Breast cancer overdiagnosis may not happen as frequently as previously thought

1. Breast cancer overdiagnosis may not happen as frequently as previously thought

HD video soundbites of the authors and Annals editors discussing the findings are available to download at www.dssimon.com/MM/ACP-mammography-overdiagnosis.

Abstract: https://www.acpjournals.org/doi/10.7326/M21-3577

Editorial: https://www.acpjournals.org/doi/10.7326/M22-0483

URL goes live when the embargo lifts

A modeling study based on data from the Breast Cancer Screening Consortium, the most authoritative data set on breast cancer screening in the U.S., found that previous estimates of breast cancer overdiagnosis may have been overestimated. The new model suggests that overdiagnosis, or the finding of tumors that may never have progressed or caused harm in a woman’s lifetime, occurs in about 15% of screen-detected cancers. The findings are published in Annals of Internal Medicine. 

The U.S. Preventive Services Task Force (USPSTF) cites overdiagnosis as one of the chief potential harms associated with mammography screening because of the burden and adverse consequences of unnecessary treatments. Therefore, knowledge about overdiagnosis is critical for supporting shared decision making about screening. However, the risk for breast cancer overdiagnosis in contemporary screening programs remains uncertain, with the most widely cited estimates reaching about 30%.

Researchers from Duke University and the Fred Hutchinson Cancer Research Center studied data from Breast Cancer Surveillance Consortium facilities to estimate the rate of breast cancer overdiagnosis in contemporary mammography practice for a cohort including 35,986 women, 82,677 mammograms, and 718 breast cancer diagnoses. To estimate overdiagnosis, the authors considered a cohort of women whose parameters for disease natural history were given by the best-fitting parameter combinations and who had annual or biennial screening, starting at age 50 years and until age 74 years or death from a cause unrelated to breast cancer, whichever occurred first. They modeled the competing mortality risk on the basis of a published age–cohort model for a 1971 birth cohort. The researchers found that in a program of biennial screening of women aged 50 to 74 years, which corresponds to USPSTF recommendations for average risk women, approximately 1 in 7 screen-detected cases would be overdiagnosed. Increasing the screening interval to annual screening did not seem to affect this number.

An editorial from Massachusetts General Hospital says that these findings may help women who are considering having mammography screening better understand the risk of overdiagnosis. Given that approximately 7 in 1,000 women will be diagnosed with invasive or noninvasive breast cancer on the basis of a screening mammogram, women should be told that approximately 1 in 1,000 women who undergo mammography will be found to have a cancer that would never have caused problems. Assuming that about 60% of the 280,000 cases of breast cancer diagnosed in the United States each year are found through mammography screening, eliminating overdiagnosis could spare 25,000 women the cost and complications of unnecessary treatment.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. The corresponding author, Marc Ryser, MD, can be reached through Sarah Avery at sara.avery@duke.edu.  To speak with editorialist, Katrina Armstrong, MD, please contact Noah Brown at nbrown9@partners.org.

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2. ACP issues final Practice Points on the use of remdesivir for hospitalized patients with COVID-19

Full text Practice Points: https://www.acpjournals.org/doi/10.7326/M21-4784

Full text Review: https://www.acpjournals.org/doi/10.7326/M21-4810  

The American College of Physicians (ACP) issued its fifth and final living, rapid Practice Points regarding the use of remdesivir in hospitalized patients with COVID-19. The updated Practice Points are based on a review of the most up-to-date published data available on the benefits and harms of remdesivir and whether those benefits and harms vary by symptom duration, disease severity, and treatment duration. The paper, developed by the Scientific Medical Policy Committee of the ACP, is published in Annals of Internal Medicine.

Remdesivir is a broad-spectrum antiviral agent administered intravenously. It was authorized on Oct. 22, 2020, for emergency use for the treatment of COVID-19 in the U.S. by the Food and Drug Administration and in other countries.

ACP’s practice points are based on a living, rapid systematic review by the researchers from the Minneapolis VA Evidence Synthesis Program combining data from previous updates with data from newly identified randomized controlled trials (RCTs) through 19 October 2021. ACP’s final updated Practice Points target patients who will most benefit from the use of remdesivir.  The advice remains the same:

• Consider remdesivir for 5 days to treat hospitalized patients with COVID-19 who do not require invasive ventilation or extracorporeal membrane oxygenation (ECMO). 
• Consider extending the use of remdesivir to 10 days to treat hospitalized patients with COVID-19 who develop the need for invasive ventilation or ECMO within a 5-day course.
• Avoid initiating remdesivir to treat hospitalized patients with COVID-19 who are already on invasive ventilation or ECMO.

ACP’s Practice Points provide advice to improve the health of individuals and populations and promote high value care based on the best available evidence derived from assessment of scientific work. Practice Points are maintained as a “living” document until ACP’s Scientific Medical Policy Committee determines that no more updates are needed. The Scientific Medical Policy Committee has decided to retire this topic from living status in order to balance current priorities and considering that the last 3 updates did not result in important changes to conclusions.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with someone from ACP, please contact Andy Hachadorian at ahachadorian@acponline.org.

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Also new in this issue:

Integrating Quality Assurance and Quality Improvement With Guidelines: Systematic Stakeholder-Driven Development of an Extension of the Guidelines International Network–McMaster Guideline Development Checklist

Thomas Piggott, MD, MSc; Miranda W. Langendam, PhD; Elena Parmelli, PhD; Jan Adolfsson, MD, PhD; Elie Akl, MD, MPH, PhD; David Armstrong, MA, MB BChir; Jeffrey Braithwaite, PhD; Romina Brignardello-Petersen, DDS, MSc, PhD; Jan Brozek, MD, PhD; Markus Follmann, MD, MPH, MSc; Ina Kopp, MD; Joerg J. Meerpohl, MD; Luciana Neamtiu, PhD; Monika Nothacker, MD, MPH; Amir Qaseem, MD, PhD, MHA; Paolo Giorgi Rossi, PhD; Zuleika Saz-Parkinson, PhD, MS; Philip J. van der Wees, PhD; and Holger J. Schünemann, MD, PhD, MSc

Ideas and Opinions

Abstract: https://www.acpjournals.org/doi/10.7326/M21-3977 

Editorial: https://www.acpjournals.org/doi/10.7326/M22-0409   

Additional new COVID-19 content in this issue:

Prescribing Nirmatrelvir–Ritonavir: How to Recognize and Manage Drug–Drug Interactions

Catia Marzolini, PharmD, PhD;Daniel R. Kuritzkes, MD; Fiona Marra, PharmD; Alison Boyle, PharmD; Sara Gibbons, MPhil; Charles Flexner, MD; Anton Pozniak, MD; Marta Boffito, MD, PhD; Laura Waters, MD; David Burger, PharmD, PhD; David Back, PhD; Saye Khoo, MD

Ideas and Opinions

Full text: https://www.acpjournals.org/doi/10.7326/M22-0281