Breast Cancer Research and Treatment

, Volume 151, Issue 1, pp 19–25 | Cite as

An open letter to panels that are deciding guidelines for breast cancer screening

  • Daniel B. Kopans


Panels are presently reviewing breast cancer screening guidelines. It is critical that they understand which publications are scientifically valid, and which analyses are methodologically flawed and not valid. The scientific evidence clearly supports annual mammography screening beginning at the age of 40. The analyses that suggest that screening leads to overdiagnosis of invasive breast cancers are flawed and incorrect. There is little if any overdiagnosis of these cancers. The vast majority of breast cancers occur in women who are not at elevated risk so that excluding them from screening and only screening high risk women will deny the benefits of early detection to most women who develop breast cancer. Guidelines panels should not make decisions that exclude women from screening. Women should be provided with accurate information so that they can make informed decisions and have unimpeded access to screening if that is their preference.


Breast Breast cancer Screening Mammography 


Conflict of interest

Dr. Kopans has no conflict of interest to disclose.


  1. 1.
  2. 2.
    US Preventive Services Task Force (2009) Screening for breast cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med 151(10):716–726CrossRefGoogle Scholar
  3. 3.
  4. 4.
    Jorgensen KJ, Gotzsche PC (2009) Overdiagnosis in publicly organised mammography screening programmes: systematic review of incidence trends. BMJ 339:b2587CrossRefPubMedCentralPubMedGoogle Scholar
  5. 5.
    Gotzsche PC, Jorgensen KJ, Zahl PH, Mæhlen J (2012) Why mammography screening hasn’t lived up to expectations from the randomised trials. Cancer Causes Control 23:15–21CrossRefPubMedGoogle Scholar
  6. 6.
    Gøtzsche PC (2011) Time to stop mammography screening? CMAJ 183(17):1957–1958CrossRefPubMedCentralPubMedGoogle Scholar
  7. 7.
    Zahl PH, Maehlen J, Welch HG (2008) The natural history of invasive breast cancers detected by screening mammography. Arch Intern Med 168(21):2302–2303CrossRefGoogle Scholar
  8. 8.
    Autier P, Boniol M, Gavin A, Vatten LJ (2011) Breast cancer mortality in neighbouring European countries with different levels of screening but similar access to treatment: trend analysis of WHO mortality database. BMJ 343:55–57CrossRefGoogle Scholar
  9. 9.
    Bleyer A, Welch HG (2012) Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med 367(21):1999–2005CrossRefGoogle Scholar
  10. 10.
    Welch HG, Frankel BA (2011) Likelihood that a woman with screen-detected breast cancer has had her “life saved” by that screening. Arch Intern Med 171(22):2043–2056CrossRefPubMedGoogle Scholar
  11. 11.
    Kalager M, Zelen M, Langmark F, Adami HO (2010) Effect of screening mammography on breast-cancer mortality in Norway. N Engl J Med 363(13):1203–1210CrossRefPubMedGoogle Scholar
  12. 12.
    Lynge E, Braaten T, Njor SH, Olsen AH, Kumle M, Waaseth M, Lund E (2011) Mammography -activity in Norway 1983 to 2008. Acta Oncol 50(7):1062–1067CrossRefPubMedGoogle Scholar
  13. 13.
    Hofvind S, Ursin G, Tretli S, Sebuødegård S, Møller B (2013) Breast cancer mortality in participants of the Norwegian Breast Cancer Screening Program. Cancer 119(17):3106–3112CrossRefPubMedGoogle Scholar
  14. 14.
