Presentation of Benefits and Harms in Cancer Screening Guidelines for Koreans: A Systematic Review

Mi Ah Han; Hunju Lee; Kwangmin Kim; Seong Jung Kim; Eu Chang Hwang; Jae Hung Jung

doi:10.4143/crt.2024.1151

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Original Article General Presentation of Benefits and Harms in Cancer Screening Guidelines for Koreans: A Systematic Review: Mi Ah Han¹, Hunju Lee², Kwangmin Kim^3,4, Seong Jung Kim⁵, Eu Chang Hwang^4,6, Jae Hung Jung^4,7; Cancer Research and Treatment : Official Journal of Korean Cancer Association 2025;57(4):923-931.
DOI: https://doi.org/10.4143/crt.2024.1151
Published online: March 27, 2025

¹Department of Preventive Medicine, Chosun University College of Medicine, Gwangju, Korea

²Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea

³Health Check-up Center, Yonsei University Wonju College of Medicine, Wonju, Korea

⁴Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea

⁵Department of Internal Medicine, Chosun University College of Medicine, Gwangju, Korea

⁶Department of Urology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea

⁷Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea

Correspondence: Mi Ah Han, Department of Preventive Medicine, Chosun University College of Medicine, 309 Pilmun-daero, Dong-gu, Gwangju 61452, Korea
Tel: 82-62-230-6481 E-mail: mahan@chosun.ac.kr

• Received: November 29, 2024 • Accepted: March 25, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract

Purpose
This study systematically reviewed cancer screening guidelines for the Korean population to evaluate the benefits and harms of the recommended cancer screening practices.
Materials and Methods
We searched international electronic databases from inception to July 2023. Two reviewers independently conducted reference screening and data extraction. Data were extracted based on recommendations from each guideline and presentation of benefits and harms. General characteristics of the cancer screening guidelines, including cancer type, recommended screening methods, certainty of evidence, were collected. Moreover, we obtained key information on the benefits and harms of screening interventions, including the quantification of their relative and absolute effects.
Results
Fifteen recommendations were identified for the use of interventions for the early detection of stomach, liver, colorectal, breast, cervical, and lung cancers in nine guidelines published between 2011 and 2015. Seven guidelines collected evidence through de novo systematic reviews. Eight guidelines presented the certainty of evidence and strength of recommendations. Benefits are presented as relative risks, and harms are presented as absolute risks. Six recommendations presented the absolute effects of both benefits and harms (comparable); eight presented them unevenly, including quantifying benefits relatively but presenting harms as absolute measures (asymmetric); and one presented neither benefits nor harms (incomplete).
Conclusion
More than half of guidelines fail to present the benefits and harms of screening in a balanced manner. To enable users and beneficiaries make informed decisions based on evidence, the benefits and harms supporting recommendations should be given in a transparent and balanced manner.
Key words: Early detection of cancer, Guideline, Mass screening, Systematic review

Introduction

The Korean National Cancer Screening Program (NCSP) has continuously expanded the scope of beneficiaries and cancer types since 1999 [1]. NCSP conducts screenings for six major cancers (stomach, liver, colon, breast, cervical, and lung) for the general public and high-risk groups. Various cancer screening methods have been implemented through private screening in Korea. The cancer screening rates based on these recommendations were 77.5%, 48.8%, 70.7%, 72.7%, and 70.2% for stomach, liver, colon, breast, and cervical in 2023, respectively [2].

Cancer screening guidelines provide evidence-based recommendations for the early detection of cancer in potential recipients to help healthcare providers provide appropriate evidence-based care and optimize health outcomes. The process of developing evidence-based guidelines includes question generation, evidence assessment and summary, and recommendation development, all of which should consider both benefits and harms [3,4]. The US Preventive Services Task Force, which provides evidence-based recommendations for clinical preventive services, highlights the importance of assessing absolute effects when estimating health effect sizes [5]. Clinicians should explain the benefits and harms of screening to recipients and use these guidelines in decision-making. When clinicians discuss these with recipients, their awareness of the magnitude of benefits and harms helps them understand the intent of the guideline developers and thus make decisions [6]. Therefore, guidelines should include a statement of the direction and strength of the recommendations along with their rationale.

