Kaleidoscope 2009 wk 47

19 11 2009

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Kaleidoscope is a new series, with a “kaleidoscope” of facts, findings, views and news gathered over the last 1-2 weeks.

Most items originate from Twitter, my Google Reader (RSS) and sometimes real articles (yeah!).

I read a lot, I bookmark a lot, but only some of those things end op in a post. Since tweets have a half-life of less than a week, I thought it would be nice to safeguard some of the tweets in a post. For me to keep, for you to read.

I don’t have the time and the discipline to post daily about health news and social media as Ves Dimov does. It looks more like the compilation at blogs of dr Shock’s (see example),  dr Bates shout-outs, Health Highlights of Highlight HEALTH and Rachel Walden’s Womens health News Round-ups, but less on one subject and less structured. It will just be a mix of old and new, Social Media and science, just a kaleidoscope. Or a potpourri  if you like.

I don’t know if this kaleidoscope will live a long live. I already wrote 2 3 4 5 6 editions, but didn’t have the time to finish them. Well, we will see, just enjoy this one.

Ooh and the beautiful kaleidoscope is made by RevBean and is called: Eyeballs divide like cells. Looks very much like the eyeball-bubblewrap of a previous post but that is thus coincidence. Here is the link (Flickr, CC)

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Medical Grand Rounds

Louise Norris at Colorado Health Insurance Insider is this week’s host of Grand Rounds.(see here). There are many interesting posts again. As a mother of two teens I especially liked the insight Nancy Brown of Teen Health 411 brings us into what teens want when it comes to their relationships with their parents and the “would you rather…?” story that Amy Tenderich of Diabetes Mine shares with us. The punch line is great. Her 9 year old melts my heart.

At InsureBlog’s Hank Stern brings us an article about a British hospital that will no longer admit expectant mothers with a BMI of more than 34, because the hospital’s labor and delivery unit is not equipped to handle complicated births. Hank concludes: “Fear not, though, portly preggies have to travel but 20 miles to the next closest facility. Assuming, of course, that they can make it that far when contractions are minutes apart.”

Dr Charles of the The Examining Room wrote an in depth article about a cheerleader who was supposedly stricken with dystonia following a seasonal flu vaccine in August. Dr Charles not only highlights why (specialists) think it is not dystonia, but gives also background information about the efficacy of vaccins.

Recent editions of the Grand Rounds were at CREGRL, flight nurse (link), NonClinicalJobs (link) and Codeblog, tales of a nurse (link). You can always find previous and upcoming hosts at the Grand Rounds Archive at Blogborygmi.

3621322354_4bc3bb115e Breast cancer screening

The update of the 2002 USPSTF recommendation statement on screening for breast cancer in the general population, published in the November issue of The Annals of Internal Medicine has led to heated discussions in the mainstream media (i.e. New York Times and MedPage Today). Based on current evidence, partly based on 2 other articles in the same journal (comparison screening schedules and an systematic review) the guidelines advise scaling back of the screening. The USPSTF recommends:

  • against routine screening mammography in women aged 40 to 49 years
  • against routine screening mammography of women 75 years or older.
  • biennial (instead of annual) screening mammography for women between the ages of 50 and 74 years.
  • against teaching breast self-examination (BSE).
  • against either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities.

The two articles published in Ann Intern Med add to the evidence that the propagation of breast cancer self exam doesn’t save lives (see Cochrane review discussed in a previous post) and that the benefits of routine mammography in the young (<50) or old (>75) do not outweigh the harm (also covered by a  Cochrane review before). Indeed, as put forward by Gary Schwitzer at Schwitzer health news blog this is NOT a new debate. He refers to Slate who republishes a five-year old piece of Amanda Schaffer that does a good job of explaining the potential harms of screening. However it is difficult for women (and some doctors) to understand that “When it comes to cancer screening, more isn’t always better.” Indeed -as Kevin Pho at Kevin MD states, the question is whether “patients will accept the new, evidence-based, breast cancer screening guidelines”.

