Recent data show that mammographic screening of asymptomatic women is effective and essential.

Abstract

http://dx.doi.org10.1118/1.3694115] OVERVIEW Screening mammography is employed widely both in the United States and abroad. Several recent publications, however, have claimed that screening does not reduce breast cancer mortality and causes over-diagnosis resulting in unnecessary mastectomies. Others claim that mammographic screening of asymptomatic women is effective and essential. This controversy is debated in this Point-Counterpoint by four of the world's leading experts in screening mammography. more than 25 years of ex-perience including Director of Women's Imaging, Body MRI, and Genitourinary Radiology, Dr. Javitt is Adjunct Professor of Radiology, Uniformed Ser-vices University of the Health Sciences, Walter Reed Army Medical Center, Washington, DC, where she leads education and teaching in Urology and Obstetrics and Gynecology. She is the Section Editor of Women's Imaging for the Ameri-can Journal of Radiology (AJR), President of the Society for the Advancement of Women's Imaging, Chair of the

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POINT/COUNTERPOINT
Suggestions for topics suitable for these Point/Counterpoint debates should be addressed to Colin G. Orton, Professor
Emeritus, Wayne State University, Detroit: ortonc@comcast.net. Persons participating in Point/Counterpoint discussions are
selected for their knowledge and communicative skill. Their positions for or against a proposition may or may not reflect their
personal opinions or the positions of their employers.
Recent data show that mammographic screening of asymptomatic women
is effective and essential
Marcia C. Javitt, M.D.
Uniformed Services University of the Health Sciences, Walter Reed Army Medical Center,
Washington, DC 20307
(Tel: 202-782-3788; E-mail: femscan@aol.com)
R. Edward Hendrick, Ph.D.
University of Colorado–Denver, Tinmath, Colorado 80547
(Tel: 970-980-5852; E-mail: edward.hendrick@gmail.com)
John D. Keen, M.D.
John H. Stroger, Jr. Hospital, Chicago, Illinois 60612
(Tel: 312-864-3825; E-mail: jkeen@cookcountyhhs.org)
Karsten Juhl Jørgensen, M.D.
The Nordic Cochrane Centre, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
(Tel: 45 3545 7151; E-mail: kj@cochrane.dk)
Colin G. Orton, Ph.D., Moderator
(Received 23 February 2012; accepted for publication 23 February 2012; published 8 June 2012)
[http://dx.doi.org10.1118/1.3694115]
OVERVIEW
Screening mammography is employed widely both in the
United States and abroad. Several recent publications,
however, have claimed that screening does not reduce breast
cancer mortality and causes over-diagnosis resulting in
unnecessary mastectomies. Others claim that mammographic
screening of asymptomatic women is effective and essential.
This controversy is debated in this Point-Counterpoint by four
of the world’s leading experts in screening mammography.
Arguing for the Proposition are
Marcia C. Javitt, M.D. and R.
Edward Hendrick, Ph.D. With
more than 25 years of ex-
perience including Director of
Women’s Imaging, Body MRI,
and Genitourinary Radiology,
Dr. Javitt is Adjunct Professor
of Radiology, Uniformed Ser-
vices University of the Health
Sciences, Walter Reed Army
Medical Center, Washington,
DC, where she leads education
and teaching in Urology and Obstetrics and Gynecology. She
is the Section Editor of Women’s Imaging for the Ameri-
can Journal of Radiology (AJR), President of the Society
for the Advancement of Women’s Imaging, Chair of the
American
ology
Subcommittee for Reproduc-
tiveEndocrinology,
of the American College of
Radiology (ACR) Appropri-
ateness Criteria Committee on
Women’s Imaging, and Chair
ofthe Radiology
Curriculum Committee
the Society of Uroradiology.
