An individualized breast cancer screening strategy for women

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Creating individualized breast cancer screening strategies is the answer to minimize the morbidity and mortality of breast cancer.
Creating individualized breast cancer screening strategies is the answer to minimize the morbidity and mortality of breast cancer.

I am often concerned about articles summarizing screening mammography data. Without fail, organizations that materially benefit most from performing mammography conclude and advocate more frequent and earlier screening mammography. Organizations composed of primary care or with minimal material benefit conclude that a more conservative screening program and more personalization, such as shared decision making, has the greatest net benefit. The cost alone, from the most aggressive screening design to the most conservative design, is in the billions of dollars. No tradeoff analysis of alternative uses of such cost is entertained.

The article, “Mammography: a review of current guidelines” characterizes the review as an effort “to minimize the morbidity and mortality of breast cancer.” The incidence of breast cancer increases with age, peaking after 50 years of age and waning after 75 years of age. The article uses relative mortality reduction as a metric of effectiveness of screening, yet the incidence in women younger than age 50 overall is low, increasing from 40 to 50 years of age. The use of relative rate reduction of mortality for a 40-year-old woman mischaracterizes the benefit of screening at that age.

Mammography started in the early 1950s with a study from HIP of New York, among others. The use of screening mammography increased precipitously during the ensuing decades typical of new technology, often for assumed or wished for benefits. A major industry was born. As happens with most new technologies, finding the optimal use or non-use takes time but almost always perseveres past the optimal benefit point or in some cases full retirement. 

I was struck by the poll results with more than 60% of respondents opting for annual mammography starting at age 40 for all women. The profile of the respondents is unknown. If this reflects the opinion of physicians at large, unbiased personalized discussions with patients as to benefits and harms of screening mammography will not ensue. The same can be said for many diagnostics and therapeutics.

I had a conversation with a radiology friend the other day. He specializes in mammography. I asked why on all of the negative screening mammogram reports that I see, the summary of findings includes a statement that the person should return in 1 year for repeat screening mammogram. He mentioned medical-legal reasons, habit, etc, but blurted out “if all physicians followed the USPSTF mammography guidelines, I would go out of business.”

So easy to ramp up, so arduous to ramp down. We owe women an unbiased discussion and most likely multiple discussions over the years about the benefits and harms of screening mammography. This effort requires acquiring the skills and the tools to perform such with excellence. Let us not be lazy and continue doing what we may have done for many years. Propagating annual screening mammography for all is not the answer. Creating individualized screening strategies for all is the answer with periodic review as the science evolves and personal values change.—Michael Montijo, MD, MPH, FACP, Nashville


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