In the Netherlands it is already practice to start biannual routine mammography at the age of 50. The official breast cancer screening site of the RIVM even states that the US is now going to follow the Dutch guidelines 😉 (one of assessed guidelines in one the Ann Intern Med papers is Dutch). But people still find the  long established guidelines difficult to accept: coincidentally I saw tweets today asking to sign a petition to advance the age of screening ‘because breast cancer is more and more frequently observed at young age…(??)’ Young, well educated, women are very willing to sign…

No time to read the full articles, but interested to know more, then listen to the podcast of this Ann Intern Med edition:

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Systematic Reviews, pharma sponsored trials and other publishing news

Cochrane reviews are regarded as scientifically rigorous, yet a review’s time to publication can be affected by factors such as the statistical significance of the findings. A study published in Open Medicine examined the factors associated with the time to publication of Cochrane reviews. A change in authors and updated reviews were predictive factors, but the favorability of the results was not.

Roy Poses of the Health Care Renewal Blog starts this blogpost as follows: “Woe to those of us who have been advocates for evidence-based medicine”. He mainly refers to a study published in the NEJM, that identified selective outcome reporting for trials of off-label use of gabapentin: for 8 of the 12 published trials, there was a disagreement between the definition of the primary outcome in the protocol and that in the published report. This seriously threatens the validity of evidence for the effectiveness of off-label interventions. Roy was surprised that the article didn’t generate much media attention. The reason may be that we have been overwhelmed by manipulation of data, ghostwriting and by the fact that pharma-sponsored trials rarely produce results that are unfavorable to the companies’ product (see previous posts about Ghostwriting (Merck/Elsevier, Conflict of Interest in Cancer Studies and David Tovey about Cochrane Reviews). At least two authors of the NEJM review (Bero and Dickersin) have repeatedly this to be the case [e.g. see here for an overview, and papers of Lisa Bero]. It is some relief that at least 3 of the 4 NEJM authors are also members of the Cochrane Collaboration. Indirectly better control of reporting, i.e. by clinical trials registries, can improve the reliability of pharma sponsored trials and thus systematic reviews summarizing them. As a matter of fact Cochrane authors always have to check these registries.

At Highlight Health Walter Jessen writes about Medical Journal Conflict of Interest Disclosure and Other Issues, which also discusses how money can taint objectivity in scientific publishing. Half of the post discusses the book The Trouble with Medical Journals, written in 2007 by Richard Smith, the former editor of the BMJ.
By the way, Walter just hosted MedLibs Round with the theme “Finding Credible Health Information Online”.

Good news in the Netherlands: right after international Open Access week and the launching of the Dutch Open Access website (www.openaccess.nl), the Netherlands Organization for Scientific Research (NWO) has announced that it is in favor of Open Access. (via PLOS-facebook).

The open access nature of PLOS itself gets out of hand: they even peer-review T-shirts (according to Bora Zivkovic of a Blog around the Clock, see here)

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Other Health & Science News:

Medline Plus summarizes an article in the Journal of Nutrition, that states that Selenium supplements, may pose a heart risk.

Even Folic Acid and vitamin B12, when taken in large doses, have been reported to Increase Cancer Risk (WebMD)

Luckily WebMD also reports that dark chocolate seems to help against stress, that is it reduced stress hormones in the blood. However @evidencematters and @NHSChoices cast doubt on that“Chocolate cuts stress, says newspaper. Does the study really say that? And who paid for the study?…”

Scientists made the unexpected discovery (published in Molecular Cell) that BRAF, which is linked to around 70 per cent of melanomas and seven per cent of all cancers, is in fact controlled by a gene from the same RAF family called CRAF – which has also been linked to the disease. For the first time it is shown “how two genes from the same ‘family’ can interact with each other to stop cancer in its tracks” (Source: Info Cancer Research UK)

For the first time, scientists have successfully used exome sequencing to quickly discover a previously unknown gene responsible for Miller syndrome, a rare disorder. The finding demonstrates the usefulness of exome sequencing in studying rare genetic disorders. The exome is enriched for coding (thus functional) DNA, it is only 1% of the total DNA, but contains 85% of the mutations (Published in , source: PhysOrg.com)

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Web 2.0
For information regarding the FDA hearings on internet and social media see #FDASM: http://www.fdasm.com.

Read Write Web summarizes the new numbers released by analytics firm Postrank that indicate that reader engagement with blogs has changed dramatically over the last three years, primarily because of the rise of online social networks.

Twitter has began to relaunch the new retweet feature, although not without controversy. What do you think about the newest feature?

The Next Web gives an overview of which Twitter application is hot and which is not.