    Tabar L, Vitak B, Tony HH, Yen MF, Duffy SW, Smith RA (2001) Beyond randomized controlled trials: organized mammographic screening substantially reduces breast carcinoma mortality. Cancer 91:1724–1731CrossRefPubMedGoogle Scholar
  15. 15.
    Duffy SW, Tabar L, Chen H, Holmqvist M, Yen M, Abdsalah S, Epstein B, E Frodis, Ljungberg E, Hedborg-Melander C, Sundbom A, Tholin M, Wiege M, Akerlund A, Wu H, Tung T, Chiu Y, Chiu C, Huang C, Smith RA, Rosen M, Stenbeck M, Holmberg L, Akerlund A (2002) The impact of organized mammography service screening on breast carcinoma mortality in seven Swedish counties. Cancer 95:458–469CrossRefPubMedGoogle Scholar
  16. 16.
    Otto SJ, Fracheboud J, Looman CWN, Broeders MJM, Boer R, Hendriks JNHCL, Verbeek ALM, de Koning HJ, The National Evaluation Team for Breast Cancer Screening (2003) Initiation of population-based mammography screening in Dutch municipalities and effect on breast-cancer mortality: a systematic review. Lancet 361:411–417CrossRefGoogle Scholar
  17. 17.
    van Schoor G, Moss SM, Otten JD, Donders R, Paap E, den Heeten GJ, Holland R, Broeders MJ, Verbeek AL (2011) Increasingly strong reduction in breast cancer mortality due to screening. Br J Cancer 104(6):910–914CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    Otto SJ, Fracheboud J, Verbeek ALM, Boer R, Reijerink-Verheij JCIY, Otten JDM, Broeders MJM, de Koning HJ, The National Evaluation Team for Breast Cancer Screening (2011) Mammography screening and risk of breast cancer death: a population-based case–control study. Cancer Epidemiol Biomark Prev. doi: 10.1158/1055-9965.EPI-11-0476 Google Scholar
  19. 19.
    Swedish Organised Service Screening Evaluation Group (2006) Reduction in breast cancer mortality from organized service screening with mammography: 1. Further confirmation with extended data. Cancer Epidemiol Biomark Prev 15:45–51CrossRefGoogle Scholar
  20. 20.
    Hellquist BN, Czene K, Hjälm A, Nyström L, Jonsson H (2015) Effectiveness of population-based service screening with mammography for women ages 40 to 49 years with a high or low risk of breast cancer: socioeconomic status, parity, and age at birth of first child. Cancer 121(2):251–258CrossRefPubMedGoogle Scholar
  21. 21.
    Coldman A, Phillips N, Warren L, Kan L (2007) Breast cancer mortality after screening mammography in British Columbia women. Int J Cancer 120(5):1076–1080CrossRefPubMedGoogle Scholar
  22. 22.
    Kopans DB (2002) Beyond randomized, controlled trials: organized mammographic screening substantially reduces breast cancer mortality. Cancer 94:580–581CrossRefPubMedGoogle Scholar
  23. 23.
    Jonsson H, Bordás P, Wallin H, Nyström L, Lenner P (2007) Service screening with mammography in Northern Sweden: effects on breast cancer mortality: an update. J Med Screen 14(2):87–93CrossRefPubMedGoogle Scholar
  24. 24.
    Paap E, Holland R, den Heeten GJ et al (2010) A remarkable reduction of breast cancer deaths in screened versus unscreened women: a case-referent study. Cancer Causes Control 21:1569–1573CrossRefPubMedGoogle Scholar
  25. 25.
    Coldman A, Phillips N, Wilson C, Decker K, Chiarelli AM, Brisson J, Zhang B, Payne J, Doyle G, Ahmad R (2014) Pan-canadian study of mammography screening and mortality from breast cancer. J Natl Cancer Inst 106(11):dju261CrossRefPubMedGoogle Scholar
  26. 26.
    Bleyer A, Welch HG (2012) Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med 367(21):1998–2005CrossRefPubMedGoogle Scholar
  27. 27.
