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The Natural History of Invasive Breast Cancers Detected by Screening Mammography
Per-Henrik Zahl, MD, PhD;
Jan Mæhlen, MD, PhD;
H. Gilbert Welch, MD, MPH
Arch Intern Med. 2008;168(21):2311-2316.
Background The introduction of screening mammography has been associated with sustained increases in breast cancer incidence. The natural history of these screen-detected cancers is not well understood.
Methods We compared cumulative breast cancer incidence in age-matched cohorts of women residing in 4 Norwegian counties before and after the initiation of biennial mammography. The screened group included all women who were invited for all 3 rounds of screening during the period 1996 through 2001 (age range in 1996, 50-64 years). The control group included all women who would have been invited for screening had there been a screening program during the period 1992 through 1997 (age range in 1992, 50-64 years). All women in the control group were invited to undergo a 1-time prevalence screen at the end of their observation period. Screening attendance was similar in both groups (screened, 78.3%, and controls, 79.5%). Counts of incident invasive breast cancers were obtained from the Norwegian Cancer Registry (in situ cancers were excluded).
Results As expected, before the age-matched controls were invited to be screened at the end of their observation period, the cumulative incidence of invasive breast cancer was significantly higher in the screened group than in the controls (4-year cumulative incidence: 1268 vs 810 per 100 000 population; relative rate, 1.57; 95% confidence interval, 1.44-1.70). Even after prevalence screening in controls, however, the cumulative incidence of invasive breast cancer remained 22% higher in the screened group (6-year cumulative incidence: 1909 vs 1564 per 100 000 population; relative rate, 1.22; 95% confidence interval, 1.16-1.30). Higher incidence was observed in screened women at each year of age.
Conclusions Because the cumulative incidence among controls never reached that of the screened group, it appears that some breast cancers detected by repeated mammographic screening would not persist to be detectable by a single mammogram at the end of 6 years. This raises the possibility that the natural course of some screen-detected invasive breast cancers is to spontaneously regress.
Author Affiliations: Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway (Dr Zahl); Department of Pathology, Ullevål University Hospital, Oslo (Dr Mæhlen); and the VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont, and the Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire (Dr Welch).
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