Section of Early Detection and Prevention, International Agency for Research on Cancer, Lyon, France.
Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
Int J Cancer. 2019 Aug 15;145(4):994-1006. doi: 10.1002/ijc.32211. Epub 2019 Mar 14.
This systematic review, stimulated by inconsistency in secondary evidence, reports the benefits and harms of breast cancer (BC) screening and their determinants according to systematic reviews. A systematic search, which identified 9,976 abstracts, led to the inclusion of 58 reviews. BC mortality reduction with screening mammography was 15-25% in trials and 28-56% in observational studies in all age groups, and the risk of stage III+ cancers was reduced for women older than 49 years. Overdiagnosis due to mammography was 1-60% in trials and 1-12% in studies with a low risk of bias, and cumulative false-positive rates were lower with biennial than annual screening (3-17% vs 0.01-41%). There is no consistency in the reviews' conclusions about the magnitude of BC mortality reduction among women younger than 50 years or older than 69 years, or determinants of benefits and harms of mammography, including the type of mammography (digital vs screen-film), the number of views and the screening interval. Similarly, there was no solid evidence on determinants of benefits and harms or BC mortality reduction with screening by ultrasonography or clinical breast examination (sensitivity ranges, 54-84% and 47-69%, respectively), and strong evidence of unfavourable benefit-to-harm ratio with breast self-examination. The reviews' conclusions were not dependent on the quality of the reviews or publication date. Systematic reviews on mammography screening, mainly from high-income countries, systematically disagree on the interpretation of the benefit-to-harm ratio. Future reviews are unlikely to clarify the discrepancies unless new original studies are published.
本系统评价受二级证据不一致性的推动，根据系统评价报告了乳腺癌（BC）筛查的获益和危害及其决定因素。系统检索确定了 9976 篇摘要，最终纳入了 58 项综述。在所有年龄组中，筛查乳房 X 光摄影术可降低 15-25%的 BC 死亡率，在观察性研究中可降低 28-56%的死亡率，且对年龄大于 49 岁的女性，可降低 III 期以上癌症的风险。在试验中，由于乳房 X 光摄影术导致的过度诊断率为 1-60%，在低偏倚风险的研究中为 1-12%，且两年一次的筛查比每年一次的筛查累积假阳性率更低（3-17% vs 0.01-41%）。对于年龄小于 50 岁或大于 69 岁的女性，或与乳房 X 光摄影术的获益和危害决定因素相关的，各系统评价的结论存在不一致，包括乳房 X 光摄影术的类型（数字与屏片）、视域数量和筛查间隔等。同样，对于超声检查或临床乳房检查筛查的获益和危害决定因素或 BC 死亡率降低，也没有确凿的证据（灵敏度范围分别为 54-84%和 47-69%），而且有强有力的证据表明乳房自我检查的获益-危害比值不利。系统评价的结论与评价质量或发表日期无关。主要来自高收入国家的乳房 X 光摄影术筛查系统评价，对获益-危害比值的解释存在分歧。除非有新的原始研究发表，否则未来的评价不太可能澄清这些差异。
