And exactly how much evidence does breastcancer.org desire before it is clear? What is your threshold?

I agree with BC.org's stance that "all medical decisions, including if and when to screen for breast cancer, should be made by each woman and her doctor based on the best available information and a woman's beliefs and preferences".  

  But I also believe there should be more options available to us than mammography and that we need to fight for legislation to have MRI's covered as part of a routine screening, at least for women at risk (such as those of us with dense breasts or women with strong family history, etc).

The current issue (Oct. 25) of The British Medical Journal, which can be read online spells out the mammogram screening controversy and what England's "cancer czar" plans to do to settle the controversy. I strongly recommend that sisters AND the breastcancer.org folks read the articles. Finally the dogma will be put to rest if the British cancer czar succeeds at convening a Task Force that will not cower. I applaud the British for this bold step.

• Breast Cancer Screening

An independent review is under wayMike Richards, national clinical director for cancer and end of life care, Department of Health, LondonMike.Richards@ncat.nhs.ukThe BMJ has published several articles over the past few years raising concerns about the accuracy and transparency of information                                 provided to women about the benefits and harms of mammography screening for breast cancer (BMJ 2006;332:538, doi:10.1136/bmj.332.7540.538; 2009;338:b86, doi:10.1136/bmj.b86; 2010;340:c3106, doi:10.1136/bmj.c3106). Last month the professor of complex obstetrics Susan Bewley sent us for publication an open letter to England's cancer tsar (BMJ 2011;343:d6894, doi:10.1136/bmj.d6894). Here is the response from Mike RichardsDear SusanYour letter raises several important issues. These include the current state of the evidence relating to the benefits and                              harms of breast screening; how this information is communicated to women in order to promote informed choice; and the process                              by which decisions on screening are made in this country, including my own role. I welcome this opportunity to discuss all                              these issues.                           When I became national cancer director 12 years ago the NHS breast screening programme was one of the few aspects of cancer                              service delivery that was generally judged to be working well. Broad decisions on screening programmes were, and still are,                              taken by the independent UK National Screening Committee, which advises ministers in all four UK countries. In addition to                              this, ministers in England were, and still are, advised by the independent Advisory Committee on Breast Cancer Screening (ACBCS).                              This committee, with membership largely nominated by the appropriate professional bodies, provides advice on the effective                              running of the existing screening programme and on the evidence underpinning and presentation of information provided by the                              screening programme.                           My role in screening has largely been to ensure that the NHS delivers on the government's commitments, though I do of course provide my own opinion to ministers if requested. Progress on screening commitments is regularly discussed at the Department of Health's Cancer Programme Board.Over the past 12 years the NHS breast screening programme has, on the advice of the ACBCS, been improved and extended, firstly                              from age 50-64 years to 50-70 years (with each woman being routinely invited seven rather than five times in her life). A                              further extension, from 47-73 (with a total of nine invitations) is, on the advice of independent academics and with the support                              of the ACBCS, being introduced through randomisation. This is likely to be the largest randomised controlled trial ever undertaken                              in the world and will provide invaluable evidence on the benefits and harms of additional screening rounds.                           Like you, I believe that screening programmes should be based on the best available evidence. This evidence is of two broad types. The first type is the randomised controlled trials on which the original decisions to introduce screening were made, which now have many additional years of follow-up. The second is a range of observational and case-control studies that have examined the effect of screening programmes in practice. The advice that ministers and I receive from the ACBCS is that breast screening saves lives and that the benefits considerably outweigh the harms. This advice is in line with the findings published in a monograph from the World Health Organization's International Agency for Research on Cancer. This concluded that screening women aged 50-69 years old reduced mortality by 35%.1 On the basis of the experience of breast screening in England, the ACBCS estimated that for every 400 women screened regularly                              over a 10 year period, one woman fewer will die from breast cancer than had they not been screened.2As with any medical intervention, screening has potential risks that must be carefully evaluated against the benefits. Work undertaken by eight leading international scientists calculated that the benefit of mammographic screening in terms of lives saved is greater than the harm in terms of overdiagnosis-concluding that an estimated 2-2.5 lives are saved for every overdiagnosed case of breast cancer.3 I am, however, well aware that a contrary view has been provided by the Cochrane collaboration.                           