And Finally: Top 100 tools for learning, compiled by Jane Hart from the contributions of 278 learning professionals worldwide. You can see the lists here (HT: http://blogs.netedu.info/?p=1005)

The web 2.0 part is relatively short, but it is time to conclude this edition. Till next time!

  • MEDLIB’s ROUND 1.6 (laikaspoetnik.wordpress.com)
  • Tool Talk: quick links re Facebook, GReader and GWave (socialfish.org)
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    The (un)usefulness of regular breast exam

    7 09 2008

    Regular breast exam, either by women theirselves (BSE, breast self exam) or a doctor or nurse, has been promoted for many years, because this would help to detect breast cancer earlier, and “when breast cancer is found earlier, it’s easier to treat and cure” . At least that is what most people believe and what has been advocated by organizations and Internet companies (i.e. selling special gloves) (see figure).

    The idea that regular breast exam is truly beneficial, however, has recently been challenged by a Cochrane Systematic Review, conducted by Kösters and Gøtzsche.[1] This review has stirred up quite a debate among doctors, guideline-makers, patients and women. Many major organizations and advocacy groups have stopped recommending routine BSE. Reactions of patients vary from ‘reluctant’ to ‘confused that it is no longer needed’ or even a bit angry (‘it is my body and I decide whether I check it or not’). See for instance these reactions: 1, 2, 3. Coverage in the media is sometimes misleading, but reactions of (some) doctors or “experts in the field” also do not always help to convey a clear message to the public either. Some seize the opportunity to rant against EBM (Evidence Based Medicine) in general, which makes things even less transparent, see for instance this post by Dr Rich (although he has some good points as well), this story in the Herald and this one in Medcape.

    In a question-answer like way I try to cover the story.

    1. What is the conclusion from the study?
    The authors conclude that regular breast examination (BE) does more harm than good and is therefore not recommended.

    2. Which harm, which good?
    Breast examination didn’t lower mortality (not beneficial), whereas it led to more unnecessary biopsies (harm).

    3. Why did they look at mortality only?
    They didn’t, they also scored the number and stage of cancers identified. However mortality (or really survival) is an outcome that matters most for patients. Suppose the screening finds more breast cancers, but early intervention does not lead to any cure, than the early recognition of the cancer is of no real value to the patient.

    4. Why are more unnecessary biopsies considered as harm?
    Biopsies are an invasive procedure and lead to unnecessary anxiety, that can have a long-lasting effect on psychological well-being. Extra tests to rule out that it is not cancer also cost a lot of money. Whether it is ‘worth it’ depends on whether -and to which extent- people’s lives are saved (or quality of life improved).

    5. What kind of study is it?
    It is a systematic review (of controlled clinical trials) made by the Cochrane Collaboration (see glossary). Generally these systematic reviews are of high methodological quality, because of the systematic and explicit methods used to identify, select and critically appraise relevant research. After extensively searching for all trials, only controlled clinical trials (studies of the highest evidence) with predefined characteristics are included. Thus authors are really looking for all the high level evidence there is, instead of grabbing some papers from the drawer or looking at the core English language journals only.

    6. Is this new information?
    No, not really. In fact this systematic review is an update of a previous version, published in 2003. The studies included and the conclusions remain the same. As shown from the scheme below (taken from a figure in a very interesting opinion paper entitled “Challenges to cancer control by screening” (see abstract here), the attitude towards breast self examination already changed soon after the original trials were published.

    Nature Reviews Cancer 3, 297 (2003)

    M.N. Pollak and W.D. Foulkes: Nature Reviews Cancer 3, 297 (2003)

    7. Omg? ….
    All Cochrane Systematic have to be regularly updated to see if there isn’t any new evidence that could alter the conclusions. In this case, after updating the search, no new studies of good quality were found. However, there are still some trials ongoing.

    8. Can we rely on these conclusions? Is the Cochrane Review of good enough quality?
    The Cochrane Review itself is of high quality, but the two randomized studies included, one from Russia (1999: ~122,500 participants) and one from Shanghai (2002: ~266,000 participants) have some serious flaws. For instance, both studies did not have an adequate allocation concealment (keeping clinicians and participants unaware of the assignments). An inadequate concealment undermines the validity of a trial (see for instance this 2002 Lancet paper). Also, description of statistical methods was lacking. Furthermore, data from the Moscow-branch of the Russian study were incomplete (these are excluded), mammography might have been used additionally and in the Shanghai trial there was a large difference in all-cause mortality in favor of the control group, suggesting that the two groups were imbalanced from the start.

