Mammascreening vs. kurative Mammographie

Stand 12.03.2014: So the last word goes to the only doctor who reported receiving a mammogram personally, an internist: „I am aware of the data over the past 20 years that routine screening mammography does not save lives. I had my first mammogram this year at age 50. I am low risk. I might not have another screening mammogram for several years. Glad to see these data support my decision.(Canadian 25 years follow up)“

Diskussion :http://www.coliquio.de/l.php?i=170526078&m=84d40f 

 

Obwohl das Mammographiescreening die z. Z. beste eine Methode zur Reihenuntersuchung
bzgl. Brustkrebs darstellt, hat die Methode auch Schwächen.

Insbesondere bei extrem dichtem Drüsengewebe ist bekannt, dass die Sensitivität der Mammographie allein stark eingeschränkt ist. Selbst mit digitaler Technik sind nach aktuellen Literaturangaben im Screening bei sehr dichtem Drüsengewebe nur Sensitivitäten von max. ca. 65% zu erwarten.

Der Ultraschall hat in der „kurativen Mammographie“ einen hohen Stellenwert als Zusatzuntersuchung erlangt. Eine Veröffentlichung von Kolb et al. zeigt, dass gerade bei dichtem Drüsengewebe ein zusätzlicher Ultraschall der Brust sinnvoll sein und die Sensitivität auf >90% gesteigert werden kann.

Bei ACR 1 Brüsten wird eine Sensitivität von 88% erreicht. Bei ACR 4 Brüsten von 62%. Somit müssten, meiner Meinung nach, konsequenter Weise ACR 3 u. ACR 4 Mamma’s aus dem Screening herausgenommen werden u. mit kurativer Mammographie gescreent werden, da die Zahl der übersehenen Karzinome sonst bis 40% betragen kann, wobei beim Screening sowieso schon 40% der Karzinome übersehen werden .

Weiterhin sollte eine familiäre Belastung mit Brustkrebs vor Durchführung des Screening ausgeschlossen werden, diese Patienten sollten gegebenenfalls dem intensivierten kurativen Früherkennungsprogramm zugeführt werden, da gerade in dieser Gruppe schnell wachsende Karzinome vorkommen. Damit könnte auch ein Beitrag zur Vermeidung von Intervallkarzinomen geleistet werden.Strahleninduzierte Karzinome könnten reduziert werden.

20 bis 30% der Frauen, die am Screening teilnehmen, bekommen wegen eines geäusserten Verdachts auf Bösartigkeit im Verlaufe des Screening zusätzliche abklärende Untersuchungen.

Das Screening kostet ca. 300 000000 Euro/Jahr.

Eine Mammographie wird mit 65Euro bezahlt.

Overdiagnosis of Invasive Breast Cancer With
Mammography Screening:

http://www.annals.org/content/156/7/491.abstract

http://www.medscape.com/viewarticle/761505

MammaScreeningKritik Jahr 2014   Antwort:Mammography Still Saves Lives

Canadian_National_25Years_Follow_up 2014

Tumorscreening_Mammascreening_Statistik

Kernaussagen:

20% Sterblichkeitsreduktion durch Mammascreening.(20% Frauen sollen vor dem Brustkrebstot gerettet werden.)

5/1000 Frauen sterben innerhalb von 10 Jahren an Brustkrebs. 1 von diesen 5 Frauen wird durch Screening gerettet.

100 von 1000 Frauen die am Screening teilnehmen bekommen den Verdacht auf Krebs geäußert und werden einer

Ausschlußdiagnostik unterzogen.

Bei 5 von 1000 Frauen wird ein Brustkrebs festgestellt und mit OP und/oder Chemotherapie behandelt ohne

dass diese Frauen jemals an diesem Krebs verstorben wären.

Wobei die Sterblichkeit(Mortalität) an Brustkrebs nach neueren Studien durch Screening nicht gesenkt wird,

die zusätzlichen Erkrankungen an Brustkrebs und Folgen der Strahlendiagnostik (Leukämie<5%?) und Therapie

noch im einzelnen statistisch belegt werden müssen.

 

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2 Responses to “Mammascreening vs. kurative Mammographie”

  1. Werner Says:

    Norwegian Study Estimates Overdiagnosis of Breast Cancer from Screening
    Physician analyzing a mammogram film A study in Norway suggests that between 15 and 25 percent of invasive breast cancers were overdiagnosed with the institution of a national mammography screening program.

    As many as 1 in 4 invasive breast cancers diagnosed in Norway through the country’s widespread, population-based mammography screening program never would have caused the woman harm or required treatment, researchers reported in the April 3 Annals of Internal Medicine. The finding, based on an analysis of the country’s breast screening program, adds to concerns about overdiagnosis in breast and other cancers.

    Overdiagnosis refers to the detection of tumors that, if left alone, would not cause any symptoms of disease or death. Because doctors cannot reliably distinguish these tumors from potentially fatal cancers, most screening-detected invasive breast cancers are treated, often with surgery and postoperative therapy that includes radiation plus hormone therapy, chemotherapy, or both systemic therapies.

    The new findings, together with previous studies, suggest that a substantial proportion of screened women are diagnosed with invasive cancers unnecessarily and are exposed to the toxic effects of treatments they don’t need.