I agree with you that the sheer weight of numbers supporting one side of an argument does not necessarily make it right. Nor,                              however, does the appellation of a Cochrane review necessarily mean that the views of the minority of experts are right either.                              However, I do believe that the ongoing controversy should, if at all possible, be resolved. Therefore some weeks ago I initiated                              the following actions.                           1. An independent review of the research evidence (randomised controlled studies and observational studies) is being undertaken,                                    led by myself and Harpal Kumar, chief executive at Cancer Research UK. We are seeking independent advisers for this review                                    who have never previously published on the topic of breast cancer screening.                                 2. Once the independent review has concluded, evidence will be presented at a workshop hosted by Cancer Research UK to which                                    experts from both sides of the argument will be invited.                                 3. A new process for developing written information for the public about each screening programme is being established on                                    behalf of NHS cancer screening programmes. This will take account of current thinking on how to synthesise information on                                    benefits and harms and how to present these so as to promote informed choice. An independent team is being commissioned to                                    lead this work and will consult widely on the new process.                                 4. The breast screening leaflet will be one of the first products to be revised through this new process.I hope this reassures you that I take the current controversy very seriously. I will do my best to achieve consensus on the                              evidence, though I realise this may not ultimately be possible. Should the independent review conclude that the balance of                              harms outweighs the benefits of breast screening, I will have no hesitation in referring the findings to the UK National Screening                              Committee and then ministers. You also have my assurance that I am fully committed to the public being given information in                              a format that they find acceptable and understandable and that enables them to make truly informed choices.                           Next SectionNotesCite this as: BMJ 2011;343:d6843                              Previous Section References↵International Agency for Research on Cancer. Effectiveness of screening: breast cancer screening. IARC Press, 2002:119-56.↵Advisory Committee on Breast Cancer Screening. Screening for breast cancer in England: past and future. Feb 2006. www.cancerscreening.nhs.uk/breastscreen/publications/nhsbsp61.pdf. (p 3)                                       ↵Duffy SW, Tabar L, Olsen AH, Vitak B, Allgood PC, Chen THH, et al. Absolute numbers of lives saved and overdiagnosis in breast                                             cancer screening, from a randomized trial and from the breast screening programme in England. J Med Screen2010;17:25-30.[Abstract/FREE Full text]CiteULikeComploreConnoteaDeliciousDiggFacebookGoogle+MendeleyRedditStumbleUponTechnoratiTwitterWhat's this?Relevant Articles: Susan Bewley[Extract][Full text][PDF]Karsten Juhl Jørgensen, Peter C Gøtzsche[Extract][Full text][PDF][Further details]Peter C Gøtzsche, Ole J Hartling, Margrethe Nielsen, John Brodersen, Karsten Juhl Jørgensen[Extract][Full text][Supplementary material]Klim McPherson[Extract][Full text]Nigel Hawkes[Extract][Full text][PDF]Observations: Breast Cancer Screening: The NHS breast screening programme needs independent review BMJ 2011;343:doi:10.1136/bmj.d6894 (Published 25 October 2011)Analysis and Comment: Public health: Content of invitations for publicly funded screening mammography BMJ 2006;332:538-541 doi:10.1136/bmj.332.7540.538 (Published 2 March 2006)Analysis: Breast screening: the facts-or maybe not BMJ 2009;338:doi:10.1136/bmj.b86 (Published 27 January 2009)Analysis: Screening for breast cancer-balancing the debate BMJ 2010;340:doi:10.1136/bmj.c3106 (Published 24 June 2010)News: Breast cancer screening is to be reviewed, cancer tsar announces BMJ 2011;343:doi:10.1136/bmj.d6905 (Published 26 October 2011)This ArticleExtractFull text

http://www.amazon.com/Overdiagnosed-Making-People-Pursuit-Health/dp/0807022004

Dr. Welch and his colleagues published a book several weeks ago, outlining the downside of screening for many illnesses (click above link).  Along with Harvard's John Abramson, MD's Overdosed America (click below), I highly recommend reading both books.

