COMMENTARY

The ACR/SBI Breast Cancer Screening Guidelines Are Wrong

John D. Keen, MD, MBA

Disclosures

March 02, 2012

In This Article

The ACR/SBI Breast Cancer Screening Guidelines Are Wrong

Opposing Views

Daniel Kopans, MD, claimed in a recent Medscape editorial[1] that the 2011 Canadian Task Force on Preventive Health Care (CTFPHC) breast cancer screening guidelines[2] are wrong. Dr. Kopans also accuses Dr. Peter Gøtzsche of the Nordic Cochrane Centre of spreading "misinformation."[3] I will argue that the 2010 breast screening recommendations from the American College of Radiology (ACR) and the Society of Breast Imaging (SBI) are the flawed guidelines.[4] Dr. Kopans coauthored these guidelines with 14 other breast imagers, assisted by Robert A. Smith, PhD, of the American Cancer Society (ACS).

John D. Keen, MD, MBA

Dr. Kopans and I were opposing radiologists in the Controversies section of the September 2011 issue of Radiology.[5,6] If Dr. Kopans believes in an open scientific discussion, I am curious why he and Dr. Smith refused to participate in a press release concerning those articles, which would have increased consumer awareness of the debate about screening mammography.[7]

Where Is the Scientific Evidence?

Dr. Kopans used to claim that randomized, controlled trials are the only accepted method for validating a screening test.[8] Yet, the ACR/SBI support screening MRI and ultrasonography when no trial evidence is available showing that these modalities reduce breast cancer mortality.[9] Furthermore, there is little support from the trial data for screening women after age 70 years,[10] yet the ACR/SBI advocate screening until life expectancy is less than 5-7 years. Likewise, there is no trial evidence for starting screening at age 25-30 years, or that screening any high-risk women reduces mortality.

The ACR/SBI cite a 1995 trials meta-analysis showing that screening mammography produced a 26% relative risk reduction. Certainly, the ACR/SBI experts are aware of 2 more recent systematic reviews by independent groups that show an effect of 15%-16%.[5] Breast cancer awareness and improved treatment over 3 decades since the trials started mean the screening effect today is more likely 10% at most.[3,5] The ACR/SBI also cite a Swedish population study claiming a 39% reduction. This does not reconcile with the 16% reduction for Swedish women aged 50-69 years from 1989-2006, or the fact that Denmark had a larger reduction -- 26% -- with minimal screening (only 20%).[11] I agree with Dr. Kopans that there is no trial evidence that supports aggressive annual screening,[2] so why does the ACR/SBI advocate this policy?

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