For years, mammography has been widely accepted as the gold standard for breast cancer screening. In 2000, a Cochrane review challenged the value of screening mammography stating there was no reliable evidence that breast cancer screening reduced mortality. Other imaging modalities, such as ultrasonography and MRI, are being considered for screening; however, currently they are utilized only in specific patient populations or clinical trials. In addition to screening controversies, there are numerous questions about the most effective way to biopsy a suspicious lesion. Once a breast abnormality is discovered, numerous diagnostic modalities exist. Image-guided interventional procedures offer high accuracy for the diagnosis of nonpalpable suspicious lesions, generally without any lasting post-procedure changes on follow-up mammography.

THE MAMMOGRAPHY DEBATE

There is no evidence that clinical examination, breast ultrasonography, or teaching self examination of the breast are effective tools for early detection. However, randomised controlled trials have shown that screening by mammography can significantly reduce mortality from breast cancer by up to 40% in those who attend. The benefit is greatest in women aged 50-70 years. Published data from the combined Swedish trials showed an overall reduction in breast cancer mortality of 29% during 12 years of follow up in women aged over 50 who were invited for screening.

—Blamey RW et al. BMJ 2000;321(7262):689-93. Full Text

In 2000, we reported that there is no reliable evidence that screening for breast cancer reduces mortality. As we discuss here, a Cochrane review has now confirmed and strengthened our previous findings. The review also shows that breast cancer mortality is a misleading outcome measure. Finally, we use data supplemental to those in the Cochrane review to show that screening leads to more aggressive treatment...We have provided detailed evidence on the mammography screening trials, and hope that women, clinicians, and policy-makers will consider these findings carefully when they decide whether or not to attend or support screening programmes. Any hope or claim that screening mammography with more modern technologies than applied in these trials will reduce mortality without causing too much harm will have to be tested in large, well-conducted randomised trials with all-cause mortality as the primary outcome.

—Olsen O, Gøtzsche PC. Lancet 2001;358(9290):1340-2. Abstract

The [report does] not inspire confidence in Olsen and Gøtzsche’s judgment of study quality or for the notion that all-cause mortality is an appropriate endpoint. As if deaths from road-traffic accidents or hip fractures were in some way indicative of the effect of breast-cancer screening. ... Nothing in the report or commentary disproves the finding of millions of person-years of experimental research, and dozens of previous expert reviews, that mammographic screening significantly reduces mortality from breast cancer.

—Duffy SW et al. Lancet

ACRIN-6652: SCREENING AND DIAGNOSTIC STUDY OF DIGITAL MAMMOGRAPHY VERSUS SCREEN-FILM MAMMOGRAPHY IN THE DETECTION OF BREAST CANCER IN WOMEN OPEN PROTOCOL PROJECTED ACCRUAL: 49,500 patients Protocol: All patients undergo a two-view digital and a two-view screen-film mammography of each breast. Quality of life assessments are performed in the first 800 patients before mammography screening and 1200 (600 with positive screening results and 600 with negative screening results) after screening.   COCHRANE REVIEW: ALL-CAUSE MORTALITY IN MEDIUM-QUALITY SCREENING TRIALS AFTER 13 YEARS. Study Screened Not Screened Relative Risk*   # of Deaths # of Women # of Deaths # of Women (95% CI) Malmö 1976 2537 21088 2593 21195 0.98 (0.93-1.04) Canada 1980a 418 25214 414 25216 1.01 (0.88-1.16) Canada 1980b 734 19711 690 19694 1.06 (0.96-1.18) Subtotal 3689 66013 3697 66105 1.00 (0.96-1.05) SURGEONS Do you believe that screening mammography significantly lowers the chance of requiring mastectomy to treat breast cancer? Yes 95% Do you believe that screening mammography significantly lowers the chance of dying from breast cancer? Yes 90% Which biopsy technique is used most often for palpable breast masses suspected to be cancer? 14 gauge core needle biopsy 40% Fine needle aspiration 30% 11 gauge core needle biopsy 20% 16 gauge core needle biopsy 10% Which biopsy technique is most commonly used for nonpalpable microcalcifications that are negative on ultrasound? Single wire localization and biopsy 45% Stereotactic percutaneous core needle biopsy 40% Bracketed wire localization and biopsy 20% Stereotactic percutaneous fine needle aspiration 5% Which biopsy techniques are most commonly used for a nonpalpable mass that on ultrasound is identified to be a solid lesion? Wire localization and biopsy 35% Stereotactic percutaneous core needle biopsy 25% Ultrasonic percutaneous core needle biopsy 20% Ultrasonic percutaneous fine needle aspiration 15% Stereotactic percutaneous fine needle aspiration 5%

Baltic S. Analysis of mammography trials renews debate on mortality reduction. J Natl Cancer Inst 2001; 93:1678-9. Abstract

Blamey RW et al. ABC of breast diseases: Screening for breast cancer. BMJ 2000;321(7262):689-93. Full Text

Delorme S. Ultrasound mammography and magnetic resonance mammography as adjunctive methods in mammography screening. Radiologe 2001;41(4):371-8. Abstract

Duffy SW et al. Screening for breast cancer with mammography. Lancet 2001;358(9299):2166. Abstract

Marcy PY et al. Medical complications and medical legal pitfalls concerning interventional radiological procedures on the breast. Bulletin du Cancer 2001;88(12):1159-1166. Abstract

Olsen O et al. Quality of Cochrane reviews: Assessment of sample from 1998. BMJ 2001;323(7317):829-32. Abstract

Home | Meeting Workbook | Educational Supplement | Posters | Opinion Survey |