The grading of recommendations, assessment, development, and evaluation (GRADE) method explicitly addresses factors that determine the direction and strength of a recommendation, including the certainty of the evidence, the balance of desirable (benefits) and undesirable (harms) consequences, resources, and values and preferences of stakeholders [7,8]. Even if benefits, such as a reduction in mortality, is evident from screening, a conditional recommendation for screening is likely if the harms of screening itself and the unnecessary treatment due to overdiagnosis are sufficiently large, requiring informed decision-making. Because the absolute effect of an intervention, unlike the relative effect, which is known to be consistent across different populations, may vary across populations with different baseline risks, GRADE suggests that estimates of absolute effects should be evaluated for decision-making in specific populations [9]. Therefore, if cancer guidelines do not present the potential benefits and harms of screening in a balanced or applicable way, they may lead to inappropriate screening recommendations and unnecessary treatments due to under- or overuse.

There has been no systematic summary of the benefits and harms presented in the cancer screening guidelines in Korea. Therefore, this study aimed to investigate whether cancer screening guidelines for Koreans explain both the benefits and harms and evaluated whether they were quantified and presented in a balanced manner.

Materials and Methods

This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement [10], and a detailed study plan can be found elsewhere [11].

1. Guideline search

A systematic search of international electronic literature databases, including MEDLINE and Embase, and Korean literature databases, including the Korean Studies Information Service System, Research Information Sharing Service, KoreaMed, Korean Medical Database, National Assembly Library, and Korea Institute of Science and Technology Information, was conducted to identify eligible cancer screening guidelines for Koreans. We also searched guideline databases, including the Guideline International Network [12], National Institute for Health and Care Excellence [13], Turning Research into Practice medical database [14], World Health Organization guidelines [15], and the Korean Medical Guideline Information Center [16]. We manually searched the websites of the National Cancer Information Center [17], academic societies, and search engines (e.g., Google). Guidelines published in Korean or English were included, and no data publication restrictions were applied. The search strategy is presented in S1 Table.

2. Guideline selection process

Guidelines addressing the early detection of cancer among Koreans with or without specific health conditions (e.g., chronic liver disease due to hepatitis B virus, more than 30 pack-years of smoking history) were included. No limits were placed on the cancer screening methods or target cancers. Conference abstracts, editorials, letters, and opinions were excluded from the analysis.

Pairs of reviewers conducted title and abstract screenings independently and in duplicate. Next, the full texts were reviewed by teams of reviewers for potentially eligible references, and the reasons for exclusion were recorded. Discrepancies were resolved by consensus or consultation with a third reviewer. Calibration exercises were performed before each stage to ensure consistency and replicability.

3. Data abstraction

After the calibration exercises, the two reviewers collected the following information independently and in duplicate for all included references using a pre-piloted data extraction form. When a guideline was reported in more than one publication (e.g., journal or report), the publication with the most detailed information was used as a reference. Disagreements were resolved through discussions.

1) General characteristics of the guidelines: guideline name, recommendation statements, target cancer type (e.g., gastric, liver, and lung), target population for screening (e.g., age group and health conditions), number of recommendations, primary screening method, and screening interval.

2) Guideline development process: source of evidence (de novo systematic review, unsystematic review, prior guideline), presentation of certainty of evidence (yes or no), certainty of evidence assessment method (not described, yes with GRADE, and yes with others), certainty of evidence assessment domain (e.g., risk of bias, inconsistency, and indirectness), presentation of the strength of recommendation (yes or no), the strength of recommendation assessment method (not described, yes with GRADE, and yes with others), the strength of recommendation assessment domain (e.g., balance of desirable and undesirable consequences, certainty of evidence, and resource), presentation of GRADE evidence table (no, yes), guideline panel members (institution of panel members, number of panels, and organization of panel members), methodologist/expert on guideline development process (not described, no, yes).

3) Presentation of the benefits and harms of recommended cancer screening interventions.

Presentation of benefits (yes or no), type of benefits (mortality, incidence), quantification of benefits (yes or no), effect measure of benefits (relative and absolute effects, or both), and location of benefit formation (main text, main table, appendix, and others).

