International Journal of Epidemiology, Volume 33, Number 1, pp. 56-64
IJE vol.33 no.1 © International Epidemiological Association 2004; all rights reserved.
Point-Counterpoint |
On the benefits and harms of screening for breast cancer
The Nordic Cochrane Centre, Rigshospitalet, Dept 7112, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark. E-mail: p.c.gotzsche@cochrane.dk
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In their qualitative review,1 Freedman, Petitti and Robins (FPR) claim that our critique of the randomized screening trials has little merit; that there is no reason to believe that the Canadian study was of better quality than the New York Health Insurance Plan (HIP) study or the Two-County study; and that the prior consensus on mammography was correct. However, their review suffers from erroneous assumptions and biased statistical analyses, and their quotations are often selective and misleading. In my discussion of the issues, I will follow when possible the sequence of arguments used by FPR.
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Overdiagnosis and overtreatment |
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FPR claim in their abstract that early detection leads to less invasive therapy. This could have been true, if the only effect of screening had been to detect the same tumours earlier that are detected later if women are not screened. FPR naively believe that screening does just that, i.e. does not lead to overdiagnosis.
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Does screening save lives? |
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Methodology of our systematic review |
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Biased misclassification of cause of death |
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The New York HIP trial |
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Baseline imbalances
Assessment of cause of death
Length bias and lead-time bias
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All-cause mortality |
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Two-County study |
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Baseline imbalances
Numbers of women and deaths
Assessment of cause of death
Total mortality
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Canadian trial |
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Baseline imbalances
Concomitant physical examination
Results of Canadian trial
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Conclusion: What are the effects of screening? |
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