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Effect of screening programme on mortality from breast cancer

BMJ 2000; 321 doi: (Published 16 December 2000) Cite this as: BMJ 2000;321:1527

Benefit of 30% may be substantial overestimate

  1. Anthony B Miller, head (
  1. Division of Clinical Epidemiology, Deutsches Krebsforschungszentrum, Heidelberg, Germany
  2. Department of Obstetrics and Gynaecology, Centre Hospitalier Universitaire St Pierre, Free University of Brussels, Brussels 1000, Belgium
  3. Department of Nuclear Medicine, Centre Hospitalier Universitaire St Pierre
  4. Royal Free and University College Medical School, University College London, Academic Division of Surgical Specialties, Gower Street Campus, Department of Surgery, London W1P 7LD
  5. Meyerstein Institute of Oncology, University College London Hospitals, Middlesex Hospital, London W1N 8AA

    EDITOR—Blanks et al have attempted to model the decline in mortality from breast cancer in England and Wales and to estimate the proportion of this decline due to screening.1 Unfortunately, even their estimate of a modest effect may be too large: the effect of tamoxifen at ages 55-74 may be larger than that at ages 50-54, as many of these younger women may be premenopausal and have oestrogen negative cancers, gaining less benefit from tamoxifen.

    Blanks et al do not comment on the unexplained rise in mortality from breast cancer in the United Kingdom from about 1965 to 1990. The recent fall in this mortality in the United Kingdom may have been partly due to the removal of the factor that caused the rise. Such a rise was not seen in North America, where mortality from breast cancer was stable until about 1990, since when similar falls in both Canada and the United States have occurred, of the same order as that in the United Kingdom.2

    Blanks et al perpetuate the unproved assumption that falls in mortality from breast cancer are due to the early detection by mammography of cancers when they are small and impalpable. It was always impossible to explain the rapid fall in mortality from breast cancer in women aged 50-64 in the health insurance plan trial3 by such an effect; recently published Canadian data cast further doubt on this assumption.4

    Gøtzsche and Olsen have suggested that imbalances in many of the breast screening trials cast doubt on …

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