Presentation of harm (yes or no), type of harm (false-positive results, overdiagnosis, and screening method complications), quantification of harm (yes or no), effect measure of harm (relative, absolute effects, or both), and location of harm information (main text, main table, appendix, etc.).

4. Analysis

We present the descriptive statistics of the included guidelines as well as their general characteristics and relevant key information. Guideline characteristics were summarized using descriptive statistics, such as frequencies, percentages, means, and standard deviations. A summary of the findings in the tables, including a presentation of the benefits and disadvantages of the cancer screening guidelines, is provided.

Based on a prior study on the presentation of benefits and harms of interventions, their comparability for each recommendation was classified into three groups (comparable, asymmetric, and incomplete) [18]. “Comparable” was defined as a recommendation that presented absolute effects for both benefits and harms. “Asymmetric” includes recommendations where information is presented unevenly, recommendations are presented without mentioning what the potential benefits are, benefits are mentioned, but potential harms are not, benefits are quantified, but harms are mentioned, but not quantified, or benefits are quantified in relative terms, but harms are quantified in absolute terms. Finally, “incomplete” was defined as a recommendation in which both benefits and harms were mentioned but neither was quantified, or both benefits and harms were assessed using only relative effects, or neither benefits nor harms were mentioned.

In Korea, clinical practice guidelines have been steadily expanding in quantity, and development has been active since 2010 [19]. We found five cancer screening guidelines developed in 2002. However, since this was before the spread of evidence-based guideline development in Korea, we present the results for these guidelines in the Supplementary Materials. For guidelines published after that, we compared the most recent guidelines, 2015, with those before.

Results

1. Guideline characteristics included

A database search identified 1,553 references and 14 guidelines [20-33] published in journals that met the inclusion criteria were included (S2 Fig.): five in 2002, two in 2012, one in 2013, and six in 2015 (S3 Table). Guidelines published since 2012 provided 15 recommendations for early detection interventions for stomach, liver, colorectal, breast, cervical, and lung cancers. Table 1 shows the target populations, screening methods, and screening intervals for each recommendation.

Seven guidelines (77.8%) were informed by new systematic reviews, and eight (88.9%) by existing guidelines. Eight guidelines (88.9%) reported the certainty of evidence, most of which used the GRADE approach. Similarly, eight (88.9%) guidelines reported the strength of the recommendation, two of which used the GRADE approach. The balance of desirable and undesirable effects and the certainty of evidence were presented as the main domains for determining the strength of the recommendations. Six guidelines presented the certainty of evidence using evidence profiles, or a summary of findings tables and seven guidelines included a methodologist in the guideline development process. Compared with guidelines published in 2011-2012, guidelines published in 2015 used GRADE more frequently, presenting certainty of evidence and strength of recommendations (Table 2).

2. Presentation of benefits and harms of recommended cancer screening interventions

The benefits of cancer screening were mentioned by 12 recommendations (80.0%), and quantification was performed for 12 recommendations. However, both the relative and absolute effects were presented in only seven recommendations; in most cases, the benefits were described in the main text. The harms of cancer screening were mentioned in 13 recommendations (86.7%), and quantification was performed in 11 recommendations. Harms were presented only as absolute effects, and in most cases, harm was described in the main text. Six guidelines presented the certainty of evidence using the GRADE evidence tables. Among them, only one recommendation presented both benefits and harms in a single table [23]. Six recommendations presented the absolute effects of both benefits and harms (comparable), 8 presented unbalanced benefits in relative terms but harms in absolute measures, presenting recommendations without mentioning the potential benefits (asymmetric), and one presented neither benefits nor harms (incomplete). Compared with guidelines published in 2011-2012, published guidelines in 2015 were more likely to quantify effects, report absolute measures, and present benefits and harms in a comparable manner (Table 3). S4 Table presents the comparability and sample texts for each recommendation.

Discussion

1. Main findings

This study is the first to systematically review the cancer screening guidelines recommended for Koreans and whether and how the potential benefits and harms of cancer screening are presented. Of the positive recommendations in the included guidelines, more than 80% quantified the benefits and harms and only 40% presented them in a comparable manner. Six recommendations were comparable, eight were asymmetric, and one was incomplete in terms of presenting benefits and harms.

