van Ravesteyn Nicolien T, Stout Natasha K, Schechter Clyde B, Heijnsdijk Eveline A M, Alagoz Oguzhan, Trentham-Dietz Amy, Mandelblatt Jeanne S, de Koning Harry J
Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (NTvR, EAMH, HJdK); Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA (NKS); Departments of Family and Social Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (CBS); Department of Industrial and Systems Engineering (OA) and Carbone Cancer Center and Department of Population Health Sciences (ATD), University of Wisconsin-Madison, Madison, WI; Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Washington, DC (JSM).
J Natl Cancer Inst. 2015 May 6;107(7). doi: 10.1093/jnci/djv103. Print 2015 Jul.
The aim of this study was to quantify the benefits and harms of mammography screening after age 74 years, focusing on the amount of overdiagnosis of invasive breast cancer and ductal carcinoma in situ (DCIS).
Three well-established microsimulation models were used to simulate a cohort of American women born in 1960. All women received biennial screening starting at age 50 years with cessation ages varying from 74 up to 96 years. We estimated the number of life-years gained (LYG), quality-adjusted life-years, breast cancer deaths averted, false-positives, and overdiagnosed women per 1000 screens.
The models predicted that there were 7.8 to 11.4 LYG per 1000 screens at age 74 years (range across models), decreasing to 4.8 to 7.8 LYG per 1000 screens at age 80 years, and 1.4 to 2.4 LYG per 1000 screens at age 90 years. When adjusted for quality-of-life decrements, the LYG decreased by 5% to 13% at age 74 years and 11% to 22% at age 80 years. At age 90 to 92 years, all LYG were counterbalanced by a loss in quality-of-life, mainly because of the increasing number of overdiagnosed breast cancers per 1000 screens: 1.2 to 5.0 at age 74 years, 1.8 to 6.0 at age 80 years, and 3.7 to 7.5 at age 90 years. The age at which harms began to outweigh benefits shifted to a younger age when larger or longer utility losses because of a breast cancer diagnosis were assumed.
The balance between screening benefits and harms becomes less favorable after age 74 years. At age 90 years, harms outweigh benefits, largely as a consequence of overdiagnosis. This age was the same across the three models, despite important model differences in assumptions on DCIS.
本研究的目的是量化74岁之后乳腺钼靶筛查的益处和危害，重点关注浸润性乳腺癌和导管原位癌（DCIS）的过度诊断数量。
使用三个成熟的微观模拟模型来模拟一组1960年出生的美国女性。所有女性从50岁开始接受两年一次的筛查，停止筛查的年龄从74岁到96岁不等。我们估计了每1000次筛查获得的生命年数（LYG）、质量调整生命年数、避免的乳腺癌死亡人数、假阳性人数以及过度诊断的女性人数。
模型预测，74岁时每1000次筛查的LYG为7.8至11.4（模型间范围），80岁时降至每1000次筛查4.8至7.8，90岁时为每1000次筛查1.4至2.4。当对生活质量下降进行调整后，74岁时LYG下降了5%至13%，80岁时下降了11%至22%。在90至92岁时，所有的LYG都被生活质量的下降所抵消，主要原因是每1000次筛查中过度诊断的乳腺癌数量增加：74岁时为1.2至5.0，80岁时为1.8至6.0，90岁时为3.7至7.5。当假设因乳腺癌诊断导致更大或更长时间的效用损失时，危害开始超过益处的年龄转移到了更年轻的年龄段。
74岁之后，筛查益处与危害之间的平衡变得不那么有利。在90岁时，危害超过益处，这主要是过度诊断的结果。尽管三个模型在DCIS假设上存在重要差异，但这个年龄在三个模型中是相同的。
