Mammography Screening for Breast Cancer
- Article
- References
Case Vignette
A 40-year-old woman presents to her primary care physician for a routine health maintenance examination. Overall, she has been feeling well. She takes no medications. She lives with her husband and their two children, who are 7 and 11 years of age. She underwent menarche at the age of 12. Before the birth of her first child, she took combined oral contraceptives for 6 years. She breast-fed each of her children for approximately 1 year. For the past 4 years, she has used a levonorgestrel intrauterine device for contraception. She works as an accountant and exercises on the weekends. Her diet includes regular consumption of fish, chicken, and vegetables, and she eats red meat once a week. She does not smoke, and she consumes an average of four glasses of wine each week. Her family history is notable for prostate cancer in her father that was diagnosed when he was 75 years of age and hypertension in her mother that was diagnosed when she was 60 years of age. There is no history of colon cancer, lung cancer, or breast cancer among her parents or grandparents. She undergoes a complete physical examination, including a clinical breast examination. All findings are normal. She has never undergone mammography, and she asks her primary care physician about recommendations regarding mammography screening.- Option 1 (89)
- Option 2 (89)
- Option 3 (89)
- Option 1Recommend Screening Mammography Starting at the Age of 40
At what age should women begin breast-cancer screening, and what information can women and their clinicians use to help inform this decision? One school of thought asserts that progress in therapy has eclipsed the benefit of early detection and that harms associated with screening are excessive and outweigh the benefits.1,2 There is substantial evidence to the contrary,3 however, and the methodologic flaws that lead to these claims have been clearly identified.4,5 Another school of thought discourages initiation of screening until the age of 50, emphasizing that the 10-year risk of breast cancer is lower when a woman is in her 40s than when she is in her 50s (1 case among 69 women vs. 1 among 42), that mammography reduces the risk of death from breast cancer by only 15%, that 1904 women 40 to 49 years of age need to be invited to be screened over a period of 11 to 20 years to save one life, and that the harms, principally false positive findings, are considerable.6 A third school of thought — one that supports screening starting at the age of 40 — is more compelling. Our ability to predict population risk is reasonably accurate, yet we are not able to tell a woman with confidence that it is safe to postpone — not probably safe to postpone — beginning screening until the age of 50. Furthermore, 73.6% of non-Hispanic white women in their 40s have an absolute risk of breast cancer that is greater than that of a 50-year-old woman without risk factors.7 In addition, one in six breast-cancer deaths is attributable to a diagnosis that was made when the woman was in her 40s, and breast cancer is a leading cause of premature death among women; one third of all the years of life lost as a result of breast cancer are due to diagnoses that were made when the women were in their 40s.8 Breast cancer among women in their 40s is a considerable, not small, fraction of the overall burden of this disease. Although a meta-analysis of randomized, controlled trials showed a 15% reduction in mortality among women randomly assigned to be invited to undergo screening mammography in their 40s,6 individual randomized, controlled trials and recent evaluations of modern mammography screening have shown substantially greater reductions in mortality. Consider the recent Swedish study showing that among women who underwent screening, there were 29% fewer deaths from breast cancer after 16 years in counties that offered mammography than in those that did not.3 The estimate that 1904 women 39 to 49 years of age need to be invited to be screened to save one life is an imprecise and nebulous surrogate for the number needed to screen because it is influenced by deaths among women in the invited group who did not undergo screening and by variable follow-up periods (ranging from 11 to 20 years) in the individual studies. In contrast, on the basis of direct observation of women 39 to 49 years of age who actually underwent screening mammography over a 7-year period and were followed for 20 years, the number needed to screen was 7269 — a number that is less even than the estimated number needed to invite (1339) for women in their 50s.6 What about harms? The risk of a false positive finding is greater than 50% during a decade of regular screening,10 and false positives are associated with temporary anxiety.6 Nevertheless, women have reported that they accept the trade-off of false positives in favor of finding breast cancer early.11 Estimates of overdiagnosis have ranged from 0 to more than 50%, but the rates are small (<10 adjust="adjust" and="and" class="ref" for="for" in="in" incidence.="incidence." lead="lead" properly="properly" span="span" studies="studies" that="that" time="time" trends="trends">12
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Source Information
From the Cancer Control Science Department, American Cancer Society, Atlanta.89 Reader's Comments
JOHN HORNBEAK, SR | Other | Disclosure: None
SAN ANTONIO TX
November 29, 2012Response to M COPUR, MD
Your statement: "Even one single death from a preventable breast cancer through a screening mammogram is too many which makes all the statistical meta-anlysis data irrelevant. I believe and recommend screening mammogram starting at age 40 for general population and earlier age for the high risk group."If even one single death is too many, then why stop at 40? Since there are "general population" women in their 30s, 20s, teens (and even some men) who will die from breast cancer (that would have been detected by routine screening), how can you justify those copious deaths? You are on the very slippery slope of a very demanding "individual rights" ethic.
