Dr. Jatoi claims that "no evidence" suggests that mammographic screening is superior to clinical breast examination alone in reducing breast cancer-related mortality for any age group. Review of data from randomized controlled trials, however, shows the following facts: 1) According to the most recent results from all the trials combined, screening significantly reduces breast cancer-related mortality in the ages studied as initially designed [range, 40 to 74 years]; 2) whereas three trials involve screening with both mammography and clinical breast examination, five trials involve screening with mammography alone [no trial involves screening with breast examination alone]; and 3) the mortality reduction from screening varies only slightly among the trials, averaging between 20% and 30%. Because the mortality reduction from screening is essentially constant regardless of the screening method tested (mammography alone or mammography plus breast examination), it follows logically that most of the screening benefit derives from mammography. This common-sense argument is strongly supported by the undisputed evidence that cancers (including or excluding carcinoma in situ) detected by mammography alone are smaller, have a lower rate of nodal metastasis, and are in an earlier stage than cancers detected by breast examination alone. Aside from the Health Insurance Plan trial done in the 1960s, which used what is now considered an archaic mammography technique, the other trials (and numerous breast cancer screening demonstration projects using even more modern mammography) show that many more cancers are detected by mammography alone than by breast examination alone. Clearly, there is considerable evidence that mammographic screening is superior to clinical breast examination.

Dr. Jatoi also claims that breast examination does less harm than mammography in women aged 40 to 49 years. This is also incorrect. In fact, as documented in our paper, the incidence of false-positive results is at least as high for screening with breast examination as it is for screening with mammography. In addition, breast examination leads to a much higher rate of benign open surgical biopsies than does mammography. Furthermore, the radiation risk associated with mammographic screening is negligible compared with the substantial benefits of screening. We do agree that the dollar cost of mammographic screening is relatively high and suggest that the debate on mammography among women aged 40 to 49 years shift to cost considerations now that its benefits have been shown.

However, for the Annals reader who agrees with Dr. Jatoi that current evidence is insufficient to justify screening in women ages 40 to 49 years, we repeat the statement made in our paper that clinicians should be scientifically consistent in their practice and omit both mammography and clinical breast examination for asymptomatic women.