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 |