Screening for breast cancer with mammography

Peter C Gøtzsche; Margrethe Nielsen

doi:10.1002/14651858.CD001877.pub2

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Analysis 1.1

Comparison 1 Screening with mammography versus no screening, Outcome 1 Deaths ascribed to breast cancer, 7 years follow up.

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Analysis 1.2

Comparison 1 Screening with mammography versus no screening, Outcome 2 Deaths ascribed to breast cancer, 13 years follow up.

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Analysis 1.3

Comparison 1 Screening with mammography versus no screening, Outcome 3 Deaths ascribed to breast cancer, 7 years follow up, women below 50 years of age (Malmö 55).

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Analysis 1.4

Comparison 1 Screening with mammography versus no screening, Outcome 4 Deaths ascribed to breast cancer, 7 years follow up, women at least 50 years of age (Malmö 55).

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Analysis 1.5

Comparison 1 Screening with mammography versus no screening, Outcome 5 Deaths ascribed to breast cancer, 13 years follow up, women below 50 years of age.

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Analysis 1.6

Comparison 1 Screening with mammography versus no screening, Outcome 6 Deaths ascribed to breast cancer, 13 years follow up, women at least 50 years of age.

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Analysis 1.7

Comparison 1 Screening with mammography versus no screening, Outcome 7 Deaths ascribed to any cancer, all women.

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Analysis 1.8

Comparison 1 Screening with mammography versus no screening, Outcome 8 Overall mortality, 7 years follow up.

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Analysis 1.9

Comparison 1 Screening with mammography versus no screening, Outcome 9 Overall mortality, 13 years follow up.

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Analysis 1.10

Comparison 1 Screening with mammography versus no screening, Outcome 10 Overall mortality, 7 years follow up, women below 50 years of age.

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Analysis 1.11

Comparison 1 Screening with mammography versus no screening, Outcome 11 Overall mortality, 7 years follow up, women at least 50 years of age.

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Analysis 1.12

Comparison 1 Screening with mammography versus no screening, Outcome 12 Overall mortality, 13 years follow up, women below 50 years of age.

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Analysis 1.13

Comparison 1 Screening with mammography versus no screening, Outcome 13 Overall mortality, 13 years follow up, women at least 50 years of age.

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Analysis 1.14

Comparison 1 Screening with mammography versus no screening, Outcome 14 Number of mastectomies and lumpectomies.

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Analysis 1.15

Comparison 1 Screening with mammography versus no screening, Outcome 15 Number of mastectomies.

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Analysis 1.16

Comparison 1 Screening with mammography versus no screening, Outcome 16 Number treated with radiotherapy.

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Analysis 1.17

Comparison 1 Screening with mammography versus no screening, Outcome 17 Number treated with chemotherapy.

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Analysis 1.18

Comparison 1 Screening with mammography versus no screening, Outcome 18 Number treated with hormone therapy.

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Analysis 1.19

Comparison 1 Screening with mammography versus no screening, Outcome 19 Mortality among breast cancer patients in the Two‐County study, 7 years follow up.

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Analysis 1.20

Comparison 1 Screening with mammography versus no screening, Outcome 20 Results for biased trial.

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Analysis 1.21

Comparison 1 Screening with mammography versus no screening, Outcome 21 Number of cancers.

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Table 1. Examples of varying numbers of women in the Swedish trials

