Perfect is the enemy of good: Going to the war on cancer with less evidence than we could have

Abstract

Randomized controlled trials have been the mainstay of high-level evidence for or against cancer screening strategies. However, simple proof of reduction in cause-specific mortality is not enough for policymaking, particularly in the last 10 years. Today's clinical and public health guidelines take into account the balance of risks to benefits from screening, costs, utilities, the political risk of inaction, the societal tolerance to risk, healthcare providers' preferences, client choices, and other imponderables or subjective variables that cannot be captured or addressed via epidemiologic studies. This commentary uses the above perspective in discussing Miettinen's arguments concerning the science of breast cancer screening.