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January 11, 1995, Vol 273, No. 2 >
Special Communication | January 11, 1995

Benefits and Costs of Screening and Treatment for Early Breast Cancer: Title and subTitle BreakDevelopment of a Basic Benefit Package

Herman Kattlove, MD, MPH; Alessandro Liberati, MD; Emmett Keeler, PhD; Robert H. Brook, MD, ScD
[+] Author Affiliations

Reprint requests to RAND Corporation, 1700 Main St, PO Box 2138, Santa Monica, CA 90407-2138 (Dr Brook).


From RAND, Santa Monica, Calif (Drs Kattlove, Liberati, Keeler, and Brook); the Department of Medicine (Drs Kattlove and Brook) and the Center for Health Sciences (Dr Brook), University of California, Los Angeles; and the Laboratory of Clinical Epidemiology, Istituto di Ricerche Farmacologiche "Mario Negri," Milan, Italy (Dr Liberati). Dr Kattlove is now with SalickNet Inc, Los Angeles, Calif.


JAMA. 1995;273(2):142-148. doi:10.1001/jama.1995.03520260064034
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Article
References

Objective.  —To develop a basic benefit package for detection and treatment of early breast cancer by evaluating the effectiveness and costs for screening mammography, primary surgery, adjuvant therapy, and follow-up care.

Data Sources.  —Published articles were retrieved through MEDLINE; additional articles were obtained through searches of their bibliographies. Cancer statistics were taken from Surveillance, Epidemiology, and End Results (SEER) Program data, population statistics were taken from US Census data, and charges from 1993 Southern California Medicare fees were used to represent costs.

Study Selection.  —Studies were selected on the basis of their design. Preference, in decreasing order, was given to meta-analyses of randomized trials, individual randomized clinical trials, prospective cohort studies, retrospective cohort studies, and case series.

Data Extraction.  —Studies were examined for the effect of the intervention on overall survival, disease-free survival, and health-related quality of life. We evaluated effects on survival in terms of number of lives saved at 10 years and average years of life saved. Costs were related to the benefits observed and modeled onto a hypothetical health care organization of 500 000 lives.

Results.  —Based on this analysis, we recommend a basic benefit plan for the detection and treatment of early breast cancer that would include the following: (1) screening mammography only for women aged 50 to 69 years; (2) choice of mastectomy or breast-conserving surgery with radiation therapy for all women with early breast cancer; (3) adjuvant therapy for all women at risk of recurrence; and (4) only clinical follow-up without routine testing for metastatic disease.

Conclusions.  —By choosing which services they provide to specific groups of patients, providers can substantially reduce their expenses and still provide quality health benefits.(JAMA. 1995;273:142-148)

REFERENCES

1 +
Boring CC, Squires TS, Tong T.  Cancer statistics 1993. CA Cancer J Clin . 1993;;43:7-26.
2 +
Ziegler J.  New database allows researchers to evaluate cancer care costs. J Natl Cancer Inst . 1993;;85:351.
3 +
Woolf SH, Battista RN, Anderson GM, Logan AG, Wang E, and the Canadian Task Force on Periodic Health Examination.  Assessing the clinical effectiveness of preventive maneuvers—analytic principles and systematic methods in reviewing evidence and developing clinical practice recommendations: a report by the Canadian Task Force on Periodic Health Examination. J Clin Epidemiol . 1990;;43:891-905.
4 +
Beck JR, Kassirer JP, Pauker SG.  A convenient approximation of life expectancy (the DEALE), 1: validation of the method and use in medical decision making. Am J Med . 1982;;73:883-897.
5 +
Miller RG. Survival Analysis . New York, NY: John Wiley & Sons Inc; 1981;.
6 +
Laupacis A, Sackett DL, Roberts RS.  An assessment of clinically useful measures of the consequences of treatment. N Engl J Med . 1988;;318: 1728-1733.
7 +
Elwood JM, Cox B, Richardson AK.  The effectiveness of breast cancer screening by mammography in young women. Online J Curr Clin Trials . (February 25) , 1993; (document No. 32).
8 +
Nystrom L, Rutqvist LE, Wall S, et al.  Breast cancer screening with mammography: overview of Swedish randomized trials. Lancet . 1993;;341:973-978.
9 +
Shapiro S.  Determining the efficacy of breast cancer screening. Cancer . 1989;;63:1873-1880.
10 +
Tabar L, Fagerberg G, Duffy SW, et al.  Update of the Swedish two-county program of mammographic screening for breast cancer. Radiol Clin North Am . 1992;;30:187-210.
11 +
Andersson I, Aspegren K, Janzon L, et al.  Mammographic screening and mortality from breast cancer: the Malmo mammographic screening trial. BMJ . 1988;;297:943-948.
12 +
Frisell J, Eklund G, Hellstrom L, Lidbrink L, Rutqvist LE, Somell A.  Randomized study of mammography screening: preliminary report on mortality in the Stockholm trial. Breast Cancer Res Treat . 1991;;18:49-56.
