Internists’ incendiary mammography advice reopens old wounds

A new guideline from the American College of Physicians suggesting that mammography for women in their forties is optional and risky has reignited an old debate mammographers thought had finally been put to rest.

The guideline, published in the peer-reviewed Annals of Internal Medicine (2007 146:511-515), advises women aged 40 to 49 to consult with their physicians regarding the appropriateness of mammography, based on their personal risk for breast cancer.

It emphasizes the risks inherent with screening, such as false positives and biopsies of benign lesions, and, controversially, questions the value of detecting ductal carcinoma in situ. According to the guideline, women should be informed of the benefits and risks of screening and reevaluate whether a mammogram is appropriate every one to two years, because the benefits of mammography increase as they grow older.

The ACP says the guideline was developed by a diverse committee of nine physicians, including community and academic doctors. It was reviewed by several college committees and distributed to external groups, including the National Cancer Institute, prior to publication. The NCI itself supports screening women in their forties, as does the American Cancer Society, among other organizations.

In interviews with Diagnostic Imaging, leading mammographers reacted to the ACP advice with incredulity. They noted that prospective randomized clinical trials clearly show that routine screening mammography helps reduce mortality rates in women aged 40 to 49 years. Mammography screening can reduce breast cancer deaths by about 20% to 35% in women aged 50 to 69 and by about 20% in women aged 40 to 49, according to the Centers for Disease Control and Prevention.

"The guideline is really silly. I don't know why the ACP is promulgating this statement. Over the past few decades, consensus from a large number of professional organizations has recommended screening for women aged 40 to 49," said Dr. Carl D'Orsi, vice chair of the ACR commission on breast imaging.

The cautious ACP guideline appears based mainly on the risks of screening, which have been deemed acceptable relative to benefits of mammography, D'Orsi said.

"I think the ACP statement is inappropriate at best and irresponsible at worst, because it may discourage [younger] women from undergoing screening. Some, perhaps, will die of breast cancer if they are not diagnosed early enough," he said.

A study published last month shows that conflicting advice from experts about mammography lowers participation and increases levels of worrying (Cancer Epidemiol Biomarkers Prev 2007;16(3)458-466). The study, conducted at the Group Health Cooperative of Puget Sound in Seattle, involved telephone surveys of women in the Maximizing Mammography Participation Trial. Most respondents were white and well educated, so it is unclear if the findings would apply to other demographic groups, according to the study authors.

The ACP says the guideline should not deter women from getting screening.

"It is important to emphasize that we are not saying women in their forties should not have mammography. If, based on risk factors and discussion of benefits and harms, a woman decides to be screened, the physicians should support that decision," said Dr. Amir Qaseem, senior medical associate in the ACP department of clinical programs and quality of care. "We are recommending periodic evaluation of an individual woman's risks of developing breast cancer and shared decision making between a woman and her clinician."

For more information from the Diagnostic Imaging archives:

Experts weigh earth-shaking implications of new breast MRI guidelines

Mammography growth slows in medicare group

Updated breast screening study revives controversy

Screening mammography: Practitioners consider Europe in quest for better quality

NCI study affirms that breast screening saves lives