Mammography Screening and Women with Symptomatic Breast Cancer Philippe Autier

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Nature Reviews Clinical Oncology published online 23 July 2013; doi:10.1038/nrclinonc.2012.126-c3

REPLY Mammography screening and women with symptomatic breast cancer Philippe Autier

The letter of Lyratzopoulos and Abel to reduce breast cancer mortality.8,9 In these Competing interests (Earlier diagnosis of breast cancer: focus‑ trials, reduction in the risk of breast cancer- The author declares no competing interests. ing on symptomatic women. Nat. Rev. Clin. related death was directly correlated with the Oncol. doi:10.1038/nrclinonc.2012.126‑c1)1 risk of being diagnosed with an advanced- 1. Lyratzopoulos, G. & Abel, G. Earlier diagnosis 10 of breast cancer: focusing on symptomatic discusses the possibility that interventions stage cancer. Hence, the ability of screen‑ women. Nat. Rev. Clin. Oncol. http:// other than mammography screening (as ing to reduce the risk of breast cancer dx.doi.org/10.1038/nrclinonc.2012.126‑c1. covered in our article [Viewpoint: Breast death is tightly dependent on its ability to 2. Autier, P., Esserman, L. J., Flowers, C. I. & Houssami, N. Breast cancer screening: the cancer screening: the questions answered. decrease the risk of advanced-stage cancer. questions answered. Nat. Rev. Clin. Oncol. 9, 2 Nat. Rev. Clin. Oncol. 9, 599–605; 2012] ) Considering this strong connection between 599–605 (2012). could contribute to reducing symptomatic change in risks and the absent or limited 3. Autier, P. et al. Advanced breast cancer breast cancer.1 Symptomatic cancer often reductions in the incidence of advanced-stage incidence following population-based mammographic screening. Ann. Oncol. 22, equates to late-stage cancer at diagnosis, cancer in well-screened populations implies 1726–1735 (2011). and screening is deemed to reduce breast that nationwide mammography screening 4. Autier, P. & Boniol, M. The incidence of cancer mortality thanks to detecting cancer programmes would have limited influence advanced breast cancer in the West Midlands, United Kingdom. Eur. J. Cancer Prev. 21, at an early stage, before it causes symptoms. on breast cancer mortality. The reason why 217–221 (2012). Lyratzopoulos and Abel posit that ‘breast there is such a discrepancy between results of 5. Nederend, J. et al. Trends in incidence and awareness’ could be a major tool for redu randomized trials and epidemiological data detection of advanced breast cancer at biennial screening mammography in The cing patient’s delay—that is, the amount of is not known. One clue is that in random‑ Netherlands: a population based study. time between first symptoms and diagnosis ized trials that found an association between Breast Cancer Res. 14, R10 (2012). especially in women in age groups not eli‑ screening and mortality reduction, women 6. Kalager, M., Adami, H. O., Bretthauer, M. & gible for screening, and in women belonging in control groups (as well as their family and Tamimi, R. M. Overdiagnosis of invasive breast cancer due to mammography screening: to low socioeconomic groups who are less doctor) ignored that they were part of a trial results from the Norwegian screening inclined to attend screening. In other words, (the so-called left-to-nature trial design). program. Ann. Intern. Med. 156, 491–499 ‘breast awareness’ could complement the job Therefore, women in intervention groups (2012). 7. Bleyer, A. & Welch, H. G. Effects of three done by mammography screening. received much more attention and informa‑ decades of screening mammography on A wealth of epidemiological data show that tion than women in control groups. Hence, breast-cancer incidence. N. Engl. J. Med. 367, in most Western Europe, US and Australian as some authors have suggested,11 breast 1998–2005 (2012). populations, the incidence of advanced-stage awareness could have translated into earlier 8. Vainio, H. & Bianchini, F. (Eds) IARC Handbooks of Cancer Prevention. Vol. 7. breast cancer has remained fairly stable over detection of cancers not detected by screen‑ Breast Cancer Screening (IARC Press, Lyon, the past 20 to 30 years, even in areas where ing (that is, interval cancers and cancers 2002). mammography screening has been in place among women not attending screening), 9. Humphrey, L. L., Helfand, M., Chan, B. K. & Woolf, S. H. Breast cancer screening: for 15 to 30 years and where participation in which would have contributed to reductions a summary of the evidence for the U. S. 3–7 screening is 70% or more. More surpris‑ in breast cancer mortality. This hypothesis Preventive Services Task Force. Ann. Intern. ing, practically no decline has been observed is supported by observational studies that Med. 137, 347–360 (2002). 10. Autier, P., Héry, C., Haukka, J., Boniol, M. & in the incidence of cancer diagnosed when showed a correlation between first symptoms Byrnes, G. Advanced breast cancer and breast 12,13 metastases have already spread in distant and visit to a doctor with cancer stage. cancer mortality in randomized controlled trials organs (that is, stage IV cancers). In this But, it remains to be demonstrated that on mammography screening. J. Clin. Oncol. 27, regard, the epidemiological data do not increasing awareness might actually contrib‑ 5919–5923 (2009). 11. Bleyer, A. & Welch, H. G. Effect of screening provide evidence that breast cancer screen‑ ute to reducing the incidence of symptomatic mammography on breast cancer incidence. ing has influenced the incidence of symp‑ cancer. The way ahead is probably to verify N. Engl. J. Med. 368, 679 (2013). tomatic cancer, which means that the burden the potential of ‘breast awareness’ though 12. Richards, M. A., Westcombe, A. M., Love, S. B., Littlejohns, P. & Ramirez, A. J. Influence of of symptomatic breast cancer is about same intervention studies. delay on survival in patients with breast today as it was before the introduction of cancer: a systematic review. Lancet 353, International Prevention Research Institute mammography screening. Recommendation 1119–1126 (1999). (iPRI) and Strathclyde Institute of Global Public of mammography screening is mainly justi‑ 13. Arndt, V. et al. Patient delay and stage of Health at iPRI, Espace Européen, Bâtiment G, diagnosis among breast cancer patients in fied by randomized trials that showed the Chemin du Saquin, 69130 Ecully, Lyon, France. Germany—a population based study. Br. J. ability of periodic mammography screening [email protected] Cancer 86, 1034–1040 (2003).