http://bmj.com/cgi/content/full/324/7336/506

 

BMJ 2002;324:506 ( 2 March )

News

US issues new guidelines as mammography debate continues

Deborah Josefson, Nebraska

US health officials have released new clinical guidelines backing routine mammography for women aged 40 and over in the wake of growing controversy over the value of such testing in reducing deaths from breast cancer.

Although it is widely accepted that screening mammography leads to earlier detection of breast cancer, questions have been raised over whether such early detection actually translates into greater survival, and these have led to a heated media debate in the United States (16 February, p 432).

A media debate began in January, when the Physicians Data Query screening and prevention editorial board, an independent panel of US medical experts that advises the National Cancer Institute, concluded that there was insufficient evidence to show that mammography reduced breast cancer mortality (2 February, p255).

The board's statements followed a Danish meta-analysis published in the Lancet (2000;355:129-34[Medline]) that concluded that screening mammography failed to affect breast cancer survival. A 1999 Swedish study found no decrease in breast cancer mortality in Sweden despite routine screening mammography in that country since 1985 (Lakartidningen 1996;96:904-13).

The latest recommendations, which support mammography, come from the US Preventive Services Task Force. They are based on a meta-analysis of eight randomised control trials with 11-20 years of follow up published since 1996. They found methodological errors in each of the trials investigated but rated only one of the trials as "poor" in quality of evidence. They concluded that the flaws in the studies were unlikely to negate the "reasonably consistent and significant mortality reductions observed in these trials."

Four of those studies evaluated mammography alone, and four evaluated the efficacy of mammography with clinical breast examinations in increasing breast cancer survival. On the basis of these analyses, the task force endorsed screening mammography every one to two years for women aged 40 and older. This is a more stringent recommendation than their last recommendation, issued in 1996, which backed screening mammography starting at age 50.

The task force acknowledged that mammography screening carries inherent risks, such as those of false positives leading to unnecessary surgery and anxiety, but it found that screening mammography could reduce a woman's risk of dying of breast cancer by about 20%

Richard Winder, deputy national coordinator of the NHS Cancer Screening Programmes, said that his organisation would like to see the evidence that led to the task force's recommendation to screen women from the age of 40.

"The NHS Breast Screening Programme has always been based on sound research evidence. We constantly review and examine the appropriateness of screening women under 50 and whether there is a need to reduce the present screening interval," he explained. There were currently two trials examining both these issues; one would report shortly and the other would report in 2005, he added.


 

(Credit: ULRIKE PREUSS)

This portrait of Henry E and his son Jerry is one of a series of paintings by Mark Gilbert (also pictured) of patients who have had facial surgery. The exhibition, organised by the charity Saving Faces, is at the National Portrait Gallery, London, until 21 April.



© BMJ 2002

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