    Bleyer A (2014) Were our estimates of over diagnosis with mammography screening in the United States “based on faulty science”? The Oncol 19:113–126CrossRefGoogle Scholar
  28. 28.
    Kopans DB (2014) Arguments against mammography screening continue to be based on faulty science. The Oncol 19:107–112CrossRefGoogle Scholar
  29. 29.
    Etzioni R, Xia J, Hubbard R, Weiss NS, Gulati R (2014) A reality check for overdiagnosis estimates associated with breast cancer screening. J Natl Cancer Inst 106(12):dju315CrossRefPubMedGoogle Scholar
  30. 30.
    Helvie MA, Chang JT, Hendrick RE, Banerjee M (2014) Reduction in late-stage breast cancer incidence in the mammography era: implications for overdiagnosis of invasive cancer. Cancer 120(17):2649–2656. doi: 10.1002/cncr.28784 [Epub ahead of print] PubMed PMID: 24840597CrossRefPubMedGoogle Scholar
  31. 31.
    Puliti D, Duffy SW, Miccinesi G, de Koning H, Lynge E, Zappa M, Paci E, EUROSCREEN Working Group (2012) Overdiagnosis in mammographic screening for breast cancer in Europe: a literature review. J Med Screen 19(Suppl 1):42–56CrossRefPubMedGoogle Scholar
  32. 32.
    Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA (2014) Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ 348:g366. doi: 10.1136/bmj.g366 CrossRefPubMedCentralPubMedGoogle Scholar
  33. 33.
    Kopans DB (1990) The Canadian screening program: a different perspective. AJR 155:748–749CrossRefGoogle Scholar
  34. 34.
    Yaffe MJ (1993) Correction: Canada study. JNCI 85:94Google Scholar
  35. 35.
    Bailar JC, MacMahon B (1997) Randomization in the Canadian National Breast Screening Study: a review for evidence of subversion. Can Med Assoc J 156:193–199Google Scholar
  36. 36.
    Kopans DB, Feig SA (1993) The Canadian National Breast Screening Study: a critical review. AJR 161:755–760CrossRefPubMedGoogle Scholar
  37. 37.
    Tarone RE (1995) The excess of patients with advanced breast cancers in young women screened with mammography in the Canadian National Breast Screening Study. Cancer 75:997–1003CrossRefPubMedGoogle Scholar
  38. 38.
    Miller AB, Baines CJ, To T, Wall C (1992) Canadian National Breast Screening Study: 1. Breast cancer detection and death rates among women aged 40 to 49 years. CMAJ 147(10):1459–1476PubMedCentralPubMedGoogle Scholar
  39. 39.
    Author of Canadian Breast Cancer Study Retracts Warnings (1992) J Natl Cancer Inst. vol 84, No. 11, 832–834Google Scholar
  40. 40.
    Kopans DB (2010) The 2009 US Preventive Services Task Force guidelines ignore important scientific evidence and should be revised or withdrawn. Radiology 256:15–20CrossRefPubMedGoogle Scholar
  41. 41.
    Kopans DB (2010) The 2009 US Preventive Services Task Force (USPSTF) guidelines are not supported by science: the scientific support for mammography screening. Radiol Clin N Am 48(5):843–857CrossRefPubMedGoogle Scholar
  42. 42.
    Hendrick RE, Helvie MA (2011) United States Preventive Services Task Force screening mammography recommendations: science ignored. AJR Am J Roentgenol 196(2):W112–W116Google Scholar
  43. 43.
    Hendrick RE, Helvie MA (2012) Mammography screening: a new estimate of number needed to screen to prevent one breast cancer death. Am J Roentgenol 198(3):723–728CrossRefGoogle Scholar
  44. 44.
    Sprague BL, Bolton KC, Mace JL, Herschorn SD, James TA, Vacek PM, Weaver DL, Geller BM (2014) Registry-based study of trends in breast cancer screening mammography before and after the 2009 U.S. Preventive Services Task Force recommendations. Radiology 270(2):354–361Google Scholar