 http://www.amazon.com/Overdosed-America-Promise-American-Medicine/dp/B000F5FNQG/ref=sr_1_1?s=books&ie=UTF8&qid=1319719589&sr=1-1

The cost of mammos and all of the rest of our american healthcare is because we have forced doctors to treat medicare and medicaid patients below cost so the rest of us make up for with higher costs.  If Medicare had to pay what your private insurance does the average cost for all would be lower.  And if we allowed insurance companies to compete accross state lines that would also allow cheaper health insurance because the pools in the groups would be larger. How about all steel workers across the country be allowed to be in one grouP?  HOw about all federal workers not matter what state they live in? how about all nurses in one group?  We need to get that done. And my cancer was caught @ 44 yr old on a mammo ...it was so small I could not even feel it. But I am high risk so even if they age went to 50 I would have still had mammos in my 40's.

LMR216...You have a great shot at living a long life because today there are great treatments available that weren't available during the 70's and 80's, when screening first became popular.  Have you read the data regarding the controversy?  Your SCREENING mammogram did EXACTLY what it was supposed to do.  There is NO controversy over women between the ages of 50 and 69 getting screening mammograms.  They know that it saves their lives more than anyone else's.

Good luck to you!

MrsBeasley -- I can't resist.....How about single payer?  It always amazes me that Americans grumble about the high cost of their healthcare -- insurance premiums, co-pays, high deductibles etc. -- and yet so many refuse to consider the very significant cost reductions achieved through a single-payer system.  Yeah, the one system where everyone is covered.....

As for the value of mammography -- I guess there are as many valid opinions on the subject as there are members on this Board.  I had my first mammo at 37 (family history and a fibroadenoma).  A diagnostic mammo picked up my ILC at age 58 (I had gone a few years without having a mammo, due to moving and other issues).  Living in Canada, cost was not a factor for me.  If patient and doctor feel a mammo or U/S is required, it gets done.  MRIs are not used for dx except in rare circumstances, but are frequently used for patients whose chance of recurrence or mets is significant.

I'm puzzled about the "slow-growing cancers that would never have killed them".  Post-mortems are recorded as having shown that the great majority of men have signs of prostate cancer which was never dx'ed and which did not kill them.  Is that also true of post-mortems on women re breast cancer? 

VR -- I think the statistics measuring bc found post-mortem would be very valuable.  Am wondering where to look to find this?

My mamo caught my 1 cm. (we estimate, no surgery yet) ILC. It was totally unpalpable by BC and me. As this cancer is quite hard to see on mamos, or feel, I am so grateful that it was caught. Could have been the location, right behind my nipple. I love mammos! They SAVE lives!!

Linda...Here's the controversy in a nutshell from the National Cancer Institute:

Harms of Screening

Additional Interventions
False Sense of Security
Radiation Exposure
Anxiety
Overdiagnosis

Mammography screening may be effective in reducing breast cancer mortality in certain populations. As with any medical intervention, it has limitations, which can pose potential harm to women who participate. These limitations are best described as false-negatives (related to the sensitivity of the test), false-positives (related to the specificity), overdiagnosis (true positives that will not become clinically significant), and radiation risk.