    9. Can the results of these rather old trials from countries as China and Russia be directly translated to the situation in Western Countries with a high standard of care?
    Intuitively I would say ‘probably not’. However, we still don’t know whether the current western quality of care would actually lead to a better outcome after early detection, because it has never be tested in a well performed controlled trial.

    10. Is this outcome applicable to anyone?
    No, the studies are applicable to healthy, middle-aged woman without any particular risk. Screening methods might be more useful or even required for woman at high risk (i.e. familiar predisposition, previous ovarian or breast cancer).

    11. Still, in recent interviews experts in the field say they do know that BSE is beneficial. One doctor for instance referred (in this Medscape paper) to a recent trial, that concluded that breast self-examination should be promoted for early detection of breast cancer (see here).
    Either these doctors/experts give their personal opinion, refer to unpublished data or to studies with a lower evidence level. For instance the study referred to by Dr. Goldstein above was a retrospective study looking at how accurately woman could detect a breast tumor. Retrospective studies are more biased (see previous post on levels of evidence for dummies). Furthermore this study didn’t evaluate a hard outcome (survival, better prognosis) and there are just as many retrospective studies that claim the opposite, i.e. this article of Newcomb et al in J Natl Cancer Inst. 1991(abstract).

    12. Should woman refrain from breast self examination then?
    I found a short article (half A4) in the Dutch woman’s magazine (!) Viva very clear and concise.
    Four woman gave their opinion.

    A patient who had had a previous breast tumor kept on checking it (high risk group).

    The director of a patient association said: “there is no evidence that BSE is beneficial: don’t feel quilty if you don’t check your breasts. But it might have a reassuring effect if you do”.
    The spokeswoman of the Dutch association “struggle against cancer” (KWF) said that they didn’t promote structural breast exam any longer, but they advised to “know your body” and know the alarm signals (retracting nipple etc), much the same way as you check for alterations in nevi. Most woman find small alterations anyway, said another, for instance when taking a shower.
    Indeed, exemplified by my own experience: 18 years ago my mother detected breast cancer when feeling a lump in her breast under the shower (malignant, but curable).

    The Cochrane authors are also very clear in their review about the necessity of women noticing changes to their breast.

    “Some women will continue with breast self-examination or will wish to be taught the technique. We suggest that the lack of supporting evidence from the two major studies should be discussed with these women to enable them to make an informed decision.
    It would be wrong, however, to conclude that women need not be aware of any breast changes. It is possible that increased breast awareness may have contributed to the decrease in mortality from breast cancer that has been noted in some countries. Women should, therefore, be encouraged to seek medical advice if they detect any change in their breasts that may be breast cancer.”

    Listen to this Podcast featuring the Cochrane authors to learn more about their findings

    [audio: http://cochrane.org/podcasts/review_summaries/mp3/issue3_2008_breast.mp3%5D

    ————————————

    Periodieke borstcontrole, uitgevoerd door vrouwen zelf of door artsen/verplegers, is jarenlang gepromoot, omdat je hierdoor eerder borstkanker zou ontdekken, waardoor het beter te genezen is. Deze gedachte wordt actief uitgedragen door verschillende organisaties en Internetbedrijven (die bijvoorbeeld speciale handschoenen verkopen, zie figuur).

    Dat regelmatige borstcontrole zinvol zou zijn, wordt echter tegengesproken door een recent Cochrane Systematisch Review, uitgevoerd door Kösters and Gøtzsche.[1] Dit review heeft heel wat losgemaakt bij dokters, makers van richtlijnen, patienten en vrouwen in het algemeen. Veel belangrijke organisaties bevelen niet langer het maandelijks controleren van de borsten aan. De reacties van (engelstalige) patienten varieert van ‘opgelucht’ tot ‘in verwarring gebracht’ of lichtelijk boos (‘ik maak verdorie zelf nog wel even uit wat ik doe’). Zie bijv. enige reacties hier: 1, 2, 3. De berichtgeving door sommige media is soms misleidend. Dat is vaker zo, maar vervelender is het dat reacties van sommige artsen of ‘experts’ heel gekleurd zijn, waardoor de boodschap niet goed overkomt bij het publiek. Sommigen grijpen de gelegenheid aan om even goed op EBM (Evidence Based Medicine) af te geven, zie bijv. deze post van Dr Rich (die overigens ook zinnige dingen opmerkt), dit bericht in de Herald and dit in Medcape (zie onder).