Here is what you are missing: The USPSTF's screening guidelines are measures of POPULATION HEALTH and use the Utilitarian ethic of the "greatest good for the greatest number". AGGREGATE benefits and harms are weighed, thus it is any individual's result that is irrelevant from every standpoint: logically, statistically and ethically. You assume you are looking through a microscope when the issue requires a wide angle lens.
Think about it and read the USPSTF's actual report.
GIOVANNI CODACCI-PISANELLI, MD | Physician | Disclosure: None
ROMA Italy
November 29, 2012In medio stat virtus
I think starting compromise screening at 50 may be a reasonable between no screening and early screening.I want to stress how relevant this topic is today, and the merit of the Journal for raising it.
Women feel somehow forced to undergo screening, today they will feel somehow "strange" if they do not. Starting at 50 may help them live more relaxed without undergoing the stress of mammography.
But once again: congratulations to everyone that dares to question the importance of mammography.
PRAVEEN HARIHARAN | Resident | Disclosure: None
BOSTON MA
November 29, 2012Economic Considerations
There is often a general misconception among the general population that screening is the only modality of prevention and it means getting mammograms, colonoscopies, Pap test etc. However, in strict terms prevention includes a wide range and far reaching initiatives including childhood immunization, taxes on cigarettes, seat belt use, restricting alcohol sales to minors, eliminating trans-fats in food chains. Although screening could be considered as one mode of prevention by detecting a disease in an early stage and possibly preventing a more serious form, it does not prevent the occurrence of the disease itself. This misconception is carry forwarded to health insurance schemes where the assumption that prevention saves money and this leads to the justification for reimbursing screening tests.This notion is reinforced by the recent results of the Oregon Medicaid experiment. Among beneficiaries who were assigned to Medicaid coverage on the basis of a lottery system at the end of one year after the lottery there was increased use of preventive services such as mammograms (by 60%) and cholesterol monitoring (by 20%).
Source:Finkelstein A,NBER July 2011
xie ze-ming | Physician | Disclosure: None
China
November 28, 2012Lessons learn from prostate cancer screening
When we are discussing about breast cancer screening, don't neglect what told us in an earlier issue of NEJM this year, about the intervention trial for prostate cancer detected by PSA testing, in which "among men with localized prostate cancer detected during the early era of PSA testing, radical prostatectomy did not significantly reduce all-cause or prostate-cancer mortality, as compared with observation, through at least 12 years of follow-up."(http://www.nejm.org/doi/full/10.1056/NEJMoa1113162)
Considering the fact that many women will still get screened in the near future, it is now ethically and scientifically rational to initiate trials to evaluate the effect of intervention vs no intervention on screen-detected breast lesions, that will provide more robust evidence for this issue .
M COPUR, MD | Physician | Disclosure: None
GRAND ISLAND NE
November 27, 2012Focus on improving screening method while utilizing what we have best
We would not be having this debate if mammogram screening were as good and effective as PAP smear test for cervical cancer screening. Mammograms may not be perfect, yet it still is the best screening method. Even one single death from a preventable breast cancer through a screening mammogram is too many which makes all the statistical meta-anlysis data irrelevant. I believe and recommend screening mammogram starting at age 40 for general population and earlier age for the high risk group.
guo yao | Student | Disclosure: None
China
November 27, 2012Recommend start screening at 50
Although, "Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence" has given a depressive result, I think there is also a number of wommen benefited from the screening programme. The small reduction in cases of late-stage cancer gives us a sign that we can decrease the false-positive rate by improving the technology. Starting screening at 50 may reduce the complication while ensuring the benefits, because mammography is less accurate in younger women, and the low incidence of disease re sults in a higher rate of false positive results and a lower rate of breast cancer deaths averted.
