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Adjuvant therapy, not mammographic screening, accounts for most of the observed breast cancer specific mortality reductions in Australian women since the national screening program began in 1991

  • Epidemiology
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Abstract

There has been a 28% reduction in age-standardised breast cancer mortality in Australia since 1991 when the free national mammographic program (BreastScreen) began. Therefore, a comparative study between BreastScreen participation and breast cancer age specific mortality trends in Australia was undertaken for two time periods between 1991 and 2007, where women aged 50–59 and 60–69 years, who were invited to screen, were compared to women aged 40–49 and 70–79 years who were not invited, but who did have access to the program. There were mortality reductions in all four age groups between 1991–1992 and 2007, resulting in 5,849 (95% CI 4,979 to 6,718) fewer women dying of breast cancer than would have otherwise been the case. Women aged 40–49 years, who had the lowest BreastScreen participation (approximately 20%), had the largest mortality reduction: 44% (95% CI 34.8–51.2). Women aged 60–69 years, who had the highest BreastScreen participation (approximately 60%), had the smallest mortality reduction: 19% (95% CI 10.5–26.9). As BreastScreen participation by invited women aged 50–69 years only reached a maximum of about 55–60% in 1998–1999, a decline in mortality in Australian women cannot be attributed to BreastScreen prior to this time. Thus, almost 60% of the Australian decline in breast cancer mortality since 1991 cannot be attributed to BreastScreen. Therefore, mammographic screening cannot account for most of the reductions in breast cancer mortality that have occurred in Australian women since 1991 and may have contributed to over-diagnosis. Most, if not all, of the reductions can be attributed to the adjuvant hormonal and chemotherapy, which Australian women have increasingly received since 1986.

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Acknowledgments

The article was supported by National Health and Medical Research Council of Australia Grant number 465130. We thank Mark Elwood, M.D., D.Sc. of the British Columbia Cancer Agency, Vancouver, and Anthony Miller, M.D., Dalla Lana School of Public Health, University of Toronto, from Canada. for valuable help in reviewing the manuscript and Victoria White, Ph.D. of The Cancer Council Victoria, Melbourne, Australia, for providing the unpublished data used in Appendix.

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Authors and Affiliations

  1. Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, VIC, 3004, Australia

    Robert C. Burton, Geetha Thiagarajah & Christopher Stevenson

  2. Women’s Health Program, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne, VIC, 3004, Australia

    Robin J. Bell

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  1. Robert C. Burton
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  2. Robin J. Bell
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  4. Christopher Stevenson
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Corresponding author

Correspondence to Robin J. Bell.

Appendix

Appendix

Estimations of the annual mortality reductions which adjuvant tamoxifen and chemotherapy could have achieved in populations of Australian women diagnosed with breast cancer in 1999. Data from Ref. [15] unless otherwise shown, and proportions of ER+ women in Ref. [15] from Dr. Victoria White, Cancer Council Victoria, Australia; relevant ER data was not available for the 1995 National survey.

Women aged 40–49 years: tamoxifen

85% (proportion of all breast cancer that was early) × 73% (proportion of women with early breast cancer who were ER+ and aged less than 50 years) × 78% (proportion of women with early breast cancer less than 50 years of age who were ER+ and received Tamoxifen) × 31% (EBCTCG: adjuvant tamoxifen reduction in mortality for ER+ women of all ages with early breast cancer [13]) = 15.0%.

Women aged 50–69 years: tamoxifen

85% (proportion of all breast cancer that was early) × 78%(proportion of women with early breast cancer EBC more than 50 years of age who were ER+) × 92% (proportion of women with early breast cancer more than 50 years who were ER+ and received Tamoxifen) × 31% (EBCTCG: adjuvant tamoxifen reduction in mortality for ER+ women of all ages with EBC [13]) = 18.9%.

Women aged 40–59 years: Chemotherapy

72% (1999 Victorian treatment survey proportion of all women aged less than 50 years with early breast cancer who received adjuvant chemotherapy) × 85% (1995 National treatment survey proportion of all women with early breast cancer) × 38% (EBCTCG : adjuvant chemotherapy reduction in mortality for women aged less than 50 years [13]) = 23.3%.

Women aged 50–69 years: Chemotherapy

29% (Victorian treatment survey proportion of all women aged 50 or more years with early breast cancer who received adjuvant chemotherapy) × 85% (1995 National treatment survey proportion of all women with early breast cancer) × 20% (EBCTCG : adjuvant chemotherapy reduction in mortality for women aged more than 50 years [13]) = 4.9%.

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Burton, R.C., Bell, R.J., Thiagarajah, G. et al. Adjuvant therapy, not mammographic screening, accounts for most of the observed breast cancer specific mortality reductions in Australian women since the national screening program began in 1991. Breast Cancer Res Treat 131, 949–955 (2012). https://doi.org/10.1007/s10549-011-1794-6

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