13 +
Roberts MM, Alexander FE, Anderson TJ, et al.  Edinburgh trial of screening for breast cancer: mortality at seven years. Lancet . 1990;;335:241-246.
14 +
Miller AB, Baines CJ, To T, Wall C.  Canadian National Breast Screening Study, 1: breast cancer detection and death rates among women aged 40 to 49 years. Can Med Assoc J . 1992;;147:1459-1476.
15 +
Miller AB, Baines CJ, To T, Wall C.  Canadian National Breast Screening Study, 2: breast cancer detection and death rates among women aged 50 to 59 years. Can Med Assoc J . 1992;;147:1477-1488.
16 +
UK Trial of Early Detection of Breast Cancer Group.  First results on mortality reduction in the UK trial of early detection of breast cancer. Lancet . 1988;;2:411-416.
17 +
UK Trial of Early Detection of Breast Cancer Group.  Specificity of screening in United Kingdom trial of early detection of breast cancer. BMJ . 1992;; 304:346-349.
18 +
Cuzick J, Stewart H, Peto R, et al.  Overview of randomized trials comparing radical mastectomy without radiotherapy against simple mastectomy with radiotherapy in breast cancer. Cancer Treat Rep . 1987;;71:7-14.
19 +
Cuzick J, Stewart H, Peto R, et al.  Overview of randomized trials of postoperative adjuvant radiotherapy in breast cancer. Cancer Treat Rep . 1987;; 71:15-29.
20 +
Blichert-Toft M, Brincker H, Anderson JA, et al.  A Danish randomized trial comparing breast-preserving therapy with mastectomy in mammary carcinoma. Acta Oncol . 1988;;27:671-677.
21 +
Veronesi U, Banfi A, Salvadori B, et al.  Breast conservation is the treatment of choice in small breast cancer: long-term results of a randomized trial. Eur J Cancer . 1990;;26:668-670.
22 +
Fisher B, Redmond C, Poisson R, et al.  Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without radiation in the treatment of breast cancer. N Engl J Med . 1989;;320:822-828.
23 +
Sarrazin D, Le MG, Arriagada R, et al.  Ten-year results of a randomized trial comparing a conservative treatment to mastectomy in early breast cancer. Radiother Oncol . 1989;;14:177-184.
24 +
van Dongen JA, Bartelink H, Fentiman IS, et al.  Factors influencing local relapse and survival and results of salvage treatment after breast-conserving therapy in operable breast cancer: EORTC trial 10801, breast conservation compared with mastectomy in TNM stage I and II breast cancer. Eur J Cancer . 1992;;28A:801-805.
25 +
Lichter AS, Lippman ME, Danforth DN, et al.  Mastectomy versus breast-conserving therapy in the treatment of stage I and II carcinoma of the breast: a randomized trial at the National Cancer Institute. J Clin Oncol . 1992;;10:976-983.
26 +
Sauer R, Schauer A, Rauschecker HF, et al.  Breast preservation versus mastectomy in early breast cancer—1991 update of the GBSG 1: protocol and prognostic factors. Strahlenther Onkol . 1992;; 168:191-202.
27 +
Clark RM, McCulloch PB, Levine MN, et al.  Randomized clinical trial to assess the effectiveness of breast irradiation following lumpectomy and axillary dissection for node-negative breast cancer. J Natl Cancer Inst . 1992;;84:683-689.
28 +
Veronesi U, Luini A, Del Vecchio M, et al.  Radiotherapy after breast-preserving surgery in women with localized cancer of the breast. N Engl J Med . 1993;;328:1587-1591.
29 +
The Uppsala-Orebro Breast Cancer Study Group.  Sector resection with or without postoperative radiotherapy: a randomized trial. J Natl Cancer Inst . 1990;;82:277-282.
30 +
Robertson JFR, Ellis IO, Elston CW, Blamey RW.  Mastectomy or tamoxifen as initial therapy for operable breast cancer in elderly patients: 5-year follow-up. Eur J Cancer . 1992;;28A:908-910.
31 +
Bates T, Riley DL, Houghton J, Fallowfield L, Baum M.  Breast cancer in elderly women: a Cancer Research Campaign trial comparing treatment with tamoxifen and optimal surgery with tamoxifen alone. Br J Surg . 1991;;78:591-594.
32 +
Gazet JC, Markopoulos CH, Ford HT, Coombes RC, Bland JM, Dixon RC.  Prospective randomized trial of tamoxifen versus surgery in elderly patients with breast cancer. Lancet . 1988;;1:679-681.
33 +
 Reanalysis of NSABP protocol B06. CancerNet News . Bethesda, Md: National Cancer Institute; May 9, 1994;.
34 +
Fallowfield LJ, Baum M, Maguire GP.  Effect of breast conservation on psychological morbidity associated with diagnosis and therapy of early breast cancer. BMJ . 1986;;293:1331-1334.