    The investigators analyzed data from the Norwegian Breast Cancer Screening Program, which began as a pilot program in 1996 in four of Norway’s 19 counties and was later expanded to include the remaining counties over a 9-year period. Specifically, they compared the number of breast cancers diagnosed in counties that had screening programs in place with the number of cases diagnosed in counties that did not have screening programs during the same period.

    The results suggest that between 15 and 25 percent of invasive breast cancers were overdiagnosed with the implementation of a mammography screening program. After 10 years of biennial screening, the study authors estimated that for every 2,500 women invited to be screened, 6 to 10 women were overdiagnosed, 20 were diagnosed with breast cancer that required treatment, and 1 death from the disease was prevented.

    The analysis did not include noninvasive tumors known as ductal carcinoma in situ (DCIS), even though most of these lesions are only detectable by mammography. The authors said DCIS should be analyzed separately because different analytic methods would be required. Inclusion of DCIS would have further increased the estimates of overdiagnosis, since a large proportion of these tumors would never become life-threatening cancers.

    The authors also acknowledged that additional factors beyond screening might have affected breast cancer rates in the counties.

    Nonetheless, the „overdiagnosis and unnecessary treatment of nonfatal cancer creates a substantial ethical and clinical dilemma and may cast doubt on whether mammography screening programs should exist,“ the authors wrote. Until doctors can reliably identify potentially fatal cancers that require early detection and treatment, „women eligible for screening need to be comprehensively informed about the risk for overdiagnosis,“ they concluded.

    The authors of an accompanying editorial emphasized that women in the United States often start annual mammography screening at age 40, whereas Norwegian women start biennial screening at age 50. „Given more frequent screening over a longer time, overdiagnosis probably occurs more often in the United States than in Norway,“ they wrote.

    Any amount of overdiagnosis is serious, however, and steps should be taken to address the issue, the editorialists continued. Most patient-education materials fail to mention overdiagnosis, and most women are unaware of its possibility. „We have an ethical responsibility to alert women to this phenomenon,“ they concluded.

    „Overdiagnosis from cancer screening is one of the most pressing clinical issues in the field of cancer screening,“ said Dr. Barry Kramer, director of NCI’s Division of Cancer Prevention and editor-in-chief of the NCI Physician Data Query (PDQ) Screening and Prevention Editorial Board.

    „With increasingly sensitive screening tests for a variety of cancers, the problem is likely to increase,“ Dr. Kramer continued. „For that reason, NCI has identified studies to distinguish overdiagnosed cancers from life-threatening cancers as a high priority area of research.“

    —Edward R. Winstead

  2. Werner Says:

    Although these women were at somewhat higher risk (they typically would have been classified as intermediate risk), they represent a group of women for which we currently don’t have enough data to recommend MRI as part of their screening, and for whom the risks of overcalling findings on imaging, and obtaining biopsies that find only a few additional cancers, are quite real.

    So here are the numbers. They screened about 2600 women over this 3-year period and 110 (4%) of those women were diagnosed with cancer during that time. Of those cancers:

    33 were seen only on mammogram;
    32 were seen only on ultrasound;
    26 were seen on both mammogram and ultrasound;
    9 were seen only on MRI; and
    11 were not seen on any imaging.

    These 11 interval cancers were found by a clinical evaluation abnormality that the patient or their physician found between annual mammography screening.

    (Dr. Kathy Miller with another Medscape Oncology video blog.ACRIN6666 Trial )

    Differenzierung der Mammakarzinome fehlt
    Differentiation of Breast Cancers Is Missing
    Dtsch Arztebl Int 2013; 110(14): 253; DOI: 10.3238/arztebl.2013.0253a
    Weth, Gerhard

    zu dem Beitrag Häufigkeit von Intervallkarzinomen im deutschen Mammographie-Screening-Programm: Auswertungen des Epidemiologischen Krebsregisters Nordrhein-Westfalen von Dr. med. Oliver Heidinger, Dipl.-Soz. Wolf Ulrich Batzler, Dr. rer. medic. Volker Krieg, Dr. med. Stefanie Weigel, Dr. rer. nat. Cornelis Biesheuvel, Prof. Dr. med. Walter Heindel, Prof. Dr. med. Hans-Werner Hense in Heft 46/2012

    In dem sonst sehr strukturiert aufgebauten Artikel vemisse ich die Differenzierung der verschiedenen Mammakarzinome.

    In meinem persönlichen Umfeld ist ein invasiv wachsendes lobuläres Mammakarzinom 11 Monate nach dem letzten Mammographiescreening mit einer Größe von 20 mm sonographisch entdeckt worden, das auch bei nachträglicher Beurteilung auf den Mammographien nicht erkennbar war. Offenbar handelt es sich um ein methodisches Problem, da – wie uns von den Radiologen versichert wurde – mit der Mammographie diese Tumoren nicht dargestellt werden. Bei einer Häufigkeit von 15–20 % ist das ein nicht vernachlässigbares Ereignis. Es handelt sich dabei weder um ein Intervallkarzinom noch um ein technisches oder menschliches Versagen.

    Ich vermisse, dass in den Bescheiden an die Überweiser über eine unauffällige Mammographie nicht darauf hingewiesen wird, dass – auch wenn man sich aus ökonomischen Gründen im Screening auf die Mammographie beschränkt – nur durch eine ergänzende Sonographie auch diese Gruppe von Karzinomen erfasst wird.

    DOI: 10.3238/arztebl.2013.0253a


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