Reviews

The great American mammography debate

It all started quite quietly. Tucked away on page 16 of the New York Times in the fourth week of January was a news item reporting that a committee of cancer expertsthe Physician Data Query screening and prevention editorial board (known as the PDQ board)had found that there was insufficient evidence to show that mammograms prevented breast cancer deaths.

The New York Times followed up its news story with a measured editorial, pointing out that a great deal of money was at stake. It predicted that it would not be easy to get an independent review of the benefits of mammography. "Mammography has been so strongly endorsed by the cancer establishment, and has become such a significant source of revenue . . . for many hospitals and doctors, that it may be difficult to excise without overwhelming evidence that it is dangerous. Officials at the National Cancer Institute are said to be reviewing the matter. The institute's new director, Dr Andrew C von Eschenbach, needs to make it a priority."

But at this stage the war was not yet fully under way. Because the committee that had published the findings was highly prestigiousmade up of experts from government, leading medical organisations, and academiait would have to be answered by organisations of comparable status if it was going to be decisively defeated.

So on 31 January, the big guns opened fire. A full page advertisement appeared in the New York Times (p A19), signed by 10 medical organisations, including the American Medical Association, the American Academy of Family Physicians, the American Cancer Society, and the American College of Preventive Medicine.

(Credit: MAURO FERMARIELLO/SPL) View larger version (102K): [in this window] [in a new window]   Breast screening: now the focus of a bitter media battle

After reviewing the background of the debate, the advertisement said: "We have grave concerns that these public debates have already begun to erode the confidence in mammography that has been built up over the past two decades. While mammography is not a perfect tool, it is effective and has contributed significantly to the declines in breast cancer mortality since 1990."

Other big guns weighed in. The National Cancer Institute, despite the fact that it uses the PDQ board to provide information for its online database, sided with the medical establishment and the status quo. It issued a press release, saying that women should continue to attend for mammograms.

It said:

• Women in their 40s should be screened every one to two years with mammography.
• Women aged 50 and older should be screened every one to two years.
• Women who are at higher than average risk of breast cancer should seek expert medical advice about whether they should begin screening before age 40 and the frequency of the screening.

Dr von Eschenbach concluded: "It is absolutely essential to look beyond the debate over the limitations of current data and to accelerate the development of better screening tools."

The war continued to rage both in the newspapers and on television. On Saturday 2 February, Weekend Journal on CBS News featured Lorraine Pace, a breast cancer survivor and mammography activist, and Dr Peter Greenwald, the National Cancer Institute's cancer prevention chief, who said: "The guidelines won't change."

It was left to the New York Times to deplore the defensiveness of much of the debate. On 5 February, an editorial entitled "Circling the Mammography Wagons" began: "As the debate over the value of mammography intensifies, it is disappointing that key organizations and individuals in the cancer establishment have mostly chosen to draw their wagons in a defensive circle."

The editorial concluded: "But a serious and open reassessment of the data is crucial." It suggested that either the National Cancer Institute or the National Academy of Sciences would be the most credible organisation for the task.

It would be nice to think that a serious reassessment of the data could be undertaken, but since the mammography business is worth between $3bn (£2.13bn) and $4bn a year and 30 million US women have mammograms every year, the signs do not look hopeful.

Fred Charatan, retired geriatric physician. 

Florida, USA