35 +
Lasry JCM, Margolese RG, Poisson R, et al.  Depression and body image following mastectomy and lumpectomy. J Chronic Dis . 1987;;40:529-534.
36 +
Schain W, Edwards BK, Gorrell CR, et al.  Psychosocial and physical outcomes of primary breast cancer: mastectomy versus excisional biopsy and irradiation. Breast Cancer Res Treat . 1983;;3:377-382.
37 +
De Haes JCJM, Van Oosterom MA, Welvaart K.  The effect of radical and conserving surgery on the quality of life of early breast cancer patients. Eur J Surg Oncol . 1986;;12:337-342.
38 +
Kemeny M, Wellish DK, Schain WS.  Psychosocial outcome in a randomized surgical trial for treatment of primary breast cancer. Cancer . 1988;; 62:1231-1237.
39 +
Ashcroft JJ, Leinster SL, Slade PD.  Breast cancer-patient choice of treatment: preliminary communication. J R Soc Med . 1985;;78:43-48.
40 +
Fallowfield LJ, Hall A, Maguire GP, Baum M.  Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. BMJ . 1990;;301:575-580.
41 +
Levy SM, Herberman RB, Lee JK, et al.  Breast conservation versus mastectomy: distress sequelae as a function of choice. J Clin Oncol . 1989;;7:367-375.
42 +
Beckman J, Johansen L, Richardt C, et al.  Psychological reactions in younger women operated on for breast cancer. Dan Med Bull . 1983;;30( (suppl 2) ):10-13.
43 +
Ganz PA, Schag CC, Lee JJ, Polinsky ML, Tan SJ.  Breast conservation after mastectomy: is there a difference in psychological adjustment or quality of life in the year after surgery? Cancer . 1992;;69: 1729-1738.
44 +
Wohlberg WH, Romsaas EP, Tanne MA, et al.  Psychosexual adaptation to breast cancer surgery. Cancer . 1989;;63:1645-1655.
45 +
Holmberg L, Omne-Ponten M, Burns T, et al.  Psychosocial adjustment after mastectomy and breast conserving treatment. Cancer . 1989;;64:969-974.
46 +
Maunsell E, Brisson J, Deshenes L.  Psychological distress after initial treatment for breast cancer: a comparison of partial and total mastectomy. J Clin Epidemiol . 1989;;42:765-771.
47 +
McArdle JM, Hughson AV, McArdle CS.  Reduced psychological morbidity after breast conservation. Br J Surg . 1990;;77:1221-1223.
48 +
Wellisch DK, DiMatteo R, Silverstein M, et al.  Psychosocial outcomes of breast cancer therapies: lumpectomy versus mastectomy. Psychosomatics . 1989;;30:365-373.
49 +
Meyer L, Aspergen K.  Long-term psychological sequelae of mastectomy for breast cancer. Acta Oncologica . 1989;;28:13-18.
50 +
Taylor SE, Lichtman RR, Wood JV, et al.  Illness-related and treatment-related factors in psychosocial adjustment to breast cancer. Cancer . 1985;;55: 2506-2513.
51 +
Bartelink H, Van Dan F, Van Dongen J.  Psychological effects of breast conserving therapy in comparison with radical mastectomy. Int J Radiat Oncol Biol Phys . 1985;;11:381-385.
52 +
Baider L, Rizel S, Kaplan De-Nour A.  Comparison of couples' adjustment to lumpectomy and mastectomy. Gen Hosp Psychiatry . 1986;;8:251-257.
53 +
Sanger CK, Reznikoff M.  A comparison of the psychological effects of breast-saving procedures with the modified radical mastectomy. Cancer . 1981;; 48:2341-2346.
54 +
Steinberg MD, Juliano MA, Wise L.  Psychological outcome of lumpectomy versus mastectomy in the treatment of breast cancer. Am J Psychiatry . 1985;;142:34-39.
55 +
Early Breast Cancer Trialists Collaborative Group.  Systemic treatment of early breast cancer by hormonal, cytotoxic, or immune therapy: 133 randomized trials involving 31,000 recurrences, and 24,000 deaths among 75,000 women. Lancet . 1992;; 339:1-15, 71-85.
56 +
GIVIO Investigators.  Impact of follow-up testing on survival and health-related quality of life in breast cancer patients. JAMA . 1994;;271:1587-1592.
57 +
Del Turco MR, Palli D, Cariddi A, Ciatto S, Pacini P, Distante V.  Intensive diagnostic follow-up after treatment of primary breast cancer. JAMA . 1994;;271:1593-1597.
58 +
Hannisdal E, Gundersen S, Kvaloy S, et al.  Follow-up of breast cancer patients stage I-II: a baseline strategy. Eur J Cancer . 1993;;29A:992-997.
