In 2012, Puliti et al conducted a literature review of numerous studies that compared breast cancer incidence rates in screened and unscreened populations; unadjusted breast cancer estimates ranged from 0% to 54%.29 However, when these figures were statistically analyzed to account for breast cancer risk and/or lead time bias, the values ranged from 1% to 10%. Bleyer and Welch concluded that on the basis of SEER (Surveillance, Epidemiology, and End Results Program) data for breast cancer incidence, 31% of all breast cancers and more than half of screening-detected breast cancers were overdiagnosed.30 Critics argue that after the exclusion of intraductal cancers, or ductal carcinoma in situ (DCIS) and after adjustments for various “assumptions” about baseline incidence, the rate of overdiagnosis was actually insignificant. 

Anxiety. The psychosocial effects of screening mammography can be difficult to assess. For example, the anxiety associated with a false-negative or false-positive result can adversely affect a woman’s well-being and ongoing adherence to breast cancer screening guidelines.31 Alternatively, the psychosocial effect of foregoing breast cancer screening on a woman who later is found to have breast cancer is theoretically profound, with feelings of guilt and regret compounding the emotional and psychological effects related to the new diagnosis. Therefore, one must not diminish the benefits of reassurance provided by true-negative examination results, which are eight times more frequent than false-positive results.32

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Like most medical tests, mammography is imperfect, with an estimated sensitivity and specificity of 85% and 90%, respectively.33 Moreover, the accuracy of mammography decreases with increasing breast density, which can both obscure some cancers and resemble signs of breast cancer, resulting in false-negative or false-positive results.34,35

Pain and discomfort. Pain and discomfort may be attributed to breast compression during mammography screening. Inconvenience and potential morbidity may be a further concern when a subsequent biopsy is indicated. Although these issues are seemingly insignificant within the context of mortality, they are nonetheless highly relevant to patients undergoing screening mammography.

Radiation oncogenesis. The risk for radiation oncogenesis, or the induction of cancer by mammographic radiation, is a noteworthy, albeit minimal, concern. According to a cohort study of 100,000 women undergoing mammography annually from age 40 to age 55 and then biennially until age 74, there was an estimated 0.086% risk for the development of an iatrogenic cancer, with a 0.011% risk for a corresponding cancer-related death.36 This is noteworthy within the context of a woman’s overall lifetime risk for the development of breast cancer, which is approximately 12.3%, and the fact that nearly 40,000 US women die of breast cancer annually.9

Mammography for women at increased risk

The debate over screening mammograms should pertain only to women with an average risk for developing breast cancer, not those who either warrant diagnostic mammography or are classified as being at high risk (eg, have a genetic predisposition to or family history of breast cancer). Approximately 5% to 10% of breast cancers can be linked to genetic mutations; this percentage increases nearly twofold in women with a first-degree relative in whom the malignancy has been diagnosed.37 Therefore, for women who are known carriers of a breast cancer mutation or who have a confirmed family history of breast cancer via breast imaging (eg, mammography, breast magnetic resonance imaging), surveillance mammography should be prescribed in accordance with their known risk factors.