2. Strengths and limitations

The strengths of this study include adherence to internationally recognized methodological standards, including a comprehensive search to identify cancer screening guidelines for Koreans, duplicate screening and data extraction, and calibration exercises at each stage to ensure reproducibility and transparency.

This study has some limitations. This study focused on how guidelines present estimates of benefits and harms, and did not assess whether every benefit and harm were presented, as this was beyond its scope. Optimal evidence-based decision-making requires determining the important benefits and harms of an intervention, and the estimates of each should be presented faithfully.

The overall methodological quality of the guidelines, such as the scope of development, purpose, certainty of evidence, or strength of the recommendations, was not evaluated. However, most guidelines published after 2010 presented systematic reviews as a source of evidence, and the GRADE method was presented as an approach to determine the level of evidence and strength of recommendation. Although quantitative and qualitative improvements in the guidelines developed in Korea have been reported, there are still many areas that need improvement [19]. Therefore, compliance with methodological standards needs to be evaluated by future studies.

3. Relation to previous works

Of the recommendations included in this study, 80.0% and 86.7% mentioned benefits and harms, respectively, and 80.0% and 73.3% quantified benefits and harms, respectively; however, only 40.0% comparably presented them. These findings are similar to those of prior studies that examined how the information on the benefits and harms of health interventions was presented. A systematic survey examined the extent to which the abstracts of 96 Cochrane and 94 non-Cochrane reviews reported the absolute effects on outcomes that were important to patients. The study found that 9.5% of the abstracts reported both absolute and relative measures of benefit, whereas only 1.1% reported both measures of harm. The study found that abstracts of systematic reviews that addressed important outcomes rarely reported measures of absolute effect and insisted that journals should require authors to report both relative and absolute effects for outcomes important to patients [34]. A prior study evaluated the comparability of benefits and harms of recommendations for cancer screening and prevention in the United States. Of the 55 included recommendations, 25% and 29% did not mention any benefits or harms, 47% and 58% did not quantify benefits and harms, and 40% and 42% presented the absolute effects of benefits and harms. Finally, 30.9% of the recommendations received similar ratings, 14.5% received incomplete ratings, and 54.5% received asymmetric ratings [18]. A study evaluating the presentation of risk information in American College of Obstetricians and Gynecologists obstetrical Practice Bulletins reported that 37% of 125 recommendations described risks numerically. Of these, 35% presented absolute changes from baseline, 55% and 48% presented benefits as absolute and relative risks, respectively, and 65% and 25% presented harms as absolute and relative risks [35]. The current guidelines seem to be negligent in expressing benefits and harms. Clear statements of the benefits and harms of interventions would enhance the recognition of important outcomes, and numerical presentations, particularly in absolute terms, would facilitate an accurate understanding of effect sizes and support evidence-based decision-making through appropriate judgments of tradeoffs.

4. Implications

Our study found that guidelines, especially those presenting benefits, have been negligent in presenting absolute effects. Prior studies have shown that clinicians are particularly familiar with relative effects, which can misrepresent the effectiveness of interventions [36,37]. Furthermore, because relative effects are consistent across populations, whereas absolute effects vary with baseline risk, recommendations for specific populations should not be made without estimating the magnitude of the absolute benefits and harms. Therefore, the developers of recommendations for specific populations should provide the best absolute estimates of the potential benefits and harms to that group.

Six of the guidelines evaluated provided evidence tables for the certainty of evidence. However, most were for benefits, and only one recommendation presented both benefits and harms in a single table [23]. The GRADE approach recommends that the evidence supporting the guideline be presented in evidence tables (e.g., evidence profiles or summary of findings tables), together with certainty of the evidence and absolute effects for important benefits and harms [38]. Unfortunately, the guidelines reviewed in this study were largely written before the introduction of the GRADE approach or before the spread of the GRADE methodology in Korea. Clinical practice guidelines developed in Korea are increasingly using the GRADE approach to assess the certainty of evidence and grade recommendations [19]. We believe that the GRADE approach can help standardize the way important essential information is presented, including absolute effect estimates for important benefits and harms. Standardized presentation of key information would accelerate the presentation, interpretation, and understanding of data and would facilitate evidence-based decision-making.

