Internists' incendiary advice reopens old wounds

New guidance from the American College of Physicians questioning the value of screening mammography of women in their forties has baffled and angered many leading mammographers.

Women aged 40 to 49 should consult with their physicians regarding the appropriateness of mammography, based on their personal risk for breast cancer, according to the new guideline, published in April. The ACP's position is that screening women in this age group results in anxiety for the patients, a high rate of false positives, and overdetection of ductal carcinoma in situ.

Prospective randomized clinical trials clearly show that routine screening mammography helps reduce mortality rates in women aged 40 to 49 years, said Dr. Carl D'Orsi, vice chair of the ACR commission on breast imaging.

"I think the ACP statement is inappropriate at best and irresponsible at worst, because it may discourage [younger] women from undergoing screening. Some, perhaps, will die of breast cancer if they are not diagnosed early enough," he said.

Randomized controlled trials may actually underestimate the benefits of mammography because they measure rates in women who are offered screening in studies rather than those who definitely underwent screening, said Dr. Laszlo Tabar, a professor of radiology at the School of Medicine in Uppsala, Sweden.

Tabar's research shows a 43% reduction in mortality rates in women aged 40 to 69 who underwent screening (Cancer Epidemiol Biomarkers Prev 2006;15(1):45-51,52-56). His research also suggests that the mean sojourn times (growth rates) of cancers are faster in women aged 40 to 49 compared with the 50 to 69 age group.

"If anybody is to be screened, it is the younger women," Tabar said.