Time to Stop Pressuring Women on Screening Mammography?

Andrew M. Kaunitz, MD


July 30, 2020

This transcript has been edited for clarity.

Although recommending screening mammograms continues to represent standard of care, studies from the United States and other countries, including the Netherlands and Norway, have questioned their value.

In the June issue of JAMA Network Open, Australian investigators assessed the relative impacts of screening and adjuvant therapy on breast cancer mortality, using data from 1986 through 2013. In recent decades, screening has increased substantially among Australian women.

For cancer screening to be effective, the number of early-stage tumors diagnosed should increase while the incidence of advanced tumors should decrease.

The investigators identified some 75,000 women with invasive breast cancer in the state of Victoria, where women aged 50-69 are offered biennial screening. During this time period, the use of adjuvant tamoxifen and chemotherapy increased substantially, and breast cancer mortality declined considerably.

However, during this same time period, the incidence of advanced breast cancer doubled.

These findings parallel those from the United States and Europe, which paradoxically found that the incidence of advanced breast cancer was stable or increased after screening mammography was introduced.

The Australian authors assert that the increased incidence of advanced cancer means that screening mammography is not responsible for declining breast cancer mortality, and that all of the decline can be attributed to greater use of adjuvant therapy. In their conclusion, they state that because screening mammography does not reduce breast cancer mortality, state-sponsored screenings should be discontinued.

Although some will view the findings and recommendations of these Australian authors with skepticism or even hostility, I view their findings as good news. We have improved the treatment of breast cancer so dramatically that it has become difficult to identify the benefits of finding early tumors with screening.

Although it is challenging, given the time constraints of office visits, I try to engage in shared decision-making with my patients regarding when to start, how often to have, and when to stop screening mammography.

Given our evolving understanding regarding the value of screening, it is time to stop pressuring patients who are reluctant or unwilling to undergo screening. Likewise, insurance companies and government agencies should stop using screening mammography as a quality metric.

Thank you for the honor of your time. I am Andrew Kaunitz.

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