59 +
Logager VB, Vestergaard A, Herrstedt J, Thomsen HS, Zedeler K, Dombernowsky P.  The limited value of routine chest x-ray in patients with stage I breast cancer. Eur J Cancer . 1990;;26:553-555.
60 +
Rutgers EJ, van Slooten EA, Kluck MM.  Follow-up after treatment of primary breast cancer. Br J Surg . 1989;;76:187-190.
61 +
Vestergaard A, Herrstedt J, Thomsen HS, Dombernowsky P, Zedeler K.  The value of yearly chest x-ray in patients with stage I breast cancer. Eur J Cancer Clin Oncol . 1989;;25:687-689.
62 +
Ormiston MC, Timoney AG, Qureshi AR.  Is follow-up of patients after surgery for breast cancer worthwhile? J R Soc Med . 1985;;78:920-921.
63 +
Scanlon EF, Oviedo MA, Cunningham MP, et al.  Preoperative and follow-up procedures on patients with breast cancer. Cancer . 1980;;46:977-979.
64 +
Wickerham L, Fisher B, Cronin W, et al.  The efficacy of bone scanning in the follow-up of patients with operable breast cancer. Breast Cancer Res Treat . 1984;;4:303-307.
65 +
Pandya KJ, McFadden ET, Kaalish LA, Carbone P.  Frequency and patterns of early disease recurrence and method of detection in operable breast cancer with pathologically positive axillary lymph nodes on Eastern Cooperative Oncology Group adjuvant studies: a preliminary report. Cancer Treat Symp . 1983;;2:117-122.
66 +
Wagman LD, Sanders RD, Terz JJ, Beatty JD, Kokal WA, Riihimaki DU.  The value of symptom directed evaluation in the surveillance for recurrence of carcinoma of the breast. Surgery . 1991;; 172:191-196.
67 +
Kindler M, Steinhoff G.  Follow-up of breast cancer patients. Oncology . 1989;;46:360-365.
68 +
Holli K, Hakama M.  Effectiveness of routine and spontaneous followup visits for breast cancer. Eur J Cancer Clin Oncol . 1989;;25:251-254.
69 +
Tomin R, Donegan WL.  Screening for recurrent breast cancer: its effectiveness and prognostic value. J Clin Oncol . 1987;;5:62-67.
70 +
Arnstein NB, Harbert JC, Byrne PJ.  Efficacy of bone and liver scanning in breast cancer patients treated with adjuvant chemotherapy. Cancer . 1984;; 54:2243-2247.
71 +
Ciatto S, Herd-Smith Q.  The role of chest x-ray in the follow-up of primary breast cancer. Tumori . 1983;;69:151-154.
72 +
Stierer M, Rosen HR.  Influence of early diagnosis on prognosis of recurrent breast cancer. Cancer . 1989;;64:1128-1131.
73 +
Zwaveling A, Albers GHR, Felthuis W, Hermans J.  An evaluation of routine follow-up for detection of breast cancer recurrences. J Surg Oncol . 1987;;34:194-197.
74 +
Broyn T, Froyn J.  Evaluation of routine follow-up after surgery for breast carcinoma. Acta Chir Scand . 1982;;148:401-404.
75 +
Dewar JA, Kerr GR.  Value of routine follow up of women treated for early carcinoma of the breast. BMJ . 1985;;291:1464-1467.
76 +
Winchester DP, Sener SF, Khandekar JD, et al.  Symptomatology as an indicator of recurrent or metastatic breast cancer. Cancer . 1979;;43:956-960.
77 +
Black PB, Morris DL.  Management of patients after mastectomy. BMJ . 1981;;282:2095-2096.
78 +
Vallagussa P, Tesoro Tess JD, Rossi A, et al.  Adjuvant CMF effect on site of first recurrence and appropriate follow-up intervals in operable breast cancer with positive axillary nodes. Breast Cancer Res Treat . 1981;;1:349-356.
79 +
Ciatto S, Pacini P, Andreoli C, et al.  Chest x-ray survey in the follow-up of breast cancer patients. Br J Cancer . 1989;;60:702-703.
80 +
Ciatto S, Del Turco MR, Pacini P, et al.  Early detection of breast cancer recurrences through periodic follow-up: is it useless? Tumori . 1985;;71:325-329.
81 +
Andreoli C, Buranelli F, Campa T, et al.  Chest x-ray survey in breast cancer follow-up: a contrary view. Tumori . 1987;;73:463-465.
82 +
Miller BA, Feuer EJ, Hankey BF.  Recent incidence trends for breast cancer in women and the relevance of early detection: an update. CA Cancer J Clin . 1993;;43:27-41.
83 +
Dixon JM.  Treatment of elderly patients with breast cancer: tamoxifen alone is no longer justified. BMJ . 1992;;304:996-997.
84 +
Rubens RD.  Age and the treatment of breast cancer. J Clin Oncol . 1993;;11:3-4.
85 +
Miller BA, Feuer EJ, Hankey BF.  Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. CA Cancer J Clin . 1993;; 43:27-41.