SIDRA YOUNUS, MD | Resident | Disclosure: None
AUSTIN TX
November 27, 2012I would want it sooner for myself!
I just finished residency training in internal medicine, and I would say screen sooner than later. 40 seems more reasonable to me than 50.. specially seeing that 1 out of 6 women diagnosed in their forties would die of breast cancer. I would certainly want to be screened sooner for myself and therefore same for my patients..
JENNY LASKARZEWSKI | Other | Disclosure: None
Screening Based on Major Major Risk Factors
A Clinical Pharmacist's Perspective:I think there is a strong consensus for routine screening mammography among women ages 50-69, based on the consistent findings from multiple randomized trials. The consensus is NOT as strong for routine screening among women ages 40-49 or women over age 70. The major risk factors for breast cancer in women are obviously age/gender (eg >50 yr females), genetic predisposition (eg genetic defect in BRCA1 or BRCA2) and estrogen exposure (eg include a breast biopsy showing atypical hyperplasia, and increased breast density [RR 1.8-6.0] & bone density [RR 2.7-3.5]). There are also breast cancer risk prediction tools out there to calculate breast cancer risk. The most widely used tool to calculate breast cancer risk is the Breast Cancer Risk Assessment Tool (BCRAT), aka the Gail Model after Dr. Mitchell Gail, this tool takes account race and ethnicity and is available online at (www.cancer.gov/bcrisktool/). In light of cancer risk assessment tools can be helpful in clarifying a patient's risk group, the accuracy for predicting whether an individual woman will develop cancer is MODEST, because not all important risks have been identified. Thanks!
JOHN HORNBEAK, SR | Other | Disclosure: None
SAN ANTONIO TX
November 26, 2012Dr. Lippert's slippery slope...
Dr. Lippert, your comment: "Try defending the fact that you are NOT recommending screening mammography to a forty year old woman who develops and dies of breast cancer during that decade."Why stop at 40? There are women in their 30s, 20s, even teens that will die of breast cancer every year (even a few men). Would your explanation to them be any easier?
Here is what is missing: screening, by definition, is a population health issue not an individual rights issue. Since the incidence of breast cancer is positively correlated to age, and there about 20 million women in each ten year age cohort, the AGGREGATE risks to patients and costs to society have to be weighed against the AGGREGATE benefits. (This is the Utilitarian construct of the "greatest good for the greatest number".)
Now completely separate from that calculus is the issue of what you will recommend to an individual patient: that's up to you and her and SHOULD include a myriad of factors (informed consent). But your patients will not be well served if you restrict your advice to: "Yes, I recommend routine screening for all women because I don't want to explain why I did not if you get breast cancer."
guo yao | Student | Disclosure: None
China
November 26, 2012Recommend start screening at 40
In China, however, there is no screening for prostate cancer while the incidence of prostate cancer increases year by year. It's doleful to be detected in a late stage without any screening before. I've read the Cancer Control Programmes of WHO, knowing that screening is a very important way to prevent cancer. So I recommend start screening at 40, the earlier the better.
BRIAN BUDENHOLZER, MD | Physician | Disclosure: None
GREENVILLE NC
November 26, 2012Shared Decision Making Should be the Standard
Some notes:Unlike CT screening for lung cancer and flexible sigmoidoscopy for colorectal cancer (though barely for CRC) the data from hundreds of thousands of women randomized to mammography screening shows no reduction in total mortality. As President Clinton recently indicated - it's arithmetic. Those who got routine, screening mammography in the randomized trials were no less likely to die than those who did not get mammography.
The likelihood of suffering harm from screening mammography is much greater if you get screening mammograms than if you don't. And as Dr. Welch and others have shown, many of the women who are breast cancer survivors are survivors because they were overdiagnosed and they were cured of their cancer because they would never have suffered or died from breast cancer.
The older the trial, the greater the benefit from mammography. From the Canadian trial onward, including the recently completed UK trial, no trial has shown a significant benefit from screening mammography. As we have improved breast cancer treatment, the benefit of mammography has diminished, Indeed maybe disappeared.