    Ik zal proberen om dit onderwerp in een vraag-en antwoord-vorm te bespreken.

    1. Wat zijn de conclusies uit de studie?
    Dat structureel borstonderzoek door vrouwen zelf of door artsen/verplegers meer kwaad dan goed doet, en dus niet langer aanbevolen kan worden.

    2. Welk kwaad, welk goed?
    Maandelijkse controle van de borsten leidt niet tot minder sterfte (niet ‘beter’), maar wel tot 2x zoveel biopsies (kwaad, ‘harm’).

    3. Waarom kijken ze alleen naar sterfte?
    Ze keken ook naar het aantal ontdekte kankers en hun stadia, maar sterfte (of eigenlijk overleving) is veel belangrijker voor de patient. Stel dàt je eerder borstkanker vindt door screening, maar dit leidt niet tot genezing en/of een betere kwaliteit van leven, dan schiet de patient daar niets mee op, integendeel (zij weet het langer).

    4. Waarom worden biopsies als ‘schadelijk’ gezien?
    Een biopsie is een medische ingreep, die -zeker in het geval van vermoede kanker-, een langdurig negatief kan effect hebben op iemand’s psychische gesteldheid. Biopsies en andere testen, die nodig
    zijn om kanker uit te sluiten kosten veel geld. Of dit het ‘waard’ is hangt af van hoe nuttig die testen werkelijk zijn, dus of ze de kans op overleving of een betere kwaliteit van leven verhogen.

    5. Wat voor een studie is het?
    Het is een systematisch review (van “gecontrolleerde” klinische studies), gemaakt door auteurs van de Cochrane Collaboration (zie Glossary). Over het algemeen zijn deze reviews van uitstekende methodologische kwaliteit, omdat studies volgens een vast stramien gezocht, geselecteerd, beoordeeld en samengevat worden. Van te voren worden alle criteria vastgelegd. Dus de auteurs proberen echt alle evidence (positief of negatief, zonder taalbeperking) boven water te krijgen in plaats van wat artikelen uit de kast te trekken of alleen maar de top-tijdschriften te selecteren.

    6. Is deze informatie nieuw?
    Nee, niet echt. Dit systematische review is in feite een update van een vorige versie uit 2003. De geincludeerde studies en de conclusies zijn hetzelfde. Zoals te zien in het schema hieronder (Nature Reviews Cancer 2003, samenvatting hier), is de houding ten opzichte van borstzelfcontrole al sinds de publicaties van de oorspronkelijke studies (die in het Cochrane Review opgenomen zijn) veranderd. De Amerikaanse Cancer Society beveelt bijvoorbeeld al sindsdien maandelijks zelfonderzoek niet meer aan.

    Nature Reviews Cancer 3, 297 (2003)

    M.N. Pollak et al: Nature Reviews Cancer 3, 297 (2003)

    7. Huh? ….
    Alle Cochrane Systematische Reviews behoren regelmatig ge-update te worden om te kijken of er geen nieuwe evidence is die tot een andere conclusie leidt. In dit geval werden er geen nieuwe studies van goede kwaliteit gevonden. Wel lopen er nog enkele studies.

    8. Kunnen we van deze conclusies op aan? Zijn Cochrane Reviews van een voldoende kwaliteit?
    Het Cochrane Review zelf is van een goede kwaliteit, maar op de 2 studies die opgenomen zijn in het review (een uit Rusland uit 1999 met ca. 122.500 deelnemers en een uit Shanghai uit 2002 met ca. 266.000 deelnemers) is wel het een en het ander aan te merken. In beide studies was de blindering van de patienten en de behandelaars voor de toewijzing van de behandeling (concealment of allocation) onvoldoende. Daarmee wordt zo’n studie minder valide (zie bijv. dit artikel uit de Lancet van 2002). Verder was de beschrijving van de statistische methoden onvolledig, waren gegevens van de Moskouse tak van de studie Russische studie niet compleet (zijn wel uitgesloten) , en was er in de Shanghai studie een groot verschil in algehele sterfte (dus niet alleen borstkanker), wat een duidelijke aanwijzing is dat de 2 groepen al vanaf het begin niet gelijkwaardig waren.

