Guidelines for Breast Cancer


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Time to stop mammography screening


Mammakarzinom, ID T1b. Mammography, breast can...Image via Wikipedia

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Cochrane Neonatal Group: revisiones sistemáticas aliadas para el mejor cuidado de los prematuros


Cochrane Neonatal Group: revisiones sistemáticas aliadas para el mejor cuidado de los prematuros

Fuente: Pediatria Basada en Pruebas.

The Cochrane Collaboration (CC) se autodefine como una organización internacional sin ánimo de lucro cuya misión es ayudar en la toma de decisiones en materia de salud proveyendo la mejor información disponible. El objetivo de la CC es analizar, mantener y divulgar revisiones sistemáticas (RS) de los efectos de la asistencia sanitaria por medio de ensayos clínicos (y, si no estuvieren disponibles ensayos clínicos, revisiones de la evidencia más fiable derivada de otras fuentes).

Las RS de CC se publican en The Cochrane Library. Actualmente están disponibles alrededor de 4.600 RS (y unos 2.000 protocolos), que experimentan un continuocrecimiento cada año. El factor de impacto de Cochrane Database of Systematic Reviews (CDSR), la base de datos de RS en The Cochrane Library, es 6,186 en el año 2010.

Un elemento fundamental en la organización de CC radica en el establecimiento de grupos colaboradores de revisión (Collaborative Review Groups, CRG). En la CC cada revisor es miembro del CRG, que está formado por profesionales de distintas disciplinas que comparten un interés específico sobre un tema determinado. Estos CRG no coinciden necesariamente con las especialidades médicas tradicionales, sino que están dirigidos a problemas o conjuntos de afecciones específicas. Los CRG son actualmente 50; de éstos, los que tradicionalmente cuentan con una mayor actividad están relacionados con la perineonatología, concretamente Cochrane Pregnancy and Childbirth y Cochrane Neonatal Group. De hecho, es conocido que el logotipo de CC refleja una RS perineonatológica: el tratamiento con corticoesteroides en mujeres gestantes con amenaza de parto prematuro.

En el momento actual Cochrane Neonatal Group tiene publicadas 280 RS. Los 5 temas prioritarios son: infección neonatal (44 RS), ventilación mecánica (37 RS), alimentación en el recién nacido de bajo peso (33 RS), síndrome de distrés respiratorio (24 RS) y displasia broncopulmonar (19 RS).
Realizamos un análisis bibliométrico de la RS del Cochrane Neonatal Group en el año 2003 (ver artículo anexo), que nos permitió conocer la dinámica de este activo CRG. Al comparar estos resultados, comprobamos que en estos 7 años el número de RS se ha duplicado y que las patologías asociadas al recién nacido prematuro y/o menor de 1500 gramos siguen siendo prioritarias. Y las actualizaciones y novedades son continuas. Como ejemplo estas dos recientes RS sobre dos intervenciones (pentoxifilinalactoferrina oral) para la sepsis y enterocolitis necrotizante.

La CC es una gran aliada para la toma de decisiones basada en pruebas en neonatología. La CC se ha convertido en un recurso indispensable en los cuidados del prematuro, para obtener mejor resultados en salud, con un mejor cociente beneficios-riesgos-costes. Una excelente fuente de información que conviene recordar en vísperas del Día del Niño Prematuro, que se celebrará mañana.

Cochrane Neonatal Group: revisiones sistemáticas aliadas para el mejor cuidado de los prematuros

British breast cancer screening now under independent review


Normal (left) versus cancerous (right) mammogr...Image via Wikipedia

Source: Health News Review

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Questions about how best to communicate to the public about the tradeoffs of potential benefits versus potential harms of mammography do not end at America‘s shores.

An independent investigation into breast cancer screening has been set up by the government’s cancer chief to try to settle the growing controversy around its usefulness and potential harms.

Prof Sir Mike Richards‘s move is an attempt to put to rest the criticisms of a number of scientists, who say the NHS (British National Health Service) screening programme wrongly identifies cancers that might never harm women, leading to unnecessary and potentially damaging treatment with surgery, drugs and radiation therapy.
They also contest the official NHS position, which is that although there is some over-treatment as a result of screening, mammograms save lives.
The BMJ today published a letter from Susan Bewley, professor of complex obstetrics, Division of Women’s Health, King’s College London, to the man BMJ calls “England’s cancer tsar,” Mike Richards. Excerpt of her letter: 

“I declined screening when it was offered, as the NHS breast screening programme was not telling the whole truth. As a non-expert in the subject, I found myself examining the evidence for breast screening with increasing doubts. I compared the NHS and Nordic Cochrane Centre leaflets and found that the NHS leaflets exaggerated benefits and did not spell out the risks. Journals showed a reputable and growing body of international opinion acknowledging that breast cancer screening was not as good as used to be thought. The distress of overdiagnosis and decision making when finding lesions that might (or might not) be cancer that might (or might not) require mutilating surgery is increasingly being exposed. The oft repeated statement that “1400 lives a year are saved” has not been subjected to proper scrutiny. Even cancer charities use lower estimates. I expressed my misgivings to you “behind the scenes” as a work colleague. You replied in a personal email “that the large majority of experts in this country disagrees with the methodology used in the Cochrane Centre reviews of breast screening.”