86 +
Gasparini G, Pozza F, Harris AL.  Evaluating the potential usefulness of new prognostic and predictive indicators in node-negative breast cancer patients. J Natl Cancer Inst . 1993;;85:1206-1219.
87 +
Sickles EA, Kopans DB.  Deficiencies in the analysis of breast cancer screening data. J Natl Cancer Inst . 1993;;85:1621-1624.
88 +
Baines CD.  Canadian national breast screening study: perspective on criticisms. Ann Intern Med . 1994;;120:326-334.
89 +
Fletcher SW, Black W, Harris R, Rimer BK, Shapiro S.  Report on the International Workshop on screening for breast cancer. J Natl Cancer Inst . 1993;;85:1644-1656.
90 +
Peer PGM, Holland R, Hendriks JHCL, Mravunac M, Verbeek ALM.  Age-specific effectiveness of the Nijmegen population-based breast cancer-screening program: assessment of early indicators of screening effectiveness. J Natl Cancer Inst . 1994;; 86:436-441.
91 +
Smigel K.  NCI proposes new breast cancer screening guidelines. J Natl Cancer Inst . 1993;;85: 1626-1628.
92 +
Jenks S.  ACS keeps mammography guidelines for women under 50. J Natl Cancer Inst . 1993;;85: 348-349.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Boring CC, Squires TS, Tong T.  Cancer statistics 1993. CA Cancer J Clin . 1993;;43:7-26.
2 +
Ziegler J.  New database allows researchers to evaluate cancer care costs. J Natl Cancer Inst . 1993;;85:351.
3 +
Woolf SH, Battista RN, Anderson GM, Logan AG, Wang E, and the Canadian Task Force on Periodic Health Examination.  Assessing the clinical effectiveness of preventive maneuvers—analytic principles and systematic methods in reviewing evidence and developing clinical practice recommendations: a report by the Canadian Task Force on Periodic Health Examination. J Clin Epidemiol . 1990;;43:891-905.
4 +
Beck JR, Kassirer JP, Pauker SG.  A convenient approximation of life expectancy (the DEALE), 1: validation of the method and use in medical decision making. Am J Med . 1982;;73:883-897.
5 +
Miller RG. Survival Analysis . New York, NY: John Wiley & Sons Inc; 1981;.
6 +
Laupacis A, Sackett DL, Roberts RS.  An assessment of clinically useful measures of the consequences of treatment. N Engl J Med . 1988;;318: 1728-1733.
7 +
Elwood JM, Cox B, Richardson AK.  The effectiveness of breast cancer screening by mammography in young women. Online J Curr Clin Trials . (February 25) , 1993; (document No. 32).
8 +
Nystrom L, Rutqvist LE, Wall S, et al.  Breast cancer screening with mammography: overview of Swedish randomized trials. Lancet . 1993;;341:973-978.
9 +
Shapiro S.  Determining the efficacy of breast cancer screening. Cancer . 1989;;63:1873-1880.
10 +
Tabar L, Fagerberg G, Duffy SW, et al.  Update of the Swedish two-county program of mammographic screening for breast cancer. Radiol Clin North Am . 1992;;30:187-210.
11 +
Andersson I, Aspegren K, Janzon L, et al.  Mammographic screening and mortality from breast cancer: the Malmo mammographic screening trial. BMJ . 1988;;297:943-948.
12 +
Frisell J, Eklund G, Hellstrom L, Lidbrink L, Rutqvist LE, Somell A.  Randomized study of mammography screening: preliminary report on mortality in the Stockholm trial. Breast Cancer Res Treat . 1991;;18:49-56.
13 +
Roberts MM, Alexander FE, Anderson TJ, et al.  Edinburgh trial of screening for breast cancer: mortality at seven years. Lancet . 1990;;335:241-246.
14 +
Miller AB, Baines CJ, To T, Wall C.  Canadian National Breast Screening Study, 1: breast cancer detection and death rates among women aged 40 to 49 years. Can Med Assoc J . 1992;;147:1459-1476.
15 +
Miller AB, Baines CJ, To T, Wall C.  Canadian National Breast Screening Study, 2: breast cancer detection and death rates among women aged 50 to 59 years. Can Med Assoc J . 1992;;147:1477-1488.
16 +
UK Trial of Early Detection of Breast Cancer Group.  First results on mortality reduction in the UK trial of early detection of breast cancer. Lancet . 1988;;2:411-416.
17 +
UK Trial of Early Detection of Breast Cancer Group.  Specificity of screening in United Kingdom trial of early detection of breast cancer. BMJ . 1992;; 304:346-349.
18 +
Cuzick J, Stewart H, Peto R, et al.  Overview of randomized trials comparing radical mastectomy without radiotherapy against simple mastectomy with radiotherapy in breast cancer. Cancer Treat Rep . 1987;;71:7-14.
