LETTER
The Breast Cancer Screening Controversy Continues
Wende W. Logan-Young;
Nancy Yanes Hoffmann; and
Joyce Janus
1 May 1993 | Volume 118 Issue 9 | Pages 746-749
TO THE EDITOR:
You are to be congratulated for reminding internists of their obligation to teach and perform a competent breast examination on every female patient [1]. Nevertheless, your recommendations, based on the Canadian study [2], to abolish screening mammography for women under the age of 50 render a grievous disservice to such women. The Canadian Study's obviously inferior mammograms were incapable of discovering early breast cancer and thus could not improve chances of survival.
In 1980, the University of Toronto asked one of us to serve as a mammographic consultant for this study. After a few months of never being allowed to see the mammograms, she felt compelled to resign. Dr. Edward Sickles of the University of California School of Medicine and Dr. Stephen Feig of Jefferson Medical College, both world-renowned mammographers, resigned for the same reason. An offer from our clinic to train Canadian radiologists and mammographic technologists to perform and interpret mammograms correctly was refused.
The Canadian study's inability to reduce breast cancer mortality in women 50 to 60 years of age contrasts markedly with the significant HIP [3], Swedish [4], and Dutch [5] mortality reductions achieved with excellent mammographic technique. Furthermore, the Canadian study presented no proof that "high quality physical examination" [1] increased the survival rate, because it did not include any control group of similar women not undergoing a physical examination.
The editorial cites the Swedish study by Tabar and colleagues [4] but does not mention the reduced mortality of 31% in women 40 to 74 years of age. Although this trial is the best on record, its findings remain skewed by major deficiencies: It used one mammographic view only, and its initial mammographic interval was 30 months, longer than the estimated lead time for women 40 to 49 years of age.
In our opinion, physicians owe it to their female patients over 40 years of age to fight breast cancer aggressively by examining these women mammographically and clinically every year.
1. Fletcher SW, Fletcher RH. The breast is close to the heart. Ann Intern Med. 1992; 117:969-71.
2. Miller AB, Baines CJ, To T, Wall C. Canadian National Breast Screening Study: 1. Breast cancer detection and death rates among women aged 40 to 49 years. Can Med Assoc J. 1992; 147:1459-88.
3. Shapiro S. Periodic Screening for Breast Cancer: the Health Insurance Plan Project and Its Sequelae, 1963-1986. Baltimore, Maryland: Johns Hopkins University Press; 1988.
4. Tabar L, Fagerberg G, Duffy SW, Day NE, Gas A, Grontoft O. Update of the Swedish two-county program of mammographic screening for breast cancer. Radiol Clin North Am. 1992; 30:187-210.
5. Verbeek A, Hendricks J, Holland R, Holland RA, Holland RB, Holland RC, et al. Mammographic screening and breast cancer mortality: age-specific effects in the Nijmegen Project 1975-1982. Lancet. 1985; 1:865-6.
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