If a woman skips screening she is assured that Ca tx is necessary.treatment
xie ze-ming | Physician | Disclosure: None
China
November 26, 2012Recommend against breast cancer screening in low risk population
I am a surgeon for breast cancer.Based on the controversy for over a decade and the finding from Peter G?tzsche and others, I would like to recommend against screening mammogram or other screening modalities such as ultrasound in average-to-low risk populations,for example, the Chinese population, which has a yearly incidence of less than 50/100,000,
The common scenario in China is that many people are now persuaded or intimidated to receive biopsy even with obviously low risk nodules found by ultrasound or mammogram, so, another reason for choosing option 3 rather than option 2 & 1 for Chinese population is that screening for breast cancer in China would result in massive increase of unnecessary biopsy, especially those performed by vacuum-assisted biopsy,which is driven not by the BIRADS scoring system or other scientific findings, but by the profitable nature of the procedure for physicians and hospitals.
Anand Narayan | Physician | Disclosure: None
India
November 26, 2012Recommend screeing at 50
I would go by option2 as the risk-cost- benefit of screening from 40-49 years average risk women is not very favorable from the above data. High risk women could be advised screening from 40 years. However the data cannot be extrapolated worldwide and adoption or modification should be based on local demographics.
M COPUR, MD | Physician | Disclosure: None
GRAND ISLAND NE
November 25, 2012Perfect the screening method while utilzing what we have
If mammograms were as effective as PAP smears we would not be having this debate. Even one life lost due to a preventable breast cancer is too many. As imperfect as it may be mammogram is still the best screning test we have. All the statstical meta-anlysis data against performing mammograms at 40 becomes so irrelevant when I see a real life case of young breast cancer who could have been saved. I support mammograms at age 40 in general and at younger ages if high risk. We should focus on perfecting the screening methods as well as determining the high risk criteria.
Herm Payen | Physician | Disclosure: None
Mammograms
Both patients and practicing physicians should drastically change their mindset about mammograms because in reality, these are just screening devices, until the American College of Radiology can guarantee us a 100% specificity and sensitivity many decades from now when hopefully the technology dramatically improves and the mammogram-specialist(radiologist).have undergone months or years of rigid mammogram specialty fellowship and certification.The final diagnosis is always through the microscope by the breast cancer pathologist
and please do not even mention mastectomy, radiation therapy and chemotherapy on those false positive breast cases, because these are very fertile reasons for lawyers to go after the doctors involved in these cases.False positive breast cancer diagnosis by pathologists should not be possible or should be very rare because currently, usually multiple pathologists have looked at these cases before appropriate treatment is recommended. These are standard operating procedures for every pathology department's risk management and quality assurance program.
Stratifying breast cancer risks should be a good reason for screening in the 30's and 40's.
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IBRAHIM ALBADAWI ALBADAWI, MD | Physician | Disclosure: None
DOHA Qatar
November 25, 2012Screening mammography.
I favour screening of high risk patients regardless of age.
RAGIP KAYAR, MD | Physician | Disclosure: None
IZMIR Turkey
November 25, 2012Over 50, but high risk group only !
I am a breast surgeon.Keeping a women under mammographic screening usually is a stressful experience for her.Therefore screening should be limited to those with high risk.If risk high enough to necessitate screening,starting age may be decreased to 35-40.
CORNELIUS COOPER, MD | Physician | Disclosure: None
NEW YORK NY
November 25, 2012The Elephant in the room
There seems to be little dispute mammography can diagnosis breast cancer and on occasion save an individual life. This benefit costs -- both physical and economic.As well, there is agreement that women can be risk stratified, those possessing BRCA genes or strong historical associations requiring more focused, aggressive screening and intervention.
The elephant in the room? How screening is situated inside the general health-scape. If dollars for health writ large will be harder to come by, the argument that early screening saved this or that life is a poor one if the social cost is not considered.
The game is zero sum-ish. Health care expenditures with minimal impact upon the population as a whole divert resources from interventions with a more robust benefit outcomes.
A living wage and an education trump everything we do.
While it is the role of the individual researcher to research. Practice implementation is a much more complex matter; medical practice mapping onto social policy. If individual physicians cannot find a way to integrate such considerations into decision making it will be done for us.