Decision aids may be considered to emphasize the importance of shared decision-making between recipients and healthcare providers and to facilitate understanding of the potential benefits and harms of evidence-based cancer screening. Decision aids might increase knowledge about the benefits and risks associated with available options and help patients choose options that are consistent with their values [39,40]. Decision aids developed for Koreans were perceived as useful in enhancing knowledge and attitudes toward cancer screening and in promoting informed decision making [41,42].

Most guidelines included in this review have not been updated since 2015. Screening recommendations should be updated periodically when new evidence is available, and should be updated using the current evidence-based methodologies. This should include presenting quantitative results, including the benefits and harms, to help the development group clearly understand the evidence and determine the direction and strength of the recommendations. These results should be presented in a format that allows healthcare providers and recipients to easily compare the benefits and harms, thereby facilitating informed judgments regarding trade-offs. National Evidence-based Healthcare Collaborating Agency and the Korean Academy of Medical Sciences published the Handbook for Clinical Practice Guideline Developer in 2022 to improve the methodological development of guidelines in Korea. This presented core principles and rigorous and transparent processes for developing evidence-based guidelines that meet international standards. This includes quantifying absolute benefits and harms so that they can be compared. And consistent table format (e.g., GRADE evidence tables) that includes essential information for presenting recommendations to users is recommended. Adherence to these guidelines would ensure a balanced and sufficiently informed presentation of benefits and harms. The recent guidelines for cancer screening developed using the GRADE approach summarize the latest evidence, quantify the benefits and harms, present them in a standardized manner, and provide recommendations based on this [43,44]. We believe that these guidelines can serve as good examples for future guideline development.

This study systematically reviewed the benefits and harms of cancer screening guidelines for the Korean population. The 15 recommendations reviewed presented the benefits of interventions as relative measures, and harms as absolute measures. If providers and recipients have inaccurate perceptions of the benefits and harms of cancer screening, they will not be able to make optimal evidence-based decisions. This study’s results could serve as a guide for the development and publication of future cancer screening guidelines and could be used to educate guideline developers and users.

Electronic Supplementary Material

Supplementary materials are available at Cancer Research and Treatment website (https://www.e-crt.org).

crt-2024-1151_S1_Table.pdf

crt-2024-1151_S2_Fig.pdf

crt-2024-1151_S3_Table.pdf

crt-2024-1151_S4_Table.pdf

NOTES

Author Contributions

Conceived and designed the analysis: Han MA, Lee H, Kim K, Kim SJ, Hwang EC, Jung JH.

Collected the data: Han MA, Lee H, Kim K, Kim SJ, Hwang EC, Jung JH.

Contributed data or analysis tools: Han MA, Lee H, Kim K.

Performed the analysis: Han MA.

Wrote the paper: Han MA, Lee H, Kim K, Kim SJ, Hwang EC, Jung JH.

Conflicts of Interest

Conflict of interest relevant to this article was not reported.

Funding

This work was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF), funded by the Korean Ministry of Education (RS-2021-NR065884) and the Korean Ministry of Science and ICT (RS-2022-NR070848).

Table 1.

Types of positive cancer screening recommendation

Publication year	Target cancer	Target population	Screening methods	Intervals
2015 [20]	Gastric	40-74 years	Gastric endoscopy	2 yr
		40-74 years	Upper gastrointestinal series	NR
2015 [21]	Liver	40 or older for hepatitis B, C, or at the time of cirrhosis diagnosis	Liver US, serum alpha-fetoprotein	6 mo
2012 [22]	Colorectal	50 or older	Fecal occult blood tests	NR
		50 or older	CT colonography
		50 or older	Double contrast barium enema
		50 or older	Colonoscopy
2015 [23]	Colorectal	45-80 years	Fecal immunochemical test	1 or 2 yr
		19 or older	Colonoscopy	NR
2015 [24]	Breast	40-69 years	Mammography	2 yr
2013 [25]	Cervix	20-70 years, commenced sexual activities	Conventional Pap or liquid-based cytology	1 yr
2015 [26]	Cervix	20 or older	Papanicolaou test or liquid-based cytology	3 yr
		NR	Combination test (cytology with HPV test)	NR
2012 [27]	Lung	55-74 years, smoked 30 pack-years or more and either continue to smoke or have quit within the past 15 years	Low-dose CT	1 yr
2015 [28]	Lung	55-74 years, 30 pack-years or more of smoking-history	Low-dose CT	1 yr

CT, computed tomography; HPV, human papillomavirus; NR, not reported; US, ultrasonography.

