Effect of screening mammography on breast cancer mortality: Quasi-experimental evidence from rollout of the Dutch population-based program with 17-year follow-up of a cohort

Int J Cancer. 2020 Apr 15;146(8):2201-2208. doi: 10.1002/ijc.32584. Epub 2019 Aug 7.


There is uncertainty about the magnitude of the effect of screening mammography on breast cancer mortality. The relevance and validity of evidence from dated randomized controlled trials has been questioned, whereas observational studies often lack a valid comparison group. There is no estimate of the effect of one screening invitation only. We exploited the geographic rollout of the Dutch screening mammography program across municipalities to estimate the effects of one additional biennial screening invitation on breast cancer and all-cause mortality. Population administrative data provided vital status and cause of death of a cohort of women aged 49-63 in 1995 over 17 years. Linear probability models were used to estimate the mortality effects. We estimated 154 fewer breast cancer deaths (95% confidence interval: 40-267; p = 0.01) over 17 years in a population of 100,000 women aged 49-63 who received one additional biennial screening invitation, which corresponds to an 9.6% risk reduction for a woman of age 56. The estimated effect on all-cause mortality was negative but not close to statistical significance. Our study shows that one single invitation for breast cancer screening is effective in reducing breast cancer mortality, which is important for health policy. The effect is smaller than previous estimates of the effect of invitation for multiple screens, which further emphasizes the importance of achieving regular participation.

Keywords: breast cancer mortality; mammography screening; population administrative data; quasi-experimental exposure.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Breast Neoplasms / diagnostic imaging*
  • Breast Neoplasms / mortality*
  • Breast Neoplasms / prevention & control
  • Cohort Studies
  • Early Detection of Cancer / methods
  • Early Detection of Cancer / statistics & numerical data
  • Female
  • Follow-Up Studies
  • Humans
  • Mammography / methods
  • Mammography / statistics & numerical data
  • Middle Aged
  • Netherlands / epidemiology
  • Patient Acceptance of Health Care
  • Reproducibility of Results