The Beleaguered Mammogram: Controversy, Damage Control, and Shortcomings

Twitter icon
Facebook icon
LinkedIn icon
e-mail icon
Google icon
 - bandaide

A headline in the newspaper proclaims, “Cancer screening expert to radiologists: Stop lying about mammograms.” The newspaper is not a supermarket tabloid, but the Los Angeles Times. The article 1, which appeared following the publication of the CNBSS 2, was written by the newspaper’s science editor.

Suggesting that the 90,000-patient study is “rather inconvenient for the die-hard fans of mammography,” the author observes that breast cancer was more likely to be diagnosed in those who underwent mammography. She thoroughly covers the commentary of Welch 3, a critic of mammography. What’s a woman to think?

The latest findings of the controversial CNBSS have once again stirred the pot of public opinion about the viability of mammography and the value of having mammograms. The US media helped, providing widespread coverage of this latest study and fanning the flames of the battle over breast screening anew.

The effect of this ongoing debate on patient care is hard to assess. In 2009, the USPSTF revised its screening-mammography guidelines, recommending that women have their first mammograms at age 50 (instead of 40) and biennially (rather than annually) thereafter. Despite the fact that the American Cancer Society (ACS) continues to recommend mammograms beginning at age 40, a reduction in mammography volumes in women ages 40 to 49 has been noted. 4

In November 2013, the USPSTF announced that it had started to review its 2009 guidelines for breast-cancer screening. Half of the key questions that it plans to review systematically include evaluations of women starting at age 40. 5

Radiologists React

Radiology Business Journal has discussed the CNBSS and its impact with four highly experienced breast-imaging specialists: one at an academic center; one at a women’s health clinic at a large, integrated multispecialty health-care organization; and two at urban radiology practices. Have they modified any recommendations to patients as a result of the CNBSS? What are patients asking about having mammograms as a result of learning about the study results? How many patients  are aware of the study?

None of these specialists report changing how they and their colleagues conduct their mammography practices. On the contrary, the fact that the study’s results were published despite obvious weaknesses angers the radiologists and makes them more committed to protecting their patients by adhering to guidelines of the ACR®, the ACS, the Society of Breast Imaging, and others.

In sum, they advocate that all women start having annual screening mammograms at the age of 40 and continue them through their 70s—and possibly longer, for healthy elderly women. An exception would be made for women with serious comorbidities for whom a survival period of five or fewer years has been predicted.

Young women identified as being at high risk (having BRCA1 or BRCA2 genes, a family history of breast cancer, or a high level of radiation exposure from prior treatment) need some form of breast imaging to complement an annual clinical exam, generally starting in their 30s (potentially as early as age 25). Breast MRI exams are recommended in lieu of mammograms for women under 30, and mammograms alternating with breast ultrasound or breast MRI should start at 30.

In addition, a disturbing number of family-practice physicians, internists, and gynecologists are not taking 20 years of data about the value of annual breast screening at face value. These physicians either are not discussing mammograms with their patients or are recommending mammograms under the guidelines of the USPSTF (biennial screening beginning at age 50).

Damage Control

One radiologist notes a lemming-like effect, calling it the if-it’s-good-enough-for-the– New England Journal of Medicine, it’s-good-enough-for-me syndrome. Jeffry Lindenbaum, MD, PhD, of Billings Clinic in Montana, is more diplomatic.

“The USPSTF guidelines carry a lot of weight,” he says. “There have been primary-care physicians within the clinic who have modified their recommendations based on them.”

Matthew Gromet, MD, a breast imager with Charlotte Radiology in North Carolina, states, “There is no serious dispute about mammography saving lives. There are about nine worldwide randomized clinical trials that proved this. They showed a mortality reduction of about 25% to 31%. Women, however, should realize that the actual benefit of annual screening is much greater, for several reasons.”

He continues, “First, the studies, by their