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NEWS EXTRA: Mammography no better than physical breast examination, study shows BMJ 2000; 321: 788e [Full text]

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Mortality is not the only measurement

Frank Leavitt   (30 September 2000)

Mammography no better than physical breast examination

Anthony B Miller   (5 October 2000)

Mortality is not the only measurement 30 September 2000
Frank Leavitt, Chairman, Centre for Asian and International Bioethics, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel Send response to journal: Re: Mortality is not the only measurement	The study (as reported here) compares only on the basis of mortality. But early detection might result in simpler surgery with less disfigurement and less need for reconstruction. So it is not yet clear that examination is as good as mammography. On the other hand the impersonal aspect of mammography should not be ignored. A woman once told me about being handed an envelope with the results of her mammography inside, and being told to take the envelope to her doctor. She could not resist reading the document. She did not understand the medical language. But one word -- "spread" -- gave her almost enough shock to kill her. When she finally got an appointment with her doctor she learned that all she had was an annoying but harmless intraductile cyst. But it took her months to recover from the shock. Obviously mammography, and reporting results to the patient, should be conducted with as much attention to doctor-patient relationship and to ethics as is examination.
Mammography no better than physical breast examination 5 October 2000
Anthony B Miller, Head, Division of Clinical Epidemiology Deutsches Krebsforschungszentrum, Heidelberg, Germany Send response to journal: Re: Mammography no better than physical breast examination	Deborah Josefson's description of our study was accurate, though she speculates that there may have been a difference in the distribution of aggressive tumour types. However, all the indicators we have of the aggressiveness of tumours, size, nodal status, estrogen receptor status show if anything the advantage was to the mammography arm. However, Dr Robert Smith, of the American Cancer Society, dismisses our findings, making accusations that have repeatedly been refuted by us, as he is well aware. To explain our lack of mortality difference he is essentially saying that the mammograms in the Canadian National Breast Screening Study were not capable of resulting in a reduction of breast cancer mortality. But he does not explain how the much greater detection rate of breast cancer in the mammography arm, the detection of a large number of small impalpable breast cancers, the lead time gained by mammography, and the reduction in interval cancer rates in the mammography arm compared to the physical examination alone arm, all expected by modern mammography and achieved in our study, fail to result in a reduction in breast cancer mortality. The fact is that we have shown that these parameters are indicators of the early detection of cancers with an inherently good prognosis, hence the lack of mortality differential. Dr Leavitt suggests that there may be an advantage to mammography from less simpler surgery, with less disfigurement and less need for reconstruction. This was not so in our study. Largely because of the much greater detection of in situ cancer, there were more women who had mastectomy in the mammography arm, and of course, many more had biopsies for non-malignant disease. The null hypothesis at the onset of our study was that mammography was responsible for the reduction in breast cancer mortality as seen in the Health Insurance Study in this age group when screening with mammography plus physical examination was compared to no screening. This hypothesis has been disproved at a 95% confidence level that excludes the benefit seen in the HIP study, and for that matter in the Swedish two county trial as well.