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In Mammography Debate, Still Seeking Clarity

December 23, 2010
Written by: , Filed in: Breast Imaging, Medical Ethics
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Earlier this week, Roni Caryn Rabin of the New York Times took a look back at last year’s federal task force recommendation against routine mammography screening for women in their 40s—and the subsequent uproar.

“Though the recommendations received saturation coverage in the news media last year,” the article says, “little attention was given a month later, when the panel modified its message. Concerned that it had been misunderstood, the panel took the extraordinary step of amending the standard language of its recommendations and removed the critical word ‘against’ as applied to routine mammography of women in their 40s.

“It let stand the language recommending that the decision to start screening every other year ‘should be an individual one’ that ‘takes patient context into account, including the patient’s values regarding the specific benefits and harms.'”

That’s not exactly the sort of language that fits easily into a headline. Nor, for that matter, does it provide crystal-clear guidance to doctors and patients.

In fact, ambiguity emerges as a theme of the Times article. It quotes Otis Brawley, MD, chief medical officer of the American Cancer Society, as saying:

Most people think mammography is much more beneficial than it actually is. Even if you take the most liberal, most pro-mammogram argument, we need something better.

And he works for an organization that continues to advise women to start regular mammograms at age 40. Dr. Brawley says that, on balance, mammography saves lives. But he points out that it misses some cancers and that its radiation will actually cause some cancers to develop.

The article also devotes considerable space to another doctor, Marisa Weiss, MD, of Wynnewood, Pennsylvania, near Philadelphia. Dr. Weiss, a radiation oncologist and specialist in breast cancer, founded the popular Web site breastcancer.org and is writing her third general-audience book on breast cancer.

This year, she also became a breast cancer survivor. In spring 2010, as she had for a decade, Dr. Weiss underwent a routine mammogram. This one found invasive Stage 1 cancer in her left breast. She had surgery and, because the cancer had not spread, avoided radiation and chemotherapy.

Dr. Weiss believes that earlier puberty, rising rates of obesity and alcohol consumption, environmental pollution, long-term use of oral contraceptives, later childbearing, and reduced rates of breast-feeding may lead to more breast cancer emerging at younger ages.

She also believes that a mammogram may have saved her life.

So taking into account “the patient’s values regarding the specific benefits and harms” gets kind of complicated, particularly for women in their 40s. We’ll let Bruce Ned Calonge, MD, chairman of the famous (or infamous) United States Preventive Services Task Force, have the last word:

We didn’t say, ‘Don’t screen.’ The intent of the task force was to promote shared decision-making between physicians and women in that age interval.

Related seminar: Breast Imaging and Digital Mammography

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