The Hellquist et al1 article in Cancer stated that there was a 26% reduction in breast cancer deaths in women aged 40-49 years in Swedish counties that invited women to have routine screening every 2 years compared with counties that did not routinely invite women to be screened. The authors concluded that the high percentage reduction in deaths is, in and of itself, proof that screening at age 40 years is a rational choice for society. This is an overreach.

Because their article uses nonrandomized controls and has many more controls than treated patients, there is a strong possibility of a study bias that did not reveal itself in the prestudy period but became significant during the 16 years of the study. The higher mortality of the controls could be, at least in part, the result of factors other than screening.

Even if we accept that mortality fell, the low incidence of breast cancer in this age group must be considered along with the magnitude of the percentage reduction in deaths. A 26% reduction (down to 803 deaths in the study group) means 282 lives were saved. A 26% reduction should save 322 of the 1238 control deaths. One million women followed during 16 years required 8 million biannual mammograms at 100% participation. Using a conservative assumption of $100 for each mammogram and the resultant visits, false positives, and biopsies, the total cost at a participation rate of 80% would be 640 million dollars, and the cost for each of the 604 lives saved would be $1,058,225. This high figure does not justify unquestioning support for routine mammography at ages 40-49 years.

Healthcare dollars are not unlimited. Resources should be allocated on a rational basis so that diseases that are less publicized than breast cancer are not shortchanged.


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    Hellquist BN, Duffy SW, Abdsaleh S, et al. Effectiveness of population-based service screening with mammography for women ages 40 to 49 years: evaluation of the Swedish Mammography Screening in Young Women (SCRY) cohort [Published online ahead of print September 29, 2010]. Cancer. DOI:10.1002/cncr.25650