Study	Age range	Study group	Control group	Reference
Malmö	40‐74	21242	21240	Andersson 1980
	40‐74	21242	21244	Andersson 1983
	40‐74	21088	21195	Andersson 1988
Kopparberg	total	47389	22658	Socialstyrelsen 1985
	40‐74	39051	18846	Tabar 1985
	40‐74	38589	18582	Tabar 1989
	40‐74	38562	18478	Nyström 1993
	40‐74	38589	18582	Tabar 1995
	40‐74	38568	18479	Nyström 2000
	40‐74	38588	18582	Nixon 2000
	40‐74	data not available	data not available	Nyström 2002
	40‐49	9625	5053	Tabar 1988
	40‐49	data not available	data not available	Nyström 1993a
	40‐49	9582	5031	Tabar 1995
	40‐49	9650	5009	Nyström 1997
Östergötland	total	47001	45933	Socialstyrelsen 1985
	40‐74	39034	37936	Tabar 1985
	40‐74	38491	37403	Tabar 1989
	40‐74	38405	37145	Nyström 1993
	40‐74	38491	37403	Tabar 1995
	40‐74	38942	37675	Nyström 2000
	40‐74	39105	37858	Nixon 2000
	40‐74	38942	37675	Nyström 2002
	40‐49	10312	10625	Tabar 1988
	40‐49	data not available	data not available	Nyström 1993a
	40‐49	10262	10573	Tabar 1995
	40‐49	10240	10411	Nyström 1997
Stockholm	40‐64	40318	19943	Frisell 1989a
	40‐65 (sic)	38525	20651	Nyström 1993
	40‐64	40318	19943	Frisell 1997
	40‐69	39139	20978	Nyström 2000
	40‐49	data not available	data not available	Nyström 1993a
	40‐49	14842	7103	Frisell 1997
	40‐49	14185	7985	Nyström 1997
	40‐49	14303	8021	Nyström 2002
Göteborg	40‐59	20724	28809	Nyström 1993
	39‐59	21650	29961	Bjurstam 1997a
	40‐59	21000	29200	Nyström 2000
	40‐49	10821	13101	Nyström 1993a
	39‐49	11724	14217	Bjurstam 1997
	40‐49	10888	13203	Nyström 2002

Table 1. Examples of varying numbers of women in the Swedish trials

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Comparison 1. Screening with mammography versus no screening

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Deaths ascribed to breast cancer, 7 years follow up Show forest plot	10	455487	Risk Ratio (M‐H, Fixed, 95% CI)	0.80 [0.70, 0.91]

1.1 Adequately randomised trials	3	132118	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.83, 1.33]
1.2 Suboptimally randomised trials	7	323369	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.61, 0.83]
2 Deaths ascribed to breast cancer, 13 years follow up Show forest plot	8	438250	Risk Ratio (M‐H, Fixed, 95% CI)	0.80 [0.73, 0.88]

2.1 Adequately randomised trials	3	131313	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.80, 1.09]
2.2 Suboptimally randomised trials	5	306937	Risk Ratio (M‐H, Fixed, 95% CI)	0.75 [0.67, 0.83]
3 Deaths ascribed to breast cancer, 7 years follow up, women below 50 years of age (Malmö 55) Show forest plot	8	195528	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.78, 1.18]

3.1 Adequately randomised trials	2	66493	Risk Ratio (M‐H, Fixed, 95% CI)	1.33 [0.92, 1.92]
3.2 Suboptimally randomised trials	6	129035	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.63, 1.05]
4 Deaths ascribed to breast cancer, 7 years follow up, women at least 50 years of age (Malmö 55) Show forest plot	7	261044	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.62, 0.85]

4.1 Adequately randomised trials	2	65625	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.64, 1.20]
4.2 Suboptimally randomised trials	5	195419	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.56, 0.81]
5 Deaths ascribed to breast cancer, 13 years follow up, women below 50 years of age Show forest plot	7	168671	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.72, 0.99]

5.1 Adequately randomised trials	2	57857	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.71, 1.18]
5.2 Suboptimally randomised trials	5	110814	Risk Ratio (M‐H, Fixed, 95% CI)	0.80 [0.64, 0.98]
6 Deaths ascribed to breast cancer, 13 years follow up, women at least 50 years of age Show forest plot	7	268874	Risk Ratio (M‐H, Fixed, 95% CI)	0.77 [0.69, 0.86]

6.1 Adequately randomised trials	2	74261	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.77, 1.15]
6.2 Suboptimally randomised trials	5	194613	Risk Ratio (M‐H, Fixed, 95% CI)	0.70 [0.62, 0.80]
7 Deaths ascribed to any cancer, all women Show forest plot	6		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

7.1 Adequately randomised trials	3	132118	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.95, 1.10]
7.2 Suboptimally randomised trials (unreliable estimates)	3	195871	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.93, 1.06]
8 Overall mortality, 7 years follow up Show forest plot	10		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

8.1 Adequately randomised trials	3	132118	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.94, 1.05]
8.2 Suboptimally randomised trials (unreliable estimates)	7	324977	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.96, 1.02]
9 Overall mortality, 13 years follow up Show forest plot	7		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

9.1 Adequately randomised trials	3	132118	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.96, 1.04]
9.2 Suboptimally randomised trials (unreliable estimates)	4	244868	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.97, 1.01]
10 Overall mortality, 7 years follow up, women below 50 years of age Show forest plot	6		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

