title: Population-Based Breast Cancer Screening With Risk-Based and Universal Mammography Screening Compared With Clinical Breast Examination: A Propensity Score Analysis of 1 429 890 Taiwanese Women.
abstract: OBJECTIVE
  Different screening strategies for breast cancer are available but have not been researched in quantitative detail.
  
  
  OBJECTIVE
  To assess the benefits and the harms of risk-based and universal mammography screening in comparison with annual clinical breast examination (CBE).
  
  
  METHODS
  Population-based cohort study comparing incidences of stage II+ disease and death from breast cancer across 3 breast cancer screening strategies, with adjustment for a propensity score for participation based on risk factors for breast cancer and comparing the 3 strategies for overdetection between January 1999 and December 2009. Asymptomatic women attending outreach screening in the community or undergoing mammography in hospitals were enrolled in the 3 screening programs.
  
  
  METHODS
  Risk-based biennial mammography, universal biennial mammography, and annual CBE.
  
  
  METHODS
  Detection rates, stage II+ disease incidence, mortality from breast cancer, and overdiagnosis were compared using a time-dependent Cox proportional hazards regression model.
  
  
  RESULTS
  A total of 1 429 890 asymptomatic women attending outreach screening in the community or undergoing mammography in hospitals were enrolled in the 3 screening programs. Detection rates (prevalent screen and subsequent screens per 1000) were the highest for universal biennial mammography (4.86 and 2.98, respectively), followed by risk-based mammography (2.80 and 2.77, respectively), and lowest for annual CBE (0.97 and 0.70, respectively). Universal biennial mammography screening, compared with annual CBE, was associated with a 41% mortality reduction (risk ratio, 0.59; 95% CI, 0.48-0.73) and a 30% reduction of stage II+ breast cancer (RR, 0.70; 95% CI, 0.66-0.74). Risk-based mammography screening was associated with an 8% reduction of stage II+ breast cancer (RR, 0.92; 95% CI, 0.86-0.99) but was not associated with a statistically significant mortality reduction (risk ratio [RR], 0.86; 95% CI, 0.73-1.02). Estimates of overdiagnosis were no different from CBE for risk-based screening and 13% higher than CBE for universal mammography.
  
  
  CONCLUSIONS
  Compared with population-based screening for breast cancer with annual CBE, universal biennial mammography resulted in a substantial reduction in breast cancer deaths, whereas risk-based biennial mammography resulted in only a modest benefit. Compared with annual CBE, risk-based and universal mammography screening did not result in significant overdiagnosis of breast cancer.
authors.affiliation: School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan.
authors.forename: Amy Ming-Fang
authors.initials: AM
authors.lastname: Yen
authors.affiliation: Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
authors.forename: Huei-Shian
authors.initials: HS
authors.lastname: Tsau
authors.affiliation: Department of Health Industry Management, School of Healthcare Management, Kainan University, Tao-Yuan, Taiwan.
authors.forename: Jean Ching-Yuan
authors.initials: JC
authors.lastname: Fann
authors.affiliation: School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan.
authors.forename: Sam Li-Sheng
authors.initials: SL
authors.lastname: Chen
authors.affiliation: Department and Graduate Institute of Health Care Management, Chang Gung University, Tao-Yuan, Taiwan.
authors.forename: Sherry Yueh-Hsia
authors.initials: SY
authors.lastname: Chiu
authors.affiliation: Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
authors.forename: Yi-Chia
authors.initials: YC
authors.lastname: Lee
authors.affiliation: Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, Taipei, Taiwan.
authors.forename: Shin-Liang
authors.initials: SL
authors.lastname: Pan
authors.affiliation: Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
authors.forename: Han-Mo
authors.initials: HM
authors.lastname: Chiu
authors.affiliation: Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.
authors.forename: Wen-Horng
authors.initials: WH
authors.lastname: Kuo
authors.affiliation: Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan8Taiwan Adventist Hospital, Taipei, Taiwan.
authors.forename: King-Jen
authors.initials: KJ
authors.lastname: Chang
authors.affiliation: Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
authors.forename: Yi-Ying
authors.initials: YY
authors.lastname: Wu
authors.affiliation: Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
authors.forename: Shu-Lin
authors.initials: SL
authors.lastname: Chuang
authors.affiliation: Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
authors.forename: Chen-Yang
authors.initials: CY
authors.lastname: Hsu
authors.affiliation: Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
authors.forename: Dun-Cheng
authors.initials: DC
authors.lastname: Chang
authors.affiliation: Health Promotion Administration, Ministry of Health and Welfare, Taiwan.
authors.forename: Shing-Lang
authors.initials: SL
authors.lastname: Koong
authors.affiliation: Health Promotion Administration, Ministry of Health and Welfare, Taiwan.
authors.forename: Chien-Yuan
authors.initials: CY
authors.lastname: Wu
authors.affiliation: Health Promotion Administration, Ministry of Health and Welfare, Taiwan.
authors.forename: Shu-Lih
authors.initials: SL
authors.lastname: Chia
authors.affiliation: Health Promotion Administration, Ministry of Health and Welfare, Taiwan.
authors.forename: Mei-Ju
authors.initials: MJ
authors.lastname: Chen
authors.affiliation: Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
authors.forename: Hsiu-Hsi
authors.initials: HH
authors.lastname: Chen
authors.affiliation: Health Promotion Administration, Ministry of Health and Welfare, Taiwan10Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Shu-Ti
authors.initials: ST
authors.lastname: Chiou
mesh_terms: D000368:Aged; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000000981:diagnostic imaging* / Q000401:mortality / Q000473:pathology; D015331:Cohort Studies; D055088:Early Detection of Cancer; D005260:Female; D006801:Humans; D008327:Mammography; D008403:Mass Screening; D008875:Middle Aged; D012307:Risk Factors