19 +
Cuzick J, Stewart H, Peto R, et al.  Overview of randomized trials of postoperative adjuvant radiotherapy in breast cancer. Cancer Treat Rep . 1987;; 71:15-29.
20 +
Blichert-Toft M, Brincker H, Anderson JA, et al.  A Danish randomized trial comparing breast-preserving therapy with mastectomy in mammary carcinoma. Acta Oncol . 1988;;27:671-677.
21 +
Veronesi U, Banfi A, Salvadori B, et al.  Breast conservation is the treatment of choice in small breast cancer: long-term results of a randomized trial. Eur J Cancer . 1990;;26:668-670.
22 +
Fisher B, Redmond C, Poisson R, et al.  Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without radiation in the treatment of breast cancer. N Engl J Med . 1989;;320:822-828.
23 +
Sarrazin D, Le MG, Arriagada R, et al.  Ten-year results of a randomized trial comparing a conservative treatment to mastectomy in early breast cancer. Radiother Oncol . 1989;;14:177-184.
24 +
van Dongen JA, Bartelink H, Fentiman IS, et al.  Factors influencing local relapse and survival and results of salvage treatment after breast-conserving therapy in operable breast cancer: EORTC trial 10801, breast conservation compared with mastectomy in TNM stage I and II breast cancer. Eur J Cancer . 1992;;28A:801-805.
25 +
Lichter AS, Lippman ME, Danforth DN, et al.  Mastectomy versus breast-conserving therapy in the treatment of stage I and II carcinoma of the breast: a randomized trial at the National Cancer Institute. J Clin Oncol . 1992;;10:976-983.
26 +
Sauer R, Schauer A, Rauschecker HF, et al.  Breast preservation versus mastectomy in early breast cancer—1991 update of the GBSG 1: protocol and prognostic factors. Strahlenther Onkol . 1992;; 168:191-202.
27 +
Clark RM, McCulloch PB, Levine MN, et al.  Randomized clinical trial to assess the effectiveness of breast irradiation following lumpectomy and axillary dissection for node-negative breast cancer. J Natl Cancer Inst . 1992;;84:683-689.
28 +
Veronesi U, Luini A, Del Vecchio M, et al.  Radiotherapy after breast-preserving surgery in women with localized cancer of the breast. N Engl J Med . 1993;;328:1587-1591.
29 +
The Uppsala-Orebro Breast Cancer Study Group.  Sector resection with or without postoperative radiotherapy: a randomized trial. J Natl Cancer Inst . 1990;;82:277-282.
30 +
Robertson JFR, Ellis IO, Elston CW, Blamey RW.  Mastectomy or tamoxifen as initial therapy for operable breast cancer in elderly patients: 5-year follow-up. Eur J Cancer . 1992;;28A:908-910.
31 +
Bates T, Riley DL, Houghton J, Fallowfield L, Baum M.  Breast cancer in elderly women: a Cancer Research Campaign trial comparing treatment with tamoxifen and optimal surgery with tamoxifen alone. Br J Surg . 1991;;78:591-594.
32 +
Gazet JC, Markopoulos CH, Ford HT, Coombes RC, Bland JM, Dixon RC.  Prospective randomized trial of tamoxifen versus surgery in elderly patients with breast cancer. Lancet . 1988;;1:679-681.
33 +
 Reanalysis of NSABP protocol B06. CancerNet News . Bethesda, Md: National Cancer Institute; May 9, 1994;.
34 +
Fallowfield LJ, Baum M, Maguire GP.  Effect of breast conservation on psychological morbidity associated with diagnosis and therapy of early breast cancer. BMJ . 1986;;293:1331-1334.
35 +
Lasry JCM, Margolese RG, Poisson R, et al.  Depression and body image following mastectomy and lumpectomy. J Chronic Dis . 1987;;40:529-534.
36 +
Schain W, Edwards BK, Gorrell CR, et al.  Psychosocial and physical outcomes of primary breast cancer: mastectomy versus excisional biopsy and irradiation. Breast Cancer Res Treat . 1983;;3:377-382.
37 +
De Haes JCJM, Van Oosterom MA, Welvaart K.  The effect of radical and conserving surgery on the quality of life of early breast cancer patients. Eur J Surg Oncol . 1986;;12:337-342.
38 +
Kemeny M, Wellish DK, Schain WS.  Psychosocial outcome in a randomized surgical trial for treatment of primary breast cancer. Cancer . 1988;; 62:1231-1237.
39 +
Ashcroft JJ, Leinster SL, Slade PD.  Breast cancer-patient choice of treatment: preliminary communication. J R Soc Med . 1985;;78:43-48.
40 +
Fallowfield LJ, Hall A, Maguire GP, Baum M.  Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. BMJ . 1990;;301:575-580.
41 +
Levy SM, Herberman RB, Lee JK, et al.  Breast conservation versus mastectomy: distress sequelae as a function of choice. J Clin Oncol . 1989;;7:367-375.