MYRTO ASHE, MD | Physician | Disclosure: None
SAN RAFAEL CA
November 24, 2012Work on reducing modifiable risk factors
We are arguing endlessly over whether screening picks up early cancers or harmless cancers. What we need is the knowledge to lower the risk of our patients.So many of the known risk factors are modifiable: environmental exposures, diet and exercise history,alcohol intake, BMI, exposure to second hand smoke, estrogen metabolite ratios, genetic polymorphisms that can be overcome by medications/supplements...etc.
We cannot decide how many women should undergo the trauma of procedures with no survival benefit in exchange for saving one life. if (when) we begin to limit health care expenditures, this calculation will be relevant to someone.
Meanwhile, health behavior change will make a terrific difference in both length and QOL. It wasn't taught in medical school, but it is the most useful skill--keep patients healthy and save the trouble/expense of diagnosing and treating them (especially for diseases that won't affect them).
RONALD CATHCART, MD | Physician | Disclosure: None
FELLSMERE FL
November 24, 2012What is the best method to screen for breast cancer?
There are 3 methods to screen for breast cancer other than breast self examination. Mammography, ultrasound and magnetic resonance imaging. Which one is best? Of course cost, harm of the procedure, and other factors need to be considered. If a clinical trial could be done with the power to show significance, this may settle the question of age at which screening should be done. Remember, we are talking about screening in asymptomatic women.
WAYNE ARTHUR LIPPERT, MD | Physician | Disclosure: None
CINCINNATI OH
November 23, 2012Mammography and the gynecologist in the United States
Try defending the fact that you are NOT recommending screening mammography to a forty year old woman who develops and dies of breast cancer during that decade.
omid eslami | Resident | Disclosure: None
Iran, Islamic Republic of
November 23, 2012Screening for breast cancer
Mammography should be recomended to all females but with different intervals for example annually for high risk women.
PROF PATRICK NEVEN | Physician | Disclosure: None
LEUVEN Belgium
November 23, 2012Yes, when incidence is highest and test most reliable: after menopause
Mammographic screening of large populations will decrease their breast cancer mortality. This gain in breast cancer related mortality, also under age 50 and expressed in absolute figures is proven but low. We have to inform our patients and acknowledge potential harms of population screening like overdiagnosis, unnecessary biopsies. But early diagnosis is more than prevention of advanced disease! The Belgian guidelines balanced benefit and harms and recommended population breast cancer screening in normal risk women every 2 years starting at age 50. I agree that well informed patients are those most likely to make the best health-related decisions.
Lynn Howard Ehrle | Other | Disclosure: None
Plymouth MI
November 23, 2012Mammograms: The Untold Story
Because of false positives, overexposure, or technician error many patients must undergo a second or third examination, affecting about 10% of all examinations. I have called several radiology labs and asked if they track total number of retakes per month, but this information is unavailable. Estimates vary, but a 2011 study of 169,000 women by the Group Health Research Institute found that over a ten-year period 61% women were called back because the first reading was inconclusive, and 8% were referred for a "false positive" biopsy. Risk from multiple x-ray exams are seldom addressed in medical journals.Under the Mammogram Quality Standards Act 38,884,700 exams were reported to the FDA as of November 1(not including multiple retakes). Total mean glandular dose (2 views each breast) of 4 mGy. If a woman receives 10-15 mammograms between the ages of 40 and 59, the cumulative dose represents a significant health risk. To ignore the fact that there is no safe dose of radiation is to deny risk for future cancers and non-cancer disease.
Teodoro Sava | Physician | Disclosure: None
Verona Italy
November 23, 2012Screening from 40: yes!
I say yes, but there are some pittfalss:1) Costs: can we afford it?
2) Is mammography sufficient in younger patients (especially for lobular in situ carcinoma)?
3) How often: every two years (but we have no data)?
4) For all: for sure for intermediate high risk; and for a young woman with no breast cancer familar history? Probably we have to discuss with her pro and cons (considering desire of pregnancy)
5) It's clearly different from prostate PSA-based screnning: nontheless, we have to remember the high rate of overdiagnosis and overtreatment (we need to redifine options for in situ carcinoma probably)
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