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Table 2 Overdiagnosis frames adopted by Australian breast screening experts

From: Framing overdiagnosis in breast screening: a qualitative study with Australian experts

Frame Defining the problem The reasons for the problem Value judgement Proposed or implied solution
1. Overdiagnosis is harming women Breast screening is resulting in significant harm to women because of overdiagnosis The harms associated with overdiagnosis are significant in both quantity and quality Breast screening programs should pay more attention to avoiding the serious harms of overdiagnosis Reduce overdiagnosis either by performing targeted screening or by reducing screening overall
2. Stop squabbling in public about overdiagnosis The public discussion of overdiagnosis is generating negative publicity which may reduce breast screening participation & is therefore a disservice to women Exaggeration of harms in public debates is causing confusion amongst women and threatening participation rates. Breast screening commentators should give priority to delivering health benefits (saving lives) Confine discussion about overdiagnosis to academic circles only, avoiding public confusion
3. Don’t hide the overdiagnosis problem from women The breast screening program is not facilitating informed choice amongst women There is a deliberate lack of communication about overdiagnosis from breast screening providers because of a desire to maximise breast screening participation Breast screening should give absolute priority to promoting autonomy via informed choice Fully inform women about overdiagnosis
4. We need to know the overdiagnosis rate It is not clear how much overdiagnosis is present in breast screening There is huge variation in overdiagnosis rates due to different methodologies and/or data sets; differences in the way overdiagnosis figures are presented hampers interpretation by non-epidemiologists Overdiagnosis research should be more rigorous, robust and consistent Commit to reaching a consensus on appropriate methodology & the way we report the figures
5. Balancing harms and benefits is a personal matter It is not clear how to compare the harms & benefits of breast screening It is impossible for experts to definitively compare harms & benefits because they are qualitatively different Breast screening decision making should be guided by a consumer-orientated process, which takes into account public attitudes to harms and benefits Use deliberative methods to inform policy decisions; support individual consumers to make personal decisions about participation
6. The problem is overtreatment Breast screening is resulting in overdiagnosis which leads to overtreatment of some women Management of some women with cancer is sometimes unnecessarily aggressive because we don’t know enough about the natural history of screen detected lesions While it is important that screening continues to save lives, we should seek ways to reduce harms from unnecessary (over) treatment Ongoing education for pathologists; renaming non-invasive lesions; research into prognostic biomarkers, targeted treatments & less aggressive management regimes; patient centred care