  45. 45.
    Duffy SW, Tabar L, Smith RA (2002) The mammographic screening trials: commentary on the recent work by Olsen and Gotzsche. Cancer J Clin 52:68–71CrossRefGoogle Scholar
  46. 46.
    Hendrick RE, Smith RA, Rutledge JH, Smart CR (1997) Benefit of screening mammography in women ages 40–49: a new meta-analysis of randomized controlled trials. Monogr Natl Cancer Inst 22:87–92PubMedGoogle Scholar
  47. 47.
    Michaelson JS, Halpern E, Kopans DB (1999) Breast cancer: computer simulation method for estimating optimal intervals for screening. Radiology 21:551–560CrossRefGoogle Scholar
  48. 48.
    Mandelblatt JS, Cronin KA, Bailey S, Berry DA, de Koning HJ, Draisma G, Huang H, Lee SJ, Munsell M, Plevritis SK, Ravdin P, Schechter CB, Sigal B, Stoto MA, Stout NK, van Ravesteyn NT, Venier J, Zelen M, Feuer EJ, Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (2009) Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms. Ann Intern Med 151(10):738–747CrossRefPubMedCentralPubMedGoogle Scholar
  49. 49.
    Kopans DB, Moore RH, McCarthy KA, Hall DA, Hulka C, Whitman GJ, Slanetz PJ, Halpern EF (1998) Biasing the interpretation of mammography screening data by age grouping: nothing changes abruptly at age 50. Breast J 4:139–145CrossRefGoogle Scholar
  50. 50.
    Kerlikowske K, Grady D, Barclay J, Sickles EA, Eaton A, Ernster V (1993) Positive predictive value of screening mammography by age and family history of breast cancer. JAMA 270:2444–2450CrossRefPubMedGoogle Scholar
  51. 51.
    Kopans DB (1994) Screening for breast cancer and mortality reduction among women 40–49 years of age. Cancer 74(1 Suppl):311–322CrossRefPubMedGoogle Scholar
  52. 52.
    Tabár L, Vitak B, Chen TH, Yen AM, Cohen A, Tot T, Chiu SY, Chen SL, Fann JC, Rosell J, Fohlin H, Smith RA, Duffy SW (2011) Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades. Radiology 260:658–663CrossRefPubMedGoogle Scholar
  53. 53.
    Seidman H, Stellman SD, Mushinski MH (1982) A different perspective on breast cancer risk factors: some implications of nonattributable risk. Cancer 32(5):301–313Google Scholar
  54. 54.
    Spivey GH, Perry BW, Clark VA (1982) Predicting the Risk of Cancer at the Time of Breast Biopsy. Am Surg 48(7):326–332PubMedGoogle Scholar
  55. 55.
    Chu KC, Tarone RE, Kessler LG, Ries LA, Hankey BF, Miller BA, Edwards BK (1996) Recent trends in US breast cancer incidence, survival, and mortality rates. J Natl Cancer Inst 88(21):1571–1579CrossRefPubMedGoogle Scholar
  56. 56.
    Ernster VL, Barclay J, Kerliikowske K, Grady D, Henderson C (1996) Incidence of and treatment for ductal carcinoma in situ of the breast. JAMA 275:913–918CrossRefPubMedGoogle Scholar
  57. 57.
    Berry DA, Cronin KA, Plevritis SK, Fryback DG, Clarke L, Zelen M, Mandelblatt JS, Yakovlev AY, Habbema JD, Feuer EJ, Cancer Intervention and Surveillance Modeling Network (CISNET) Collaborators (2005) Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 353:1784–1792CrossRefPubMedGoogle Scholar
  58. 58.
    Webb ML, Cady B, Michaelson JS, Bush DM, Calvillo KZ, Kopans DB, Smith BL (2014) A failure analysis of invasive breast cancer: most deaths from disease occur in women not regularly screened. Cancer 120(18):2839–2846CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Harvard Medical School BostonBostonUSA
  2. 2.Breast Imaging DivisionMassachusetts General HospitalBostonUSA

Personalised recommendations