The Mammogram Controversy

We are coming up on two years since the U.S. Preventive Services Task Force (USPSTF) released updated guidelines for breast cancer screening resulting in a heated national debate. Its recommendation that women between the ages of 40 and 49 should not undergo routine mammography was interpreted by many to mean that the USPSTF was opposed to mammography and has led physicians, advocacy groups, professional societies and even politicians to react with concern.

The panel’s controversial recommendation actually reflects a longstanding area of debate regarding screening women in their 40's. The USPSTF acknowledges that mammography benefits women ages 40 to 49 by detecting early cancers and decreasing mortality, but the risk/benefit ratio and the impact on mortality for these women is less than that for women ages 50 and above.  Breast cancer is less common in younger women, so that while screening 1,339 women in their 50's can save one life, 1,904 women ages 40 to 49 would have to be screened to achieve the same effect.  Whether the impact in this age group is great enough to recommend routine screening is a matter of opinion, hence the difference in recommendations among various different professional societies.

Whereas the American Cancer Society as well as other groups recommend routine annual screening for all women beginning at age 40, the USPSTF recognizes that mammography may be appropriate for some women in their 40's and the decision to undergo screening requires a dialogue between a woman and her physician.

Most women are well aware of the benefits of mammography, but screening also has its shortcomings.  False-positives are a problem with any test that lacks 100 percent specificity, and it has been estimated that 60 percent more false positive results and unnecessary biopsies would occur by initiating screening at age 40 compared to age 50. However, perhaps the most harmful potential consequence of mammography is overdiagnosis -- finding and treating a cancer, such as a non-invasive tumor, that was never destined to cause symptoms or threaten a woman's life.  For many young women, these potential risks would not make screening worthwhile, whereas others would still choose to undergo mammography.

We have now entered an era of "personalized medicine" in which, rather than taking a "one size fits all" approach, the goal is to individualize therapy to maximize benefit while minimizing harm.  This type of approach should also extend to risk assessment, and every woman should discuss her risk of developing breast cancer with her physician, taking into account factors such as reproductive history as well as personal and family history.

The controversy regarding the optimal age and frequency for breast cancer screening is unlikely to be settled in the near future.  However, amidst all the commotion generated by the current guidelines, we must not lose sight of the fact that despite clear consensus that routine mammography should be performed in women ages 50 to 74, one-third of women in the U.S. fail to adhere to these recommendations.  It is our responsibility to promote ongoing education and minimize barriers to access so that all women who should be screened take advantage of this potential life-saving test.

Courtesy of Deborah Toppmeyer, M.D., chief medical officer and director of the Stacy Goldstein Breast Cancer Center at The Cancer Institute of New Jersey (CINJ) and an associate professor of medicine at UMDNJ-Robert Wood Johnson Medical School, and Serena Wong, M.D., a medical oncologist at the Stacy Goldstein Breast Cancer Center at CINJ and an assistant professor of medicine at UMDNJ-Robert Wood Johnson Medical School.