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The original decision to introduce mammographic screening in the UK was based on The Forrest report [1] which analyzed the costs and benefits of screening in terms of quality-adjusted life-years (QALYs) and found that screening would reduce the death rate from breast cancer by almost one-third with few harms and at low cost. Since that time, certain harms associated with breast screening have been identified including overdiagnosis and unnecessary surgery [2].


A recently published paper [3] set out to replicate the original Forrest report using baseline mortality and risk of surgery from English data (not originally used by Forrest) but also included the perceived harms noted above, using estimates based on those published by The Nordic Cochrane Centre [4] and by Nelson and colleagues [5,6] for The US Preventive Services Task Force.


The outcomes of 100,000 women aged 50 years were modelled in two cohorts, one screened, the other not. Outcomes measured were deaths from breast cancer, deaths from all other causes and the number of women having false-positive diagnoses and surgery, which were combined into QALYs. The authors found that inclusion of the effects of harms reduced the updated estimate of net cumulative QALYs gained after 20 years from 3301 to 1536 or more than 50%. Using Nordic Cochrane Centre estimates generated negative QALYs for the first 7 years of screening and only 70 positive QALYs after 10 years and 834 after 20 years. Results were similar when estimates used by Nelson were applied. Hence breast cancer screening might have caused net harm for up to 10 years from the start of screening.


  • Rod Baber
    Clinical Associate Professor of Obstetrics and Gynaecology, Sydney Medical School, The University of Sydney, NSW, Australia


  1. Forrest P. Breast cancer screening. Report to the Health Ministers of England, Wales, Scotland and N Ireland by a working group chaired by Professor Sir Patrick Forrest. HMSO, 1986.
  2. WHO IARC. Breast cancer screening. International Agency for Research on Cancer/WHO, 2002.
  3. Raftery J, Chorozoglou M. Possible net harms of breast cancer screening; updated modelling of Forrest report. BMJ 2011;343:d7627.
  4. Gtzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database Syst Rev 2009;4:CD001877.
  5. Nelson H, Tyne K, Naik A, et al. Screening for breast cancer: an update for the US Preventive Services Task Force. Ann Intern Med 2009; 151:727-37.
  6. Nelson H, Tyne K, Naik A, et al. Screening for breast cancer: an update for the US Preventive Services Task Force. Agency for Healthcare Research and Quality, 2009.
  7. Kalager M, Zelen M, Langmark F, Adami HO. Effect of screening mammography on breast-cancer mortality in Norway. N Engl J Med 2010;363:1203-10.
  8. Jorgensen K, Gotzsche P. Overdiagnosis in publicly organized mammographic screening programmes: a systematic review of incidence trends. BMJ 2009;339:b2587.
  9. Gtzsche PC, Jrgensen KJ, Zahl PH, Mhlen J. Why mammographic screening has failed to live up to expectations from randomized trials. Cancer Causes Controls 2012;23:15-21.
  10. de Gelder R, Heijnsdijk EA, van Ravesteyn NT, et al. Interpreting overdiagnosis estimates in population-based mammographic screening. Epidemiol Rev 2011;33:111-21.

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