A plea for more careful scholarship in reviewing evidence: the case of mammographic screening

OBJECTIVES: To identify issues of principle and practice giving rise to misunderstandings in reviewing evidence, to illustrate these by reference to the Nordic Cochrane Review (NCR) and its interpretation of two trials of mammographic screening, and to draw lessons for future reviewing of published results. METHODS: A narrative review of the publications of the Nordic Cochrane Review of mammographic screening (NCR), the Swedish Two-County Trial (S2C) and the Canadian National Breast Screening Study 1 and 2 (CNBSS-1 and CNBSS-2). RESULTS: The NCR concluded that the S2C was unreliable, despite the review’s complaints being shown to be mistaken, by direct reference to the original primary publications of the S2C. Repeated concerns were expressed by others about potential subversion of randomisation in CNBSS-1 and CNBSS-2; however, the NCR continued to rely heavily on the results of these trials. Since 2022, however, eyewitness evidence of such subversion has been in the public domain. CONCLUSIONS: An over-reliance on nominal satisfaction of checklists of criteria in systematic reviewing can lead to erroneous conclusions. This occurred in the case of the NCR, which concluded that mammographic screening was ineffective or minimally effective. Broader and more even-handed reviews of the evidence show that screening confers a substantial reduction in breast cancer mortality. ADVANCES IN KNOWLEDGE: Those carrying out systematic reviews should be aware of the dangers of over-reliance on checklists and guidelines. Readers of systematic reviews should be aware that a systematic review is just another study, with the capability that all studies have of coming to incorrect conclusions. When a review seems to overturn the current position, it is essential to revisit the publications of the primary research.