What do I think the "truth" is about screening mammography? The simple truth is surely complex: whether or not mammography helps depends on a number of factors.
First, whether or not mammography helps depends on what it's being compared to. It is certainly better than nothing when "nothing" is no mammography, no clinical breast exam, and low awareness of breast cancer in general. In fact, one of the side effects of promoting mammography may have been to increase women's awareness of breast cancer in general, such that they seek medical care more quickly when they find a breast lump for the duration of normal life.
It is equally possible, however, that mammography is no better than a good clinical breast exam though to be certain, it might be challenging such an exam. The clinical breast exam done in the Canadian trial was carefully standardized, lengthy (5–15 minutes per patient), and generally performed by specially trained nurses. One of the advantages of mammography may be that it is easier to standardize the practice of the less than 10,000 American radiologists who read mammograms than it is to standardize the practice of the quarter of a million clinicians who might offer women clinical breast exams.
Nevertheless, the Canadian experience contains an important lesson: there is no obvious value to finding breast cancers that are so small they cannot be felt, such as most DCIS. It's also quite possible that routine screening mammography has nothing to offer women who are already sensitized to seek medical care when they find a breast lump for the duration of normal life. These women may have just the right amount of early detection.
Second, whether mammography helps depends on how one defines "helps." The truth is that mammography, like any screening test, has a combination of outcomes. Afew women probably have their lives extended those who might have ignored a new lump or those who happen to possess a mammogram at the perfect time to catch and treat a fast-growing cancer. However, many women suffer the short-term anxiety of a cancer scare because of a falsely positive exam. Some women will know about a breast cancer earlier yet not have their death postponed; they simply live longer knowing they have breast cancer. Others will be diagnosed with pseudodisease and receive surgery and radiation unnecessarily. A few will even have their lives shortened by treatment.
To date, researchers have focused largely on the number of breast cancer deaths. Little attention has been given to measuring the adverse effects of breast cancer screening and treatment.
Finally, whether or not mammography helps depends on how it is done. Although we often use the word mammography as if it were a simple procedure, in reality it's a multistep process, each step having its own set of questions. How often should it be done?
How many views should be taken? How much should the image be enhanced or magnified? How aggressively should the radiologist recommend biopsy for abnormalities? How aggressively should early abnormalities be treated? How these questions are answered will ultimately determine the effect of screening. It is commonly assumed that more is always better: more frequent mammograms, more views, more magnification, more recommendations for biopsy, and more aggressive treatment will all result in a better result. Of course, it's not that simple.
It's possible, for example, that annual mammography for women in their 40s makes little difference, but doing it every three months would do some good, since younger women are apt to have faster-growing cancers. Yet that might be too much radiation, in addition to meaning more biopsies, more cancers found, and more people being treated.
What if instead of more we did less might that not lead to a better result? To avoid a lot of pseudodisease and false positives, what if radiologists just looked for masses? The tiny microcalcifications associated with DCIS could be watchfully monitored (or ignored), but treatment could be deferred until it was clear that the abnormality was something to act on. As for treatment, might not some mammographically detected cancers be best treated not by surgery, but with hormonal manipulation (i.e., by stopping estrogen in those women who are on it and/or giving an antiestrogen like Tamoxifen)?
But then again, maybe if we do less, some cancers would be missed or undertreated. To understand these variables better, more research is needed.
Are you paying attention? I just walked you through eight big studies which have been conducted over the past 40 years: almost 500, 000 women entered in randomized trials of mammography; millions of dollars' worth of research. No cancer test has been more carefully studied. And we still need more research? The truth is, we do. There are other questions we need answers to before we can say how best to screen for breast cancer.
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