Table 2.

Guideline development process

Characteristic	Total (n=9)	Year of publication
Characteristic	Total (n=9)	2011-2012 (n=3)	2015 (n=6)
Source of evidence^a)
De novo SR	7 (77.8)	1 (33.3)	6 (100)
Unsystematic review	1 (11.1)	1 (33.3)	0
Prior guideline	8 (88.9)	3 (100)	5 (83.3)
Presentation of certainty of evidence
No	1 (11.1)	1 (33.3)	0
Yes	8 (88.9)	2 (66.7)	6 (100)
Certainty of evidence assessment method
NA	1 (11.1)	1 (33.3)	0
Not described	1 (11.1)	0	1 (16.7)
Yes with GRADE	7 (77.8)	2 (66.7)	5 (83.3)
Certainty of evidence assessment domain
NA	1 (11.1)	1 (33.3)	0
Not described	1 (11.1)	1 (33.3)	0
Five main domains	7 (77.8)	1 (33.3)	6 (100)
Presentation of the strength of recommendation
No	1 (11.1)	1 (33.3)	0
Yes	8 (88.9)	2 (66.7)	6 (100)
The strength of recommendation assessment method
NA	1 (11.1)	1 (33.3)	0
Not described	1 (11.1)	0	1 (16.7)
Yes with GRADE	2 (22.2)	2 (66.7)	0
Yes with others	5 (55.6)	0	5 (83.3)
Strength of recommendation assessment domain^a)
NA	1 (11.1)	1 (33.3)	0
Not described	1 (11.1)	1 (33.3)	0
Balance of desirable and undesirable effect	7 (77.8)	1 (33.3)	6 (100)
Certainty of evidence	7 (77.8)	1 (33.3)	6 (100)
Value and preference	4 (44.4)	1 (33.3)	3 (50.0)
Resources and cost	2 (22.2)	1 (33.3)	1 (16.7)
Presentation of GRADE evidence table
No	3 (33.3)	3 (100)	0
Yes	6 (66.7)	0	6 (100)
Institution of panel members
Governmental and institutional	7 (77.8)	1 (33.3)	6 (100)
Institutional only	2 (22.2)	2 (66.7)	0
Methodologist on guideline development process
Not described	2 (22.2)	1 (33.3)	1 (16.7)
Yes	7 (77.8)	2 (66.7)	5 (83.3)

Values are presented as number (%). GRADE, grading of recommendations, assessment, development, and evaluation; NA, not applicable; SR, systematic review.

^a) Multiple responses.

Table 3.

