JAMA Article Slams Mammography: At What Cost?

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When JAMA published an opinion piece 1 in October 2009 questioning the effectiveness of mammography screening and calling for new screening protocols to separate life-threatening cancers from less harmful lesions, the mammography community reacted with alarm. Lawrence Bassett, MD, FACR, Iris Cantor professor of breast imaging at the David Geffen School of Medicine at the University of California Los Angeles, says that the takeaway message for patients could be that because mammography is imperfect, exams can be skipped.

Such a response would be very dangerous, he notes. “Women might use this as an excuse not to get mammograms,” he says.

Ellen B. Mendelson, MD, professor of radiology and section chief of breast imaging at Northwestern Memorial Hospital, Chicago, Illinois, is equally adamant that women must continue to get mammograms according to current guidelines, despite the concerns raised in the JAMA article by Laura Esserman, MD, MBA, a professor of surgery and radiology at the University of California San Francisco, and her coauthors.

“One suggestion by Esserman should not be taken as the last word; it would be completely wrong,” Mendelson says. “If she wants a new path, fine, but until that path ends in something documented, there should be no change. This is serious,” Mendelson adds. “This whole edifice of breast-cancer screening took decades. Nothing should change.”

Bassett says that women don’t need another reason to put off a mammogram. “No one wants to deal with going in to find a breast cancer,” he says. “Some women are very scared each time they go, and they want the results right away, even though it only takes a day or so.” Not only is a woman’s sexual image at risk from breast cancer, Bassett adds, but the thought that cancer could kill her in the midst of her childrearing years is even more frightening. “We found that in a study we did on breast biopsies,” he says.

Faulty Conclusions

Bassett says that he was more upset about news coverage of the JAMA article than he was by the article itself. Particularly troublesome was an October 21 New York Times article 2 indicating that the American Cancer Society (ACS) might revise its mammography guidelines, Bassett says, because the article was inaccurate. In a letter, the ACS has called for women to continue breast screening.

“The test is beneficial in that it saves lives, but it is not perfect. It can miss cancers that need treatment, and in some cases finds disease that does not need treatment,” Otis W. Brawley, MD, chief medical officer of the ACS, writes. “Understanding these limitations will help researchers develop better screening tests.” He adds that the ACS “stands by its recommendation that women 40 and over should receive annual mammography.”

The ACS letter was written in response to the New York Times article, and on the same day. In that article, Brawley is quoted as saying, “We don’t want people to panic. But I’m admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.” 2 The ACS response letter did not mention the New York Times quotes.

The JAMA article surveyed results for both mammography and prostate-cancer screening, and its conclusion wrapped both tests together in calling for revised protocols. “Screening for breast and prostate cancers has increased the numbers of cancers detected, generating expense and morbidity from detection and treatment of cancers that pose minimal risk,” Esserman et al write.

“To improve screening, a new focus is recommended for research and care to identify markers that discriminate minimal-risk from high-risk disease,” they add. “About $20 billion is spent to screen for breast cancer and prostate cancer in the United States. Highly innovative businesses typically invest 10% to 20% of their sales into research and development of the next new product. A similar investment is needed to improve screening, accelerate prevention research, and reduce harm from breast cancer and prostate cancer deaths.” 1The Real World

In comments to the media following release of the JAMA article, Esserman charged that mammography screening was a poor tool for spotting aggressive cancers that can kill quickly. Bassett and Mendelson do not question that there are shortcomings in current mammography screening, but both emphasize that the screening tools to differentiate cancer types that Esserman calls for aren’t available yet.

“What we need are