Dr. Javitt is co-founder and
co-editor of the AJR “Masters
BoardofRadi-
Exam(ABR)Core
Chair
Resident
for
of Radiology Series.” She has authored two textbooks and
multiple book chapters and her main research interests
are women’s and genitourinary imaging, and preoperative
staging of gynecologic malignancies. Dr. Hendrick is Clinical
Professor of Radiology at the University of Colorado–Denver,
School of Medicine. A board-certified diagnostic medical
physicist, he helped establish the ACR’s Mammography,
Stereotactic Breast Biopsy, MRI, and Breast MRI Accredita-
tion programs, and currently serves as Co-Chair of the Breast
MRI Accreditation program. He helped define both ACR and
Federal Drug Administration (FDA) standards for mammog-
raphy equipment and quality control, is the lead author on all
four editions of ACR’s Mammography Quality Control Man-
ual, and was co-principal investigator of the NCI-sponsored
ACRIN DMIST trial of digital mammography.
4047Med. Phys. 39 (7), July 2012© 2012 Am. Assoc. Phys. Med. 40470094-2405/2012/39(7)/4047/4/$30.00

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4048Javitt et al.: Point/Counterpoint4048
Arguing against the Propo-
sition are John Keen, M.D.
and Karsten Juhl Jørgensen,
M.D. Dr. Keen received co-
terminal AB/BS degrees in
Economics and Chemical En-
gineering from Stanford Uni-
versity in 1985. He worked as
an economist and consumer ad-
vocate for several years with
the state of California, and re-
ceived an MBA from the Uni-
versity of California, Berkeley
in 1989. He obtained his M.D.
degree from the University
of Illinois where he did grad-
uate research in microwave
spectroscopy. He completed a
residency in diagnostic radiol-
ogy at Cook County John H.
Stroger Jr. Hospital in Chicago
in 2000, and currently works
there as an attending radiol-
ogist. His research interests
includeeconomic
and consumer awareness in
analysis
radiology. Dr. Jørgensen received his medical degree from
the University of Copenhagen, Denmark in 2003. Since
completing his internship at the University Hospital in
Herlev, Copenhagen, he has been employed as a researcher
at the Nordic Cochrane Centre in Copenhagen. His research
training includes a stay at the Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD in 2006. His main
research interest is breast screening, including systematic
reviews, epidemiological studies, and ethical aspects of
invitations and informed consent. His research has also
included research methodology and general health checks.
FOR THE PROPOSITION: Marcia C. Javitt, M.D.
and R. Edward Hendrick, Ph.D.
Opening statement
Although screening mammography is hotly debated, re-
cent randomized controlled trial (RCT), case-control (com-
paring women who had developed breast cancer with matched
control subjects who had not), and service screening (women
invited to a screening service) data confirm that screening
mammography saves women’s lives.
A 29-year follow-up of the Swedish two-county trial
showed that women aged 40–74 “invited to screening” had
a statistically significant 31% fewer breast cancer deaths than
uninvited women.1This is consistent with the first published
results from this study that showed a significant 30% re-
duction in breast cancer mortality among women invited to
screen.2
Three other population-based trials in Sweden (1976–
1990) compared groups of women invited to screening mam-
mography to a usual-care (non-invited but may or may not
have received mammograms as part of their normal health
care) control group. While all four Swedish trials differed in
numbers of rounds of screening (2–5), screen intervals (18–
33 months), numbers of mammographic views (1 or 2), and
ages of women at entry to the study (39–74 years), the four
trials combined showed a statistically significant 23% reduc-
tion in breast cancer deaths in the “invited to screen” group
compared with uninvited women (95% confidence interval:
12%–33%).3,4Two other population-based RCTs, the Health
Insurance Plan of New York (HIP) and Edinburgh trials, each
demonstrated statistically significant benefit from “invitation
to screening.”5–8Recent analysis of RCTs done for the U.S.
Preventive Services Task Force yielded a statistically sig-
nificant mortality benefit from screening mammography in
women of each age decade from 40 to 69 years.9,10
RCTs underestimate the true benefit of screening because
not all women randomized to “invitation to screening” at-
tend screening, but all breast cancer deaths in this group
count toward mortality in the “invited” group, whether they
attended mammography or not. Of women invited to screen-
ing in the HIP trial, only 67% attended the first round, 53%
attended the second round, and less than half attended 3rd and
4th rounds.5–7Similarly, women randomized to the uninvited
group can receive mammography outside the trial, but their
breast cancer deaths are counted as mortality among the con-
trol group. It was estimated that 20%–30% of control group
women in RCTs had at least one mammography exam outside
the trial.11
Most RCTs had longer screening intervals than the ACR
recommendation of annual screening, some used only a single
view per breast rather than two as ACR recommends, and all
were performed with old technology.