42 +
Beckman J, Johansen L, Richardt C, et al.  Psychological reactions in younger women operated on for breast cancer. Dan Med Bull . 1983;;30( (suppl 2) ):10-13.
43 +
Ganz PA, Schag CC, Lee JJ, Polinsky ML, Tan SJ.  Breast conservation after mastectomy: is there a difference in psychological adjustment or quality of life in the year after surgery? Cancer . 1992;;69: 1729-1738.
44 +
Wohlberg WH, Romsaas EP, Tanne MA, et al.  Psychosexual adaptation to breast cancer surgery. Cancer . 1989;;63:1645-1655.
45 +
Holmberg L, Omne-Ponten M, Burns T, et al.  Psychosocial adjustment after mastectomy and breast conserving treatment. Cancer . 1989;;64:969-974.
46 +
Maunsell E, Brisson J, Deshenes L.  Psychological distress after initial treatment for breast cancer: a comparison of partial and total mastectomy. J Clin Epidemiol . 1989;;42:765-771.
47 +
McArdle JM, Hughson AV, McArdle CS.  Reduced psychological morbidity after breast conservation. Br J Surg . 1990;;77:1221-1223.
48 +
Wellisch DK, DiMatteo R, Silverstein M, et al.  Psychosocial outcomes of breast cancer therapies: lumpectomy versus mastectomy. Psychosomatics . 1989;;30:365-373.
49 +
Meyer L, Aspergen K.  Long-term psychological sequelae of mastectomy for breast cancer. Acta Oncologica . 1989;;28:13-18.
50 +
Taylor SE, Lichtman RR, Wood JV, et al.  Illness-related and treatment-related factors in psychosocial adjustment to breast cancer. Cancer . 1985;;55: 2506-2513.
51 +
Bartelink H, Van Dan F, Van Dongen J.  Psychological effects of breast conserving therapy in comparison with radical mastectomy. Int J Radiat Oncol Biol Phys . 1985;;11:381-385.
52 +
Baider L, Rizel S, Kaplan De-Nour A.  Comparison of couples' adjustment to lumpectomy and mastectomy. Gen Hosp Psychiatry . 1986;;8:251-257.
53 +
Sanger CK, Reznikoff M.  A comparison of the psychological effects of breast-saving procedures with the modified radical mastectomy. Cancer . 1981;; 48:2341-2346.
54 +
Steinberg MD, Juliano MA, Wise L.  Psychological outcome of lumpectomy versus mastectomy in the treatment of breast cancer. Am J Psychiatry . 1985;;142:34-39.
55 +
Early Breast Cancer Trialists Collaborative Group.  Systemic treatment of early breast cancer by hormonal, cytotoxic, or immune therapy: 133 randomized trials involving 31,000 recurrences, and 24,000 deaths among 75,000 women. Lancet . 1992;; 339:1-15, 71-85.
56 +
GIVIO Investigators.  Impact of follow-up testing on survival and health-related quality of life in breast cancer patients. JAMA . 1994;;271:1587-1592.
57 +
Del Turco MR, Palli D, Cariddi A, Ciatto S, Pacini P, Distante V.  Intensive diagnostic follow-up after treatment of primary breast cancer. JAMA . 1994;;271:1593-1597.
58 +
Hannisdal E, Gundersen S, Kvaloy S, et al.  Follow-up of breast cancer patients stage I-II: a baseline strategy. Eur J Cancer . 1993;;29A:992-997.
59 +
Logager VB, Vestergaard A, Herrstedt J, Thomsen HS, Zedeler K, Dombernowsky P.  The limited value of routine chest x-ray in patients with stage I breast cancer. Eur J Cancer . 1990;;26:553-555.
60 +
Rutgers EJ, van Slooten EA, Kluck MM.  Follow-up after treatment of primary breast cancer. Br J Surg . 1989;;76:187-190.
61 +
Vestergaard A, Herrstedt J, Thomsen HS, Dombernowsky P, Zedeler K.  The value of yearly chest x-ray in patients with stage I breast cancer. Eur J Cancer Clin Oncol . 1989;;25:687-689.
62 +
Ormiston MC, Timoney AG, Qureshi AR.  Is follow-up of patients after surgery for breast cancer worthwhile? J R Soc Med . 1985;;78:920-921.
63 +
Scanlon EF, Oviedo MA, Cunningham MP, et al.  Preoperative and follow-up procedures on patients with breast cancer. Cancer . 1980;;46:977-979.
64 +
Wickerham L, Fisher B, Cronin W, et al.  The efficacy of bone scanning in the follow-up of patients with operable breast cancer. Breast Cancer Res Treat . 1984;;4:303-307.
65 +
Pandya KJ, McFadden ET, Kaalish LA, Carbone P.  Frequency and patterns of early disease recurrence and method of detection in operable breast cancer with pathologically positive axillary lymph nodes on Eastern Cooperative Oncology Group adjuvant studies: a preliminary report. Cancer Treat Symp . 1983;;2:117-122.