Presentation of benefits and harms of recommended cancer screening interventions

Characteristic	Total (n=15)	Year of publication
Characteristic	Total (n=15)	2011-2012 (n=6)	2015 (n=9)
Benefits
Presentation of benefits
No	3 (20.0)	3 (50.0)	0
Yes	12 (80.0)	3 (50.0)	9 (100)
Type of benefits^a)
Mortality	11 (73.3)	3 (50.0)	8 (88.9)
Incidence	7 (46.7)	3 (50.0)	4 (44.4)
Quantification of benefits
No	3 (20.0)	3 (50.0)	0
Yes	12 (80.0)	3 (50.0)	9 (100)
Effect measure of benefits
NR	3 (20.0)	3 (50.0)	0
Relative only	5 (33.3)	2 (33.3)	3 (33.3)
Absolute only	0	0	0
Both	7 (46.7)	1 (16.7)	6 (66.7)
Location of benefit formation^a)
Main text	12 (80.0)	3 (50.0)	9 (100)
Main table/Figure	8 (53.3)	0	8 (88.9)
Appendix	4 (26.7)	1 (16.7)	3 (33.3)
Harms
Presentation of harm
No	2 (13.3)	2 (33.3)	0
Yes	13 (86.7)	4 (66.7)	9 (100)
Type of harm^a)
False-positive results	9 (60.0)	1 (16.7)	8 (88.9)
Overdiagnosis	4 (26.7)	0	4 (44.4)
Screening method complications	12 (80.0)	4 (66.7)	8 (88.9)
Quantification of harms
No	4 (26.7)	2 (33.3)	2 (22.2)
Yes	11 (73.3)	4 (66.7)	7 (77.8)
Effect measure of harm
NR	4 (26.7)	2 (33.3)	2 (22.2)
Relative	0	0	0
Absolute	11 (73.3)	4 (66.7)	7 (77.8)
Both	0	0	0
Location of the harm information^a)
Main text	13 (86.7)	4 (66.7)	9 (100)
Main table/Figure	3 (20.0)	0	3 (33.3)
Appendix	3 (20.0)	1 (16.7)	2 (22.2)
Comparability of benefits and harms
Comparable	6 (40.0)	1 (16.7)	5 (55.6)
Asymmetric	8 (53.3)	4 (66.7)	4 (44.4)
Incomplete	1 (6.7)	1 (16.7)	0

Values are presented as number (%). NR, not reported.

^a) Multiple responses.

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Presentation of Benefits and Harms in Cancer Screening Guidelines for Koreans: A Systematic Review

Cancer Res Treat. 2025;57(4):923-931. Published online March 27, 2025

DOI: https://doi.org/10.4143/crt.2024.1151

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Abstract
Introduction
Materials and Methods
Results
Discussion
Electronic Supplementary Material
NOTES
REFERENCES

Presentation of Benefits and Harms in Cancer Screening Guidelines for Koreans: A Systematic Review

Publication year	Target cancer	Target population	Screening methods	Intervals
2015 [20]	Gastric	40-74 years	Gastric endoscopy	2 yr
		40-74 years	Upper gastrointestinal series	NR
2015 [21]	Liver	40 or older for hepatitis B, C, or at the time of cirrhosis diagnosis	Liver US, serum alpha-fetoprotein	6 mo
2012 [22]	Colorectal	50 or older	Fecal occult blood tests	NR
		50 or older	CT colonography
		50 or older	Double contrast barium enema
		50 or older	Colonoscopy
2015 [23]	Colorectal	45-80 years	Fecal immunochemical test	1 or 2 yr
		19 or older	Colonoscopy	NR
2015 [24]	Breast	40-69 years	Mammography	2 yr
2013 [25]	Cervix	20-70 years, commenced sexual activities	Conventional Pap or liquid-based cytology	1 yr
2015 [26]	Cervix	20 or older	Papanicolaou test or liquid-based cytology	3 yr
		NR	Combination test (cytology with HPV test)	NR
2012 [27]	Lung	55-74 years, smoked 30 pack-years or more and either continue to smoke or have quit within the past 15 years	Low-dose CT	1 yr
2015 [28]	Lung	55-74 years, 30 pack-years or more of smoking-history	Low-dose CT	1 yr