It is extraordinary to be told that methodology is contentious so many years into the national programme.”

“I take the current controversy very seriously. I will do my best to achieve consensus on the evidence, though I realise this may not ultimately be possible. Should the independent review conclude that the balance of harms outweighs the benefits of breast screening, I will have no hesitation in referring the findings to the UK National Screening Committee and then ministers. You also have my assurance that I am fully committed to the public being given information in a format that they find acceptable and understandable and that enables them to make truly informed choices.”

Most women with screen-detected breast cancer have not had their life saved by screening


Age-standardised death rates from Breast cance...Image via Wikipedia

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That’s the conclusion of an article published today in the Archives of Internal Medicine. I’m on the run today, but here’s the abstract


Background Perhaps the most persuasive messages promoting screening mammography come from women who argue that the test “saved my life.” Because other possibilities exist, we sought to determine how often lives were actually saved by mammography screening.

Methods We created a simple method to estimate the probability that a woman with screen-detected breast cancer has had her life saved because of screening. We used DevCan, the National Cancer Institute‘s software for analyzing Surveillance Epidemiology and End Results (SEER) data, to estimate the 10-year risk of diagnosis and the 20-year risk of death–a time horizon long enough to capture the downstream benefits of screening. Using a range of estimates on the ability of screening mammography to reduce breast cancer mortality (relative risk reduction [RRR], 5%-25%), we estimated the risk of dying from breast cancer in the presence and absence of mammography in women of various ages (ages 40, 50, 60, and 70 years).
Results We found that for a 50-year-old woman, the estimated risk of having a screen-detected breast cancer in the next 10 years is 1910 per 100 000. Her observed 20-year risk of breast cancer death is 990 per 100 000. Assuming that mammography has already reduced this risk by 20%, the risk of death in the absence of screening would be 1240 per 100 000, which suggests that the mortality benefit accrued to 250 per 100 000. Thus, the probability that a woman with screen-detected breast cancer avoids a breast cancer death because of mammography is 13% (250/1910). This number falls to 3% if screening mammography reduces breast cancer mortality by 5%. Similar analyses of women of different ages all yield probability estimates below 25%.
Conclusions Most women with screen-detected breast cancer have not had their life saved by screening. They are instead either diagnosed early (with no effect on their mortality) or overdiagnosed.

Breast Cancer Screening


By Graham McMahon

The latest article in our Clinical Practice series reviews current recommendations for breast-cancer screening and thesupporting evidence, including the controversy regarding mammographic screening of women in their 40s.
Worldwide, breast cancer is now the most common cancer diagnosed in women and is the leading cause of deaths from cancer among women, with approximately 1.3 million new cases and 458,000 deaths reported in 2008.OK

Clinical Pearls

 How have the screening recommendations from the U.S. Preventive Services Task Force (USPSTF) changed in recent years?
In contrast to its 2002 guidelines, the more recent recommendations of the USPSTF, published in November 2009, support a reduction in the use of screening mammography. The two most controversial changes were the reclassification of screening for women between the ages of 40 and 49 years from a B recommendation (based on moderately strong evidence) to a C recommendation (“the decision . . . should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms”), and the recommendation that the frequency of screening be reduced from every 1 to 2 years to every 2 years.
 What is the consensus recommendation regarding mammographic screening for women between the ages of 50 and 69?
Screening mammography for women 50 to 69 years of age is universally recommended. All but one of the trials that included women in their 60s showed a significant reduction in mortality in the screened group, although this was not true for the subgroup of women in their 50s. Still, a meta-analysis revealed significant reductions in the number of deaths in both these age groups — 14% for women in their 50s and 32% for those in their 60s.

Morning Report Questions

Q: For a 42-year-old woman with no risk factors, what are the benefits and risks of screening mammography?
A: Her chance of having invasive breast cancer over the next 8 years is about 1 in 80, and her chance of dying from it is about 1 in 400. Biennial mammographic screening will detect two out of three cancers in women her age and will reduce her risk of death from breast cancer by 15%. However, there is about a 40% chance that she will be called back for further imaging tests and a 3% chance that she will undergo biopsy, with a benign finding.
Q: What are the benefits of digital mammography?
A: The contrast between breast tumors and surrounding normal parenchyma is greater with digital mammography than with film mammography, particularly when the breast tissue is dense. In one study in which almost 50,000 asymptomatic women 40 years of age or older underwent both digital and film mammography, the two techniques were equivalent overall in sensitivity (70% and 66%, respectively) and specificity (92% for both). However, in women under the age of 50 years, digital mammography was significantly more sensitive than film (78% vs. 51%).
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