COMMENTARY

Mammography Debated: To Do or Not to Do

Brandon Cohen

Disclosures

March 12, 2014

Nearly 40 million mammograms were performed in the United States last year. To many, they are seen as vital tools for saving lives, but a number of physicians see reason to doubt the efficacy and value of mammograms. In a recent all-physician discussion on Medscape Connect, the worth and the cost of mammograms came under closer scrutiny.

An internist began the discussion by citing a recent Canadian study[1]: "Annual mammography failed to reduce breast cancer mortality in women, ages 40 to 59, compared with physical examination or routine care, according to 25-year follow-up data from a Canadian screening program."

An oncologist gave an overview of the conflict as it stands today:

This is one of the most emotionally and politically charged issues we face. Published studies...have shown conflicting and/or equivocal results, and legitimate criticisms have been raised about the trial conduct for both the positive (survival benefit) and negative (no or equivocal survival benefit) trials. As always, there will be tremendous backlash from the advocacy groups and mammographers.

Colleagues joined in by pointing out additional problems these mass screenings could cause, such as "false-positives and unnecessary surgery in addition to the anxiety that patients go through."

A cynical internist took it a step further, viewing sinister motives behind the widespread use of the procedure: "Screening is an excellent business model: Create policies and recommendations, create mass hysteria, and then masses demand the politicians to create a budget and enforce it, while the businessmen/women work on the background, as we stroke our egos as physicians, that 'we saved a life.'"

And a hematologist loudly sounded the alarm, drawing damning comparisons between regular screening and dangerous drugs:

If there were a pill that did what screening mammography does -- cut off breasts, give chemotherapy, hormones, life-changing side effects, and anxiety, while maybe saving a few lives -- it would never get approved. Think about it: The only reason screening is even allowed is because it's not a medication and not subject to the same rigorous review.

I have seen many women's lives completely ruined from screening mammograms -- from anxiety, lymphedema, chemo, and hormonal side effects. It's crazy to think how many of them would have been fine if they had not gone in for the exam...If there were not a lot of very expensive biologics and aromatase inhibitors in breast cancer, I don't think we would see so many pink ribbons.

Although some argued for curtailing mammography, the procedure had its supporters. Some of them were rather tepid. "Mammography was invented almost a century ago," wrote a primary care physician, "and nothing better [has emerged] since."

A colleague then pointed out that the issue is larger than simple mortality and wondered how many breasts had been saved through early detection.

One radiologist offered strong support of mammograms: "I am sticking my head in, as none of my colleagues have so far opined here...too many unnecessary studies are done...Mammograms will certainly save lives and reduce drastic operations and uncomfortable radiation and chemo when cancer is detected early...Many women are more confused now by the repeated telling about this study and explanations by unqualified doctors." He suggested that it would be wise to 'always get a second opinion from a senior radiologist.'"

An internist then offered a candid admission of practical behavior: "For the record, I'm still going to order yearly mammograms until some authoritative body tells me differently. I don't wish to be trying to tell a judge and jury how useless the test might be."

And an oncologist offered a possible positive result of this debate: "I think a risk-related screening algorithm will probably emerge."

But a gastroenterologist quickly countered: "We already have a risk-based strategy. It is already age- and sex-based. We can add more risks to make us look smarter by putting genetic profiles and some other factors to make it more complicated. It will justify milking the people for another few decades until evidence emerge that these factors do not make any difference either."

Some physicians felt that the emphasis placed by many on catching cancer early was missing a broader point. "The problem with medical society is a preoccupation with screening for early disease as opposed to prevention," wrote an internist.

Another internist concurred: "True prevention is listening to Mom -- no reimbursement or glory in that. Get off the couch and go play outside; eat your veggies; brush your teeth; it's bedtime, go to sleep; no smoking, drinking, or drugs allowed."

A neurologist then opined that whether or not tumors were detected was largely irrelevant: "It is metastasis that kills you. Until we understand the cell biology of metastasis and how it relates to uncontrolled proliferation, all the population-based screening in the world will not reduce deaths. Screening for tumors of any kind will continue to just detect huge numbers of tumors that would not have killed anyone if left alone, and these statistically dilute out the small number of lives that actually are saved."

In this limited sample of doctors, the overwhelming view of the value of mammograms was one of marked skepticism and concern, so the last word goes to the only doctor who reported receiving a mammogram personally, an internist: "I am aware of the data over the past 20 years that routine screening mammography does not save lives. I had my first mammogram this year at age 50. I am low risk. I might not have another screening mammogram for several years. Glad to see these data support my decision."

The full discussion of this topic is available online. Please note that this is open to physicians only.

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