    9. Zijn de resultaten uit deze oudere studies uit landen als China en Rusland zondermeer op Westerse landen van toepassing?
    Intuitief zou ik zeggen van niet. De zorg in Westerse landen en de hedendaagse behandelingen zijn mogelijk beter. Alleen weten we niet of screening door zelfonderzoek hier wel tot een betere uitkomst zou leiden, omdat dat nooit in goede gecontroleerde studies is bestudeerd.

    10. Gelden de conclusies voor alle vrouwen?
    Nee, de studies zijn allen gedaan -en daarom alleen van toepassing op gezonde vrouwen van zo’n 35 tot 65 jaar. Screeningsmethoden, waaronder borstzelfonderzoek, zijn wel aan te bevelen voor vrouwen, die tot de risicogroep behoren (vrouwen die erfelijk belast zijn of die eerder al borst- of eierstokkanker hebben gehad).

    11. Toch stellen bepaalde deskundigen dat zelfonderzoek wel gunstig is. Een dokter (Dr. Goldstein) verwees daarbij in een interview in Medscape (zie hier) naar een heel recente studie (zie hier).
    Deze artsen/deskundigen geven hun persoonlijke mening, verwijzen naar niet-gepubliceerde studies of naar studies met een lagere bewijskracht. De studie waar Dr. Goldstein naar verwijst is bijvoorbeeld een retrospectieve studie, die alleen onderzoekt hoe goed vrouwen borstkanker kunnen vaststellen. Retrospectieve studies hebben altijd meer vertekening (zie een vorig bericht over het beste studietype… voor dummies). Verder keek deze studie niet naar harde uitkomsten (overleving, betere prognose). Daarnaast zijn er evengoed retrospectieve studies die het tegenovergestelde beweren, zie bijvoorbeeld dit artikel van Newcomb PA et al in J Natl Cancer Inst. 1991(abstract).

    http://breastselfexam.ca/section1slide2.html

    12. Moeten vrouwen dan helemaal geen borstcontrole meer doen?
    Ik kwam toevallig ergens op een terrasje een klein stukje in de Viva (1-7 aug 2008) tegen dat ik heel duidelijk vond.
    4 Vrouwen gaven hun mening.

    Een vrouw die eerder borstkanker had gehad bleef maandelijks controleren (risicogroep).
    De directeur van de Borstkankervereniging zei: “Wetenschappelijk is aangetoond dat borstcontrole niet zorgt voor minder sterfte door borstkanker. Voel je niet schuldig als je het niet doet. Doe je het wel om zo je borsten goed te leren kennen, dan heeft dat vooral een psychologisch effect”. De woordvoerdster van de KWF Kankerbestrijding zei dat ze periodieke zelfcontrole niet langer promoten, maar dat ze ook niet zeggen dat het zinloos is. Het is net als bij moedervlekken, die controleer je ook niet gestructureerd, maar als je een verandering ziet ga je wel naar de huisarts. Daarmee in overeenstemming zei de directeur van Pink Ribbon dat 90% van de vrouwen borstkanker zelf opmerkt: als er iets zit merk je het toch wel, bijvoorbeeld tijdens het douchen. Inderdaad kan ik dat uit eigen ervaring bevestigen. Mijn moeder voelde jaren geleden een knobbeltje terwijl ze zich aan het douchen was (kwaardaardig, maar genezen).

    De Cochrane auteurs zeggen in hun review ook heel expliciet dat het absoluut noodzakelijk is om naar de dokter te gaan als vrouwen veranderingen aan hun borst opmerken.

    “Some women will continue with breast self-examination or will wish to be taught the technique. We suggest that the lack of supporting evidence from the two major studies should be discussed with these women to enable them to make an informed decision.
    It would be wrong, however, to conclude that women need not be aware of any breast changes. It is possible that increased breast awareness may have contributed to the decrease in mortality from breast cancer that has been noted in some countries. Women should, therefore, be encouraged to seek medical advice if they detect any change in their breasts that may be breast cancer.”

    Hier is de Podcast waarin de Cochrane auteurs over hun studie vertellen.

    [audio: http://cochrane.org/podcasts/review_summaries/mp3/issue3_2008_breast.mp3%5D
    zie Engels gedeelte hierboven