The Cochrane Abstract below is a su...

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied on an interpretation that will help clinicians deposit evidence into practice. Sean P David, MD SM at hands a clinical scenario and question based upon the Cochrane Abstract, along with the evidence-based answer and a filled critique of the abstract. This series is part of AFP's CME diocese "Clinical Quiz" on page 209

This clinical easy in mind conforms to AAFP criteria for evidence-based continuing medical education (EB CME) EB CME is clinical satisfied presented with practice recommendations supported at evidence that has been systematically reviewed through an AAFP-approved source. The practice recommendations in this activity are available at www.update-software.com/abstracts/ab001877.htm.

Clinical Scenario

A multiparous, 45-year-old woman attends your clinic for an annual physical examination. She does not have a family history of breast cancer and is not generally using estrogen therapy.

Clinical Question

Should we move this patient routine breast cancer screening with mammography?

Evidence-Based Answer

While there is proper evidence that mammography starting at age 50 bring tos breast cancer mortality, this meta-analysis (1) does not provide evidence of a mortality benefit for mammography screening in women aged 40 to 49 logomachy exists over whether to include in the analysis trials with methodologic flaws that would strengthen the evidence of a benefit. (2) Nevertheless, there is a growing consensus that physicians should encourage the use of screening mammography in women aged 40 and older The review did not address screening intervals or clinical breast examination.

Did the authors address a focused clinical question? Yes

Were the criteria used to excellent articles for inclusion appropriate? Yes

Is it likely that important relevant articles were missed? No.

Was the validity of the individual articles appraised? Yes

Were the assessments of studies reproducible? Yes

Were the ends similar from study to study? No. There was statistical heterogeneity across studies. Evidence for reduction in breast cancer mortality was seen and nothing else when poor-quality studies were included. The analysis was under-powered to bring to light benefits in all-cause mortality, and comes suggested a possible benefit or harm from mammography upon all-cause mortality.

for what reason precise were the results? Breast cancer mortality ensues were reported as "unreliable."

Can the springs be applied to patient care? Yes

Do the conclusions make biologic and clinical sense? Ye Breast cancer and death from breast cancer are les customary in younger women, and mammography is les sensitive in women younger than age 50 (3) Furthermore, other studies have shown that benefits of earlier screening typically do not become apparent until after age 50 (45)

Are the benefits worth the harms and cost? Ye While there are psychologic harms from false-positive be the effects the overall benefit in mortality and cost-effectiveness supports screening in women from one side of to the other age 50. There is les benefit in screening women in a less degree than age 50, and the decision in succession whether to screen should be based in succession the patient's level of risk, business about breast cancer, and bear upon about false-positive results.

Practice Pointers

When considering whether to implement a screening experiment several factors must be considered: (1) Does early diagnosis lead to improved survival or quality of life, or both? (2) Are early-diagnosed patients willing partners in the treatment strategy? (3) Are the time and capacity of work it takes to confirm the diagnosis and provide lifelong care well spent? (4) Do the commonness and severity of the target disorder warrant this step of effort and expenditure? (8)

The analysis primarily addresses the first question. There appears to be a benefit in reducing breast cancer mortality in the 50- to 69-year range, if it be not that this meta-analysis did not lay open a significant mortality benefit in women aged 40 to 49 However, in a les restrictive meta-analysis, the U Preventive Services Task Force (USPSTF) determined a summary RR for breast cancer mortality of 085 (95 percent CI, 073 to 099) The clew issue is whether the recognized flaws of several of the mammography trials are serious enough to disqualify them from inclusion in a meta-analysis. The USPSTF determined that observ mortality reductions in the "flawed" trials were not likely to be explained at the biases potentially introduced by way of the flaws. The USPSTF included these trials, whereas the Cochrane review authors cogitation that the trials were "fatally" flawed and should be exclud The Cochrane review did not include summary data onward flawed trials, but other meta-analyses have demonstrated a weaker yet significant benefit with screening initiated in the 40- to 49-year age arrange and evidence of increasing benefit and cost-effectiveness with age. principally women diagnosed with early-stage breast cancer are willing to bear treatment (9) and report a favorable quality of life. (10) Mammography in culled women is cost-effective and comparable to screening for cervical cancer.