assumptions are made on the likely course of life or disease, respectively and the remaining life-span is thus multiplied with a quality of life (QoL) value based on the Karnofsky index. There is no reference how the SMB derived the QoL values nor where the data for the scenarios are taken from. For example, it is assumed that a false-positive mammogram will lead to a reduced QoL of 0.9 for 6 months as measured with the Karnofsky index. This appears to be an estimate and no evidence is given to justify this assumption. Eventually, the result shows that mammography screening will not be cost-effective. A one-way sensitivity analysis does show that this assumption is highly sensitive to the duration of the reduced QoL after a false-positive mammogram, i.e. if it is shortened to 2 months the cost-effectiveness will be reversed.Finally, the four recommendations are not directly linked to the analyses provided by the SMB; in fact they seem to appear without any clear connection to the analytical work but rather seem to reflect the discussions that probably have taken place within the SMB working group. In short, it is unclear whether and to what extent the SMB conclusions are based on evidence.References:[1] Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD001877. DOI: 10.1002/14651858.CD001877.pub5.[2] Health Council of the Netherlands. Population screening for breast cancer: expectations and developments. The Hague: Health Council of the Netherlands, 2014; publication no. 2014/01E. ISBN 978-94-6281-011-2.
A peace maker, finally?
Posted on August 26, 2014
Hans W. Hense
Institute of Epidemiology & Social Medicine, University of Munster, Germany
Conflict of Interest: Principal investigator of a feasibility study that investigates options to evaluate the impact on breast cancer mortality of the German mammography screening program.
I fully agree with each of the three statements which we have been trying to get across for a long time. A much needed, balanced and relieving contribution to this empoisoned 'war zone' - finally...
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