Characteristic	Total (n=9)	Year of publication
Characteristic	Total (n=9)	2011-2012 (n=3)	2015 (n=6)
Source of evidence^a)
De novo SR	7 (77.8)	1 (33.3)	6 (100)
Unsystematic review	1 (11.1)	1 (33.3)	0
Prior guideline	8 (88.9)	3 (100)	5 (83.3)
Presentation of certainty of evidence
No	1 (11.1)	1 (33.3)	0
Yes	8 (88.9)	2 (66.7)	6 (100)
Certainty of evidence assessment method
NA	1 (11.1)	1 (33.3)	0
Not described	1 (11.1)	0	1 (16.7)
Yes with GRADE	7 (77.8)	2 (66.7)	5 (83.3)
Certainty of evidence assessment domain
NA	1 (11.1)	1 (33.3)	0
Not described	1 (11.1)	1 (33.3)	0
Five main domains	7 (77.8)	1 (33.3)	6 (100)
Presentation of the strength of recommendation
No	1 (11.1)	1 (33.3)	0
Yes	8 (88.9)	2 (66.7)	6 (100)
The strength of recommendation assessment method
NA	1 (11.1)	1 (33.3)	0
Not described	1 (11.1)	0	1 (16.7)
Yes with GRADE	2 (22.2)	2 (66.7)	0
Yes with others	5 (55.6)	0	5 (83.3)
Strength of recommendation assessment domain^a)
NA	1 (11.1)	1 (33.3)	0
Not described	1 (11.1)	1 (33.3)	0
Balance of desirable and undesirable effect	7 (77.8)	1 (33.3)	6 (100)
Certainty of evidence	7 (77.8)	1 (33.3)	6 (100)
Value and preference	4 (44.4)	1 (33.3)	3 (50.0)
Resources and cost	2 (22.2)	1 (33.3)	1 (16.7)
Presentation of GRADE evidence table
No	3 (33.3)	3 (100)	0
Yes	6 (66.7)	0	6 (100)
Institution of panel members
Governmental and institutional	7 (77.8)	1 (33.3)	6 (100)
Institutional only	2 (22.2)	2 (66.7)	0
Methodologist on guideline development process
Not described	2 (22.2)	1 (33.3)	1 (16.7)
Yes	7 (77.8)	2 (66.7)	5 (83.3)

Characteristic	Total (n=15)	Year of publication
Characteristic	Total (n=15)	2011-2012 (n=6)	2015 (n=9)
Benefits
Presentation of benefits
No	3 (20.0)	3 (50.0)	0
Yes	12 (80.0)	3 (50.0)	9 (100)
Type of benefits^a)
Mortality	11 (73.3)	3 (50.0)	8 (88.9)
Incidence	7 (46.7)	3 (50.0)	4 (44.4)
Quantification of benefits
No	3 (20.0)	3 (50.0)	0
Yes	12 (80.0)	3 (50.0)	9 (100)
Effect measure of benefits
NR	3 (20.0)	3 (50.0)	0
Relative only	5 (33.3)	2 (33.3)	3 (33.3)
Absolute only	0	0	0
Both	7 (46.7)	1 (16.7)	6 (66.7)
Location of benefit formation^a)
Main text	12 (80.0)	3 (50.0)	9 (100)
Main table/Figure	8 (53.3)	0	8 (88.9)
Appendix	4 (26.7)	1 (16.7)	3 (33.3)
Harms
Presentation of harm
No	2 (13.3)	2 (33.3)	0
Yes	13 (86.7)	4 (66.7)	9 (100)
Type of harm^a)
False-positive results	9 (60.0)	1 (16.7)	8 (88.9)
Overdiagnosis	4 (26.7)	0	4 (44.4)
Screening method complications	12 (80.0)	4 (66.7)	8 (88.9)
Quantification of harms
No	4 (26.7)	2 (33.3)	2 (22.2)
Yes	11 (73.3)	4 (66.7)	7 (77.8)
Effect measure of harm
NR	4 (26.7)	2 (33.3)	2 (22.2)
Relative	0	0	0
Absolute	11 (73.3)	4 (66.7)	7 (77.8)
Both	0	0	0
Location of the harm information^a)
Main text	13 (86.7)	4 (66.7)	9 (100)
Main table/Figure	3 (20.0)	0	3 (33.3)
Appendix	3 (20.0)	1 (16.7)	2 (22.2)
Comparability of benefits and harms
Comparable	6 (40.0)	1 (16.7)	5 (55.6)
Asymmetric	8 (53.3)	4 (66.7)	4 (44.4)
Incomplete	1 (6.7)	1 (16.7)	0

Table 1. Types of positive cancer screening recommendation

CT, computed tomography; HPV, human papillomavirus; NR, not reported; US, ultrasonography.

Table 2. Guideline development process

Values are presented as number (%). GRADE, grading of recommendations, assessment, development, and evaluation; NA, not applicable; SR, systematic review.

Multiple responses.

Table 3. Presentation of benefits and harms of recommended cancer screening interventions