More recent case-control and service screening studies
have assessed the benefit of mammography among women
who actually received screening compared to women who
did not. A case-control study of the Dutch population-based
screening program showed that mammography screening re-
duced breast cancer deaths by 49% compared to unscreened
women.12These results are consistent with service screening
programs showing that women screened regularly have 40%–
76% fewer breast cancer deaths than unscreened women.13–15
Ironically, increased criticism of screening mammography
is occurring just when we are starting to get mammography
“right” with high technical quality, improved interpretation,
and minimally invasive breast biopsy. The real question is not
whether we should be screening U.S. women with mammog-
raphy, but how we can overcome socio-economic barriers16
and extend the proven benefits of mammography screening to
all U.S. women over age 40.
AGAINST THE PROPOSITION: John D. Keen, M.D.
and Karsten Juhl Jørgensen, M.D.
Opening statement
Over the past few years, multiple papers have questioned
the benefit of mammographic screening17,18and have shown
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4049Javitt et al.: Point/Counterpoint4049
thatscreeningcauses over-diagnosis (diagnosisofdiseasethat
would never cause symptoms), leading to increased mastec-
tomy use.19,20
The premise of mass screening is that earlier interven-
tion will prevent advanced disease and therefore reduce breast
cancer deaths. However, an overview of seven countries with
long availability of breast screening, including the United
States, found no reduction in late stage disease since screen-
ing started.21This is not surprising. Screening detects breast
cancers that are a little over 1 cm in diameter on average,
rather than 2 cm for clinically detected disease.22This rep-
resents a reduction of 1–2 volume doublings of the 32 neces-
sary to reach 2 cm (Ref. 22) and is equivalent to a few months
growth for aggressive, fast-growing cancers22which therefore
easily“slipthrough the screen.” Onthe contrary,screening ef-
fectively detects slow-growing and dormant tumors, resulting
in over-diagnosis.
Screening advocates usually cite trials from Sweden. But
despite high participation since screening started in the
mid-1980s, the breast cancer mortality reduction in Swe-
den has been only 16% from 1989 to 2006 in women aged
50–69 years, much less than in Denmark (−26%) and Nor-
way (−23%), which had only limited screening, e.g., only
20% of women aged 50–69 years were offered screening in
Denmark.24The average reduction in breast cancer mortality
in Europe has been almost twice as large in younger, non-
screened age groups as in those screened, and equally large in
countries with and without screening.24The primary cause of
improvements in mortality has been more effective therapy,
not screening.25
Screening’s effect on the recorded incidence of ductal car-
cinoma in situand early stage invasive breast cancers has been
massive,bothincreasingseveral-foldsincescreeningbegan.25
This is due to the detection of cancers which would never
become clinically evident, let alone lethal, without screening
(over-diagnosis). Screening participation turns thousands of
healthy women into breast cancer patients, whom we treat
with surgery, radiotherapy, and possibly chemotherapy, as we
cannot tell which cancers are over-diagnosed. If screening re-
duces breast cancer mortality by 15%, which is optimistic, ten
times as many women receive unnecessary treatment as will
benefit.25
The U.S. status quo, aggressive annual screening starting
at age 40 that our colleagues continue to advocate,26likely
costs close to one million dollars for every life-year saved,
10–20 times more than we accept for other interventions.27
Independent panels in both the United States9and Canada28
found that screening women in their 40s is questionable and
thatbiennialscreeningstartingatage50ispreferred,inagree-
ment with policies in Europe. Hubbard et al. have shown that
annual screening does not reduce the proportion of advanced
cancers. Furthermore, the cumulative false-positive rate af-
ter 10 years for women ages 40–59 was 61% with annual
versus 42% with biennial screening.29Certain professional
groups benefit from the status quo,30while many doctors are
reluctant to change established beliefs about cancer biology.
Currently, the United Kingdom is reviewing the rationale for
breast screening because of the new evidence.31We question
if screening mammography is justifiable at all, but especially
the aggressive annual screening of younger women.
Rebuttal: Marcia C. Javitt, M.D. and R. Edward
Hendrick, Ph.D.
Screening mammography saves lives.1–10,12–15Our col-
leagues distract readers from this fact by raising issues such as
over-diagnosis, irrelevant population mortality data, and mis-
stated RCT data. They confuse over-diagnosis with overtreat-
ment (mastectomy). The great majority of cancers, including
high-grade DCIS (the DCIS predominately detected by mam-
mography), will progress to metastatic breast cancer (distant
metastases) if untreated. Recent estimates of the rate of over-
diagnosis by screening mammography range from less than
1% to 10%.9,10Since no marker exists to identify the few
cancers that would not progress, it would be irresponsible
to advise against treating a diagnosed breast cancer. Breast
cancer treatment in the United States is now highly person-
alized, taking into account cancer biology, patient age, and
health. The vast majority of women with mammographically
detected breast cancers are offered breast conserving therapy.
Mastectomy is reserved for women who are not candidates
for, or decline, breast conservation.
In the United States, at diagnosis less than 5% of breast
cancers are stage IV (distant metastases) and less than 6%
are stage III (locally advanced) (SEER Cancer Statistics Re-
view, 1975–2008, and SEER Survival Monograph, 2007)). It
is faulty logic to criticize screening mammography by point-
ing to a lack of reduction in late stage cancers in a popula-
tion where more than one-third of eligible women are not
screened. In truth, mammography screening yields a signif-
icant decrease in late stage breast cancers, decreasing mor-
bidity as well as mortality, and empowering more women to
benefit from breast-conserving treatment.
Our colleagues’ statement “If screening reduces breast
cancer mortality by 15%, which is optimistic, ten times as
many women receive unnecessary treatment as will benefit” is
incorrect. They inappropriately apply RCT results for women
40–49 to all women age 40 and over, underestimating lives
saved by screening by as much as two-fold.1–10Case con-
trol and service screening results show that women attend-
ing screening have mortality reductions ranging from 28% to
65%.11–15
The consequences of less screening are later stage breast
cancers and increased breast cancer mortality. Failure to pro-
vide screening mammography puts women’s lives at risk.
Rebuttal: John D. Keen, M.D. and Karsten Juhl
Jørgensen, M.D.
Evidence-based medicine is about relying on the best
available evidence and discarding that which is flawed. Our
opponents seem to prefer the most optimistic results without
assessing their validity, and to disregard unwelcome ones.
The Edinburgh trial is widely recognized as untrustwor-
thy. It randomized 87 general practices, which led to substan-
tial baseline imbalances. Twenty-six percent of the controls
belonged to the highest social group versus 53% of the
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4050Javitt et al.: Point/Counterpoint4050
intervention group, leading to a spurious 26% reduction in
cardiovascular mortality in those screened, which obviously
cannot be a screening effect. The Swedish Two-County trial
randomized only half as many clusters, but we cannot know
if this led to similar baseline imbalances, as only the age
distribution has been published, where there was a differ-
ence between groups. The lead investigator has not accommo-
dated requests for supplementary baseline data. Long follow-
up cannot compensate for fundamental flaws, and trials of
high methodological quality (the Malmö and Canadian trials)
did not find an effect of screening.28
Reports have repeatedly pointed out that case-control stud-
ies should not be used to assess cancer screening because the
small possible effect is prone to substantial bias that favors
screening.32These studies compare breast cancer mortality in
attendees with non-attendees, but the attendees are predomi-
nantly the affluent and healthy. When the Malmö randomized
trial was analyzed as a case-control study, it showed a 58%
reduction in breast cancer mortality after 9 years when in fact
the trial found only a 4%, non-significant, reduction.32
Benefits should be presented in context. A 15% relative
risk reduction for ages 40–49 is 0.047% in absolute terms.28
Increased screening participation also means proportional in-
creased over-diagnosis, while increased screening frequency
does not provide further benefit.28
Flawed studies have determined our current screening
policy. We must stop uncritically accepting results we like
and face the facts: comparisons between screened and non-
screened countries and age groups clearly show that better
treatment, not screening, has caused the decline in breast
cancer mortality.
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The views expressed in this article are those of the authors
and do not necessarily reflect the official policy or position of
the Department of the Army, Navy, Department of Defense,
nor the US Government.
Medical Physics, Vol. 39, No. 7, July 2012