10.1 Adequately randomised trials	1	50430	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.82, 1.27]
10.2 Suboptimally randomised trials (unreliable estimates)	5	99656	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.98, 1.16]
11 Overall mortality, 7 years follow up, women at least 50 years of age Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

11.1 Adequately randomised trials	1	39405	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.85, 1.20]
11.2 Suboptimally randomised trials (unreliable estimates)	4	161519	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.94, 1.00]
12 Overall mortality, 13 years follow up, women below 50 years of age Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

12.1 Adequately randomised trials	2	58484	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.91, 1.14]
12.2 Suboptimally randomised trials (unreliable estimates)	3	61344	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.92, 1.10]
13 Overall mortality, 13 years follow up, women at least 50 years of age Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

13.1 Adequately randomised trials	2	73634	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.95, 1.04]
13.2 Suboptimally randomised trials (unreliable estimates)	2	98261	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.97, 1.02]
14 Number of mastectomies and lumpectomies Show forest plot	5	250479	Risk Ratio (M‐H, Fixed, 95% CI)	1.35 [1.26, 1.44]

14.1 Adequately randomised trials	3	132321	Risk Ratio (M‐H, Fixed, 95% CI)	1.31 [1.22, 1.42]
14.2 Suboptimally randomised trials	2	118158	Risk Ratio (M‐H, Fixed, 95% CI)	1.42 [1.26, 1.61]
15 Number of mastectomies Show forest plot	5	250479	Risk Ratio (M‐H, Fixed, 95% CI)	1.20 [1.11, 1.30]

15.1 Adequately randomised trials	3	132321	Risk Ratio (M‐H, Fixed, 95% CI)	1.20 [1.08, 1.32]
15.2 Suboptimally randomised trials	2	118158	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [1.06, 1.38]
16 Number treated with radiotherapy Show forest plot	2	100383	Risk Ratio (M‐H, Fixed, 95% CI)	1.32 [1.16, 1.50]

16.1 Adequately randomised trials	1	42486	Risk Ratio (M‐H, Fixed, 95% CI)	1.24 [1.04, 1.49]
16.2 Suboptimally randomised trials	1	57897	Risk Ratio (M‐H, Fixed, 95% CI)	1.40 [1.17, 1.69]
17 Number treated with chemotherapy Show forest plot	2	100383	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.78, 1.19]

17.1 Adequately randomised trials	1	42486	Risk Ratio (M‐H, Fixed, 95% CI)	0.63 [0.39, 1.04]
17.2 Suboptimally randomised trials	1	57897	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.84, 1.34]
18 Number treated with hormone therapy Show forest plot	2	100383	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.55, 0.96]

18.1 Adequately randomised trials	1	42486	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.60, 1.08]
18.2 Suboptimally randomised trials	1	57897	Risk Ratio (M‐H, Fixed, 95% CI)	0.30 [0.12, 0.72]
19 Mortality among breast cancer patients in the Two‐County study, 7 years follow up Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

19.1 Mortality from cancers other than breast cancer	2	2063	Risk Ratio (M‐H, Fixed, 95% CI)	2.42 [1.00, 5.85]
19.2 Mortality from causes other than breast cancer	2	2063	Risk Ratio (M‐H, Fixed, 95% CI)	1.37 [0.93, 2.04]
20 Results for biased trial Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

20.1 Deaths ascribed to breast cancer, 7 years follow up	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.2 Deaths ascribed to breast cancer, 13 years follow up	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.3 Deaths ascribed to breast cancer, 7 years follow up, younger women (below 50 years of age)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.4 Deaths ascribed to breast cancer, 7 years follow up, elderly women (at least 50 years of age)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.5 Deaths ascribed to breast cancer, 13 years follow up, younger women (below 50 years of age)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.6 Deaths ascribed to breast cancer, 13 years follow up, elderly women (at least 50 years of age)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.7 Overall mortality, 7 years follow up	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.8 Number treated with radiotherapy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21 Number of cancers Show forest plot	6		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

21.1 Adequately randomised trials (after 7‐9 years)	3	132118	Risk Ratio (M‐H, Fixed, 95% CI)	1.30 [1.20, 1.40]
21.2 Suboptimally randomised trials (before control group screen)	3	219267	Risk Ratio (M‐H, Fixed, 95% CI)	1.33 [1.24, 1.44]

Comparison 1. Screening with mammography versus no screening

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