Additional Interventions

The specificity of mammography (refer to the Mammography section of this summary for more information) affects the number of "unnecessary" interventions due to false-positive results. Even though breast cancer is the most common noncutaneous cancer in women, only a very small fraction (0.1%-0.5%, depending on age) actually have the disease when they are screened. Therefore, even though the specificity of mammography is approximately 90%, most abnormal tests are false-positives.[1] Women with abnormal screening test results have additional procedures performed to determine whether the mammographic finding is cancer. These procedures include additional mammographic imaging (e.g., magnification of the area of concern), ultrasound, and tissue sampling (by fine-needle aspiration, core biopsy, or excisional biopsy). A study of breast cancer screening in 2,400 women enrolled in a health maintenance organization found that over a 10-year period, 88 cancers were diagnosed, 58 of which were identified on mammography. During that period, one-third of the women had an abnormal mammogram result that required additional testing, including 539 additional mammograms, 186 ultrasound examinations, and 188 biopsies. The actuarial cumulative biopsy rate (the rate of true positives) due to mammographic findings was approximately 1 in 4 (23.6%). The positive predictive value (PPV) of an abnormal screening mammogram in this population was 6.3% for women aged 40 to 49 years, 6.6% for women aged 50 to 59 years, and 7.8% for women aged 60 to 69 years.[2] A subsequent analysis and modeling of data from the same cohort of women, all of whom were continuously enrolled in the Harvard Pilgrim Health Care plan from July 1983 through June 1995, estimated that the risk of having at least one false-positive mammogram was 7.4% (95% confidence interval [CI], 6.4%-8.5%) at the first mammogram, 26.0% (95% CI, 24.0%-28.2%) by the fifth mammogram, and 43.1% (95% CI, 36.6%-53.6%) by the ninth mammogram.[3] Cumulative risk of at least one false-positive by the ninth mammogram varied from 5% to 100%, depending on four patient variables and three radiologic variables. Patient variables independently associated with increased chance of a false-positive result included younger age, higher number of previous breast biopsies, family history of breast cancer, and current estrogen use. Radiologic variables included longer time between screenings, failure to compare the current and previous mammograms, and the individual radiologist's tendency to interpret mammograms as abnormal, which ranged from 2.6% to 24.4% across 93 radiologists in the study. Overall, the largest risk factor for having a false-positive mammogram was the individual radiologist's tendency to read mammograms as abnormal. The authors noted that CIs for estimates of false-positives beyond five mammograms were wide because of the relatively small numbers of women in the analysis with more than five mammograms.

By reviewing Medicare claims following mammographic screening in 23,172 women older than 65 years, one study [4] found that 85 per 1,000 had follow-up testing and 23 per 1,000 had biopsies. The cancer detection rate was 7 per 1,000, so the PPV for an abnormal mammogram was 8%. For women older than 70 years, the PPV was 14%. An audit of mammograms done in 1998 at a single institution revealed that 14.7% of examinations resulted in a recommendation for additional testing (Breast Imaging Reporting and Data System category 0), 1.8% resulted in a recommendation for biopsy (categories 4 and 5), and 5.7% resulted in a recommendation for short-term interval mammography (category 3). Cancer was diagnosed in 1 out of 30 of the cases referred for additional testing.[5]

False Sense of Security

The sensitivity of mammography (refer to the Mammography section of this summary for more information) ranges from 70% to 90%, depending on a woman's age and the density of her breasts, which is affected by her genetic predisposition, hormone status, and diet. Assuming an average sensitivity of 80%, mammograms will miss approximately 20% of the breast cancers that are present at the time of screening (false-negatives). If a woman does not seek medical attention for a breast symptom or if her physician is reluctant to evaluate that symptom because she has a "normal" mammogram, she may suffer adverse consequences. Whereas the medical community has been carefully educated that a negative diagnostic mammogram should not deter work-up of a palpable lump, the medical and lay communities should be made aware that a negative screening mammogram misses one in five cancers.

Radiation Exposure

Because radiation exposure is a known risk factor for the development of breast cancer, it is ironic that ionizing radiation is our best screening tool. The major predictors of risk are young age at the time of radiation exposure and the radiation dose. For women older than 40 years, the benefits of annual mammograms may outweigh any potential risk of radiation exposure due to mammography.[6] It is speculated that certain subpopulations of women may have an inherited susceptibility to ionizing radiation damage,[7,8] but mammography has never been shown to be harmful in these, or any, subgroups. In the United States, the mean glandular dose for screening mammography is 1 mGy to 2 mGy (100-200 mrad) per view or 2 mGy to 4 mGy (200-400 mrad) per standard two-view exam.[9,10]

Anxiety

Because large numbers of women have false-positive tests, the issue of psychological distress-which may be provoked by the additional testing-has been studied. A telephone survey of 308 women performed 3 months after screening mammography revealed that about one-fourth of the 68 women with a "suspicious" result were still experiencing worry that affected their mood or functioning, even though subsequent testing had ruled out a cancer diagnosis.[11] Several studies,[12-14] however, show that the anxiety following evaluation of a false-positive test leads to increased participation in future screening examinations.[15]

Overdiagnosis

Overdiagnosed disease is a neoplasm that would never become clinically apparent prior to a patient's death without screening. An example is a tumