A recent short article by Tracy Clark-Flory on Salon.com asks the provocative question: “Should we be pushing mammograms?” Her question is based on a July 21 editorial in the Journal of the National Cancer Institute, which reviewed  one of the journal’s  recent research papers: “Interventions to promote repeat breast cancer screening with mammography; a systematic review and meta-analysis.”

In that paper, Sally W. Vernon and her research team evaluate the effectiveness of various methods in getting women to return for their screening mammograms. Their findings suggested that certain methods of educating women about screening guidelines are not an effective use of time or money. (Presumably the methods they named are what Clark-Flory is referring to when she asks about “pushing.”) A number of reasons are cited in the editorial, which states that “women are making an informed choice to not use an imperfect technology” (in other words, routine screening mammograms). Clark-Flory seized on this bold statement, calling it “a radical hypothesis.”

But is it really true? How are women making this informed choice, and on what basis? And is there a better, more “perfect” screening technology?

Regarding the first question, what does an informed choice mean? Are large numbers of women deciding whether or not they should have a mammogram after evaluating the scientific literature—including multiple randomized control trials and their mathematical models—and poring over the statistical and outcome analysis of the research? Or are they influenced by a cascade of editorial sound bites and articles in the general press reinforcing their choice as correct? Of course, it’s the latter. (Other factors, like the costs, inconvenience, and anxiety that accompany any screening test can’t be ignored, but even so…)

Furthermore, while benefits of screening mammograms can be quantified to a great degree by assessing additional years lived (i.e., lives saved) for those who are screened, the “harms” associated with false positive mammograms are difficult to quantify: they’re more subjective. Finally, a cost-benefit analysis of paying for screening tests is also by definition subjective, requiring societal value judgments to determine how much money a woman’s life is worth.

The notion of subjectivity, added to the scientific and social uncertainty when analyzing the benefit of screening mammograms, is even present in the controversial November 2009 US Preventive Services Task Force Recommendations. While the USPSTF recommended against routine screening mammography before the age of 50—based on its evaluation of benefits and “harms”—it concluded that “the decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms.” This statement is an acknowledgment that their recommendations are based in part on subjectively weighing the risks, rewards, and cost of screening mammograms.

So how is a woman able to make an informed decision when it is hotly contested by scientific researchers, and when science and subjectivity are interwoven in attempts to formulate public policy?

Women, much as any segment of the population, are influenced by their physicians and by the media’s interpretations of the screening debate.

In order to choose, they must be fairly apprised of the validity, benefits, and consequences of a screening mammogram. Therefore, authors who comment on this subject should use caution in how their ideas are formulated, worded, and presented as they may become the basis of “informed choice.”

Regarding the second question concerning mammograms being imperfect: Yes, they are.

I myself reported this in in 1998 and 2002, in original publications that first examined the effect of breast density, age, and hormonal status on the accuracy of the mammogram. But let’s not forget that a screening mammogram is the only proven method that reduces mortality of breast cancer (i.e., saves lives) in both younger and older age groups. One may argue that it does not do enough. But none of the others — neither MRI, ultrasound, clinical or self-examination, nor any other test — has been proven to save lives, either. They are all imperfect as well. There should be no question that there is benefit to having a screening mammogram.

The JNCI editorial concludes that “new paradigms, guided by evidence from modeling, novel trials and new science discovery will be needed to realize the promise of eliminating the burden of cancer.” Eliminating the burden will certainly be difficult, but arguing for new paradigms is easy and not really new. I’ve scientifically researched and published articles about alternative methods of screening, most notably screening breast ultrasound. No one understands better than I do that we need better screening (and treatment) methods to lessen the burden of breast cancer. But we are not there yet.

Vernon’s study helps define which methods it may be useful to continue funding to help increase the rate of women doing return mammographic screening. It is highly desirable to shift saved research dollars into the discovery and study of new methods of screening that may be more beneficial than mammograms. But this is hardly a new paradigm. Trivializing mammograms as flawed and imperfect tests that are being pushed on the public does women a great disservice. It is not the optimal way to educate and allow for an informed choice.

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  • Julie Ross January 25, 2013 at 6:17 am

    I like this “Regarding the second question concerning mammograms being imperfect: Yes, they are.”

    Very true… Because nobody is.

    A very close friend of mine got a routine mammogram checkup and after a month they ruled out cancer.. But then after 6 months, they point out the cancer.. Very sad.

    Keep up the writings. Thanks