Issues in mammography

Article Abstract:

There is no doubt that mammography has the potential to save the lives of thousands of women by promoting the early diagnosis of breast cancer. However, implementing programs capable of ensuring regular breast cancer screening for every American woman over the age of 40 is a daunting undertaking, and much needs to be done. Women themselves need to be convinced that the procedure is not only safe, but very important for their health. Ironically, some women avoid mammography out of fear of the cosmetic devastation of mastectomy when mammography may make breast-conserving surgery a practical alternative. There is also some fear of the danger of radiation during mammography, but advances in technology have reduced this risk to extremely low levels. The author points out that the risk incurred by radiation exposure during mammography is estimated to be less that risk of traveling 70 miles by plane, 10 miles by car, smoking one-eighth of one cigarette, or being a 60-year-old man for three minutes. Further complications to the implementation of effective mammography programs are the technical demands of the mammography procedure and the difficulty in interpreting the results. A mammogram that does not meet technical standards does not accomplish its task, and a radiologist who is not sufficiently familiar with mammography may miss important observations. The American College of Radiology has established an accreditation program for mammography. About 30 percent of the applicants have failed the exam. Perhaps more disturbing is the fact that 80 percent of those practicing mammography have not applied for the voluntary accreditation. The requirement of accreditation by insurance companies, which provide reimbursement, may be the most direct way of encouraging practitioners to obtain accreditation. At the author's hospital, 20 years ago, 63 percent of breast cancer patients historically had lymph node involvement at the time of diagnosis, and in only 25 percent disease was limited to the breast. Mammography has been largely responsible for turning these figures upside down; today only 22 percent of patients present with lymph node involvement and 65 percent have disease limited to the breast. (Consumer Summary produced by Reliance Medical Information, Inc.)

Evaluation, Social policy, Study and teaching

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Cost effectiveness in program delivery

Article Abstract:

The Group Health Cooperative of Puget Sound is the largest health maintenance organization in the US which is governed by consumers. Since 1985 the Cooperative has had a screening program for breast cancer. However, unlike programs which recommend screening simply on the basis of age, the Cooperative recommends screening based on the calculated risk of the individual woman. Such a method dramatically reduces the cost of the program. Among women over 50, those without any risk factors are encouraged to have mammography every three years. Those with a first degree relative, i.e. mother, sister, or daughter, with breast cancer or with two minor risk factors are urged to have mammography every two years. Women with two first degree relatives with breast cancer, or a personal history of breast cancer, or abnormal breast tissue, should have mammography on a yearly basis. The recommendations for women between 40 and 50 are similar; they are urged to have a yearly mammogram if they have major risk factors. A single first degree relative with breast cancer is an indication for biannual mammography, and minor factors are an indication for mammography every three years. Women under 40 without any major or minor risk factors should receive mammography only on referral by their physician. For the purposes of breast screening, minor risk factors have been defined as a more distant relative with breast cancer, menarche before 11 or menopause after 54, first child after 30 or no children, or a previous breast biopsy. Using this risk-based method has resulted in about 10 early case findings per 1,000 women, which is nearly double the rate of programs without patient pre-selection based on risk. Although this is indicative of risk concentration, much more time will be needed before a comparison of breast cancer incidence in all the risk groups can be analyzed for cancer staging (which reflects severity) at diagnosis and mortality rate. (Consumer Summary produced by Reliance Medical Information, Inc.)

Economic aspects, Risk factors

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Challenges and progress with mammography

Article Abstract:

There is no doubt that mammography has produced a reduction in mortality due to breast cancer. The manner in which screening should take place, however, remains somewhat controversial. While the American Cancer Society endorses mammography at one- or two-year intervals for women between 40 and 50, both the American College of Physicians and the American College of Surgeons do not support routine mammography for women under 50. Studies have not shown as conclusive a benefit for younger women as for women over 50. However, there may be some rationale for providing screening which is more frequent for younger women and less frequent for those over 50. Breast cancer is often more aggressive in younger women, and therefore has a shorter 'lead-time' between its appearance and its ultimate spread. Curiously, the primary care physician is a major obstacle to breast cancer screening. The low yield of actual cancer cases has resulted in a perception that mammography is not cost-effective, though a low yield is what must occur in any mass screening program. Obtaining the maximum potential for mortality reduction from mammography will require wider availability of the necessary training for radiologists, and a careful audit method for assessing results. Without the objective assessment of results there is no opportunity to improve skills and no incentive for improving performance. (Consumer Summary produced by Reliance Medical Information, Inc.)

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