Beyond the Mammography Debate: A Moderate Perspective

Abstract

After some decades of contention, one can almost despair and conclude that (paraphrasing) "the mammography debate you will have with you always." Against that sentiment, in this review I argue, after reflecting on some of the major themes of this long-standing debate, that we must begin to move beyond the narrow borders of claim and counterclaim to seek consensus on what the balance of methodologically sound and critically appraised evidence demonstrates, and also to find overlooked underlying convergences; after acknowledging the reality of some residual and non-trivial harms from mammography, to promote effective strategies for harm mitigation; and to encourage deployment of new screening modalities that will render many of the issues and concerns in the debate obsolete.To these ends, I provide a sketch of what this looking forward and beyond the current debate might look like, leveraging advantages from abbreviated breast magnetic resonance imaging technologies (such as the ultrafast and twist protocols) and from digital breast tomosynthesis-also known as three-dimensional mammography. I also locate the debate within the broader context of mammography in the real world as it plays out not for the disputants, but for the stakeholders themselves: the screening-eligible patients and the physicians in the front lines who are charged with enabling both the acts of screening and the facts of screening at their maximally objective and patientaccessible levels to facilitate informed decisions. Key Words REFLECTIONS ON SOME CENTRAL THEMESAll screening programmes do harm; some do good as well, and, of these, some do more good than harm at reasonable cost.-Sir Muir Grey, former director of the U.K. National Screening Committee 1 Some Issues Deserving More AttentionSeveral core issues require closer examination:1. The potential benefits of mammographic screening independent of whether ultimate survival is affected, including diagnosis at earlier stages, typically with smaller tumours and node negativity; reduced likelihood of aggressive treatments and morbidities; detection of high-risk lesions (most diagnosed in the screened group 2 ) allowing for chemoprevention or magnetic resonance imaging (mri) surveillance against occult malignancies, or both; and avoidance of compromised quality of life after diagnosis of advanced disease It is not clear, as often assumed, that survival is the best (or only) measure for judging mammographic screening 2,3 . And it remains open whether claimed harms truly are disproportionate to benefits when using, for instance, a more nuanced definition of overdetection than simply breast cancer (bca) diagnosed but not bca expired (distinguishing, for example, longer recurrence-free survival from simple overall survival benefit).

Breast Cancer Screening: An Assessment of Awareness, Attitude and Practice among Female Clients Utilizing Breast Imaging Services in South-Western Nigeria

“…Notwithstanding, the contribution of breast self-examination, clinical breast examination, ultrasonography and even mammography to reduce the number of deaths from cancer is currently a source of controversy. [16] However in developing countries were late presentations is rampant, promoting the practice of breast self-examination, clinical breast examination and regular mammography screening remains advantageous. Mammography is gradually becoming more available in health care facilities across Nigeria.…”

The WISDOM Study: breaking the deadlock in the breast cancer screening debate

“…Like the screening debates that preceded it, the controversy surrounding overdiagnosis has now settled into a familiar pattern. It focuses on largely technical arguments over statistical assumptions, corrections for lead time bias and varied demographics 23 , 24 that create uncertainties in the data and ultimately have shifted the debate into the realm of opinion, rather than fact. Recent characterization of a molecular profile to define an ultralow risk biology may provide a tool to more objectively categorize ultralow risk breast cancers that have little systemic risk of progression.…”

Family doctors should engage with patients about mammography

“…The Independent UK Panel on Breast Cancer Screening reported that for every 10 000 UK women aged 50 years invited to screening for the next 20 years, 43 deaths from breast cancer would be prevented and 129 cases of breast cancer, invasive and non‐invasive, would be over diagnosed (Marmot, ). The purpose of this editorial is not to resolve the debate about the risk‐benefit ratio of mammography but to place this debate in the context of primary care clinical practice (Kaniklidis, ).…”

“…The purpose of this editorial is not to resolve the debate about the risk-benefit ratio of mammography but to place this debate in the context of primary care clinical practice (Kaniklidis, 2015).…”