A paper appeared earlier this week in the Annals of Internal Medicine entitled “Screening for breast cancer in average-risk women: a guidance statement from the American College of Physicians” that has stirred up a hornet’s nest. The American College of Radiology (ACR) and the Society of Breast Imaging (SBI) have responded, making clear their opposition to the ACP guidelines that recommend biennial mammographic screening beginning at age 50. The battles lines have been drawn: it’s the physicians versus the radiologists.
The new guidelines recommend that the starting age for breast screening should be delayed from age 40 to 50, while the frequency of screening should be reduced from once a year to every other year. The ACR and SBI are adamant that these changes could lead to 10,000 unnecessary deaths per annum in the USA. They also believe that if these guidelines were followed, there would be thousands of additional surgeries, mastectomies and chemotherapy, while having a minimal impact on the so-called harms of screening (false positives and overdiagnosis).
There is a certain irony in this controversy: the published research on which the ACP guidelines are based was produced largely by radiologists. In fact, by consulting PubMed and Google Scholar, one can show that the ACP authors have never published any original research on breast cancer diagnosis or treatment. They relied exclusively on randomized controlled trials (RCTs) but as Debra Monticciolo, professor of radiology at Texas A&M pointed out: “While many RCTs are good studies, all are more than 25 years old – some more than 50 years old – and do not represent current mammography techniques. This is a major limitation of the ACP report.”
Monticciolo also commented that the ACP report included information that was simply wrong, for example stating that the incidence of breast cancer in women younger than 60 is low. In fact, almost half of all invasive breast cancers occur in women under 60. Laurie Margolies, professor of radiology in New York, took issue with the ACP’s claims related to harms caused by false positives and related overdiagnosis, stating: “It is important to remember that a false positive does not mean a woman is told she has breast cancer when she does not.” The standard protocol in these cases is further imaging, such as ultrasound, to make a conclusive diagnosis and most women do not end up with a biopsy.
Monticciolo’s advice is clear: “If a woman wants to have the best chance of avoiding breast cancer death, she will want to have a mammogram every year starting at age 40.”