Because the four letters of correspondence describe a variety of concerns, I have organized them according to their general topic and in some instances re-emphasized data from the original reports .
Background Annual Percent Change (APC) in Breast Cancer Incidence
Drs. Baker and Kopans cite Helvie et al. in contending that the background APC since 1980 has been ≥1. Reasons why this is an overestimate include:
- 1. Helvie et al.’s central APC estimate of 1.3 from the Connecticut data was based on only 6 years, 1977–1982. Visual inspection of the in situ incidence shows that the incidence has already begun to rise in 1982 ( Fig 1 , green curve). Joinpoint analysis demonstrates 1980 as the year of change in slope ( Fig 1 , inset). When the last year, 1982, is not included, the APC for in situ cancer decreases 48% from a statistically significant rate of 9.2 ( P = 0.03) for 1977–1982 to a nonstatistically significant rate of 4.8 for 1977–1981 ( Fig 1 , table).
2. The Health Insurance Plan of Greater New York, next door to Connecticut, had been studying screening mammography since 1963 and favorable results have been reported by 1973 . By 1982, 5–10% of Connecticut’s women were already undergoing screening .
3. The incidence of unstaged breast cancer also increased by 1982 ( Fig 1 , blue curve), as expected from the uncertainty of the pathologic findings that occurred in the initial group of screened women. A few years later, when ductal carcinoma in situ (DCIS) became an established pathologic entity, the incidence of unstaged cancers declined. When 1982 is not included in the 1977–1982 calculation, the APC in unstaged cancer decreases from 8.0 ( P = 0.00) to 5.9 ( P = 0.02) ( Fig 1 , table).
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Diversity of Overdiagnosis Estimates
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Proportion of Women Screened
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Nonexistence of Overdiagnosis
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women per year of screening age who are diagnosed in the United States to have DCIS and treated for breast cancer. On one hand, Drs. Kopans and Arleo would have us eliminate DCIS from any consideration of overdiagnosis. On the other hand, Drs. Arleo and Baker and other mammographers want all women with DCIS treated for cancer because we cannot (as yet) distinguish women with preinvasive cancer from those with indolent, nonmalignant lesions. As the saying goes, you cannot have it both ways (eliminate DCIS and treat all as cancer). David Seidenwurm, MD, of the Diagnostic Division of Radiologic Associates of Sacramento may have said it best: “We cannot discuss mammography without DCIS any more than we can discuss DCIS without mammography” .
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Impact of Screening Mammography on Late-stage Disease
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RCTs of Screening Mammography
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Role of Spontaneous Regression
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Final Comments
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Acknowledgment(s)
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