66 +
Wagman LD, Sanders RD, Terz JJ, Beatty JD, Kokal WA, Riihimaki DU.  The value of symptom directed evaluation in the surveillance for recurrence of carcinoma of the breast. Surgery . 1991;; 172:191-196.
67 +
Kindler M, Steinhoff G.  Follow-up of breast cancer patients. Oncology . 1989;;46:360-365.
68 +
Holli K, Hakama M.  Effectiveness of routine and spontaneous followup visits for breast cancer. Eur J Cancer Clin Oncol . 1989;;25:251-254.
69 +
Tomin R, Donegan WL.  Screening for recurrent breast cancer: its effectiveness and prognostic value. J Clin Oncol . 1987;;5:62-67.
70 +
Arnstein NB, Harbert JC, Byrne PJ.  Efficacy of bone and liver scanning in breast cancer patients treated with adjuvant chemotherapy. Cancer . 1984;; 54:2243-2247.
71 +
Ciatto S, Herd-Smith Q.  The role of chest x-ray in the follow-up of primary breast cancer. Tumori . 1983;;69:151-154.
72 +
Stierer M, Rosen HR.  Influence of early diagnosis on prognosis of recurrent breast cancer. Cancer . 1989;;64:1128-1131.
73 +
Zwaveling A, Albers GHR, Felthuis W, Hermans J.  An evaluation of routine follow-up for detection of breast cancer recurrences. J Surg Oncol . 1987;;34:194-197.
74 +
Broyn T, Froyn J.  Evaluation of routine follow-up after surgery for breast carcinoma. Acta Chir Scand . 1982;;148:401-404.
75 +
Dewar JA, Kerr GR.  Value of routine follow up of women treated for early carcinoma of the breast. BMJ . 1985;;291:1464-1467.
76 +
Winchester DP, Sener SF, Khandekar JD, et al.  Symptomatology as an indicator of recurrent or metastatic breast cancer. Cancer . 1979;;43:956-960.
77 +
Black PB, Morris DL.  Management of patients after mastectomy. BMJ . 1981;;282:2095-2096.
78 +
Vallagussa P, Tesoro Tess JD, Rossi A, et al.  Adjuvant CMF effect on site of first recurrence and appropriate follow-up intervals in operable breast cancer with positive axillary nodes. Breast Cancer Res Treat . 1981;;1:349-356.
79 +
Ciatto S, Pacini P, Andreoli C, et al.  Chest x-ray survey in the follow-up of breast cancer patients. Br J Cancer . 1989;;60:702-703.
80 +
Ciatto S, Del Turco MR, Pacini P, et al.  Early detection of breast cancer recurrences through periodic follow-up: is it useless? Tumori . 1985;;71:325-329.
81 +
Andreoli C, Buranelli F, Campa T, et al.  Chest x-ray survey in breast cancer follow-up: a contrary view. Tumori . 1987;;73:463-465.
82 +
Miller BA, Feuer EJ, Hankey BF.  Recent incidence trends for breast cancer in women and the relevance of early detection: an update. CA Cancer J Clin . 1993;;43:27-41.
83 +
Dixon JM.  Treatment of elderly patients with breast cancer: tamoxifen alone is no longer justified. BMJ . 1992;;304:996-997.
84 +
Rubens RD.  Age and the treatment of breast cancer. J Clin Oncol . 1993;;11:3-4.
85 +
Miller BA, Feuer EJ, Hankey BF.  Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. CA Cancer J Clin . 1993;; 43:27-41.
86 +
Gasparini G, Pozza F, Harris AL.  Evaluating the potential usefulness of new prognostic and predictive indicators in node-negative breast cancer patients. J Natl Cancer Inst . 1993;;85:1206-1219.
87 +
Sickles EA, Kopans DB.  Deficiencies in the analysis of breast cancer screening data. J Natl Cancer Inst . 1993;;85:1621-1624.
88 +
Baines CD.  Canadian national breast screening study: perspective on criticisms. Ann Intern Med . 1994;;120:326-334.
89 +
Fletcher SW, Black W, Harris R, Rimer BK, Shapiro S.  Report on the International Workshop on screening for breast cancer. J Natl Cancer Inst . 1993;;85:1644-1656.
90 +
Peer PGM, Holland R, Hendriks JHCL, Mravunac M, Verbeek ALM.  Age-specific effectiveness of the Nijmegen population-based breast cancer-screening program: assessment of early indicators of screening effectiveness. J Natl Cancer Inst . 1994;; 86:436-441.
91 +
Smigel K.  NCI proposes new breast cancer screening guidelines. J Natl Cancer Inst . 1993;;85: 1626-1628.
92 +
Jenks S.  ACS keeps mammography guidelines for women under 50. J Natl Cancer Inst . 1993;;85: 348-349.

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To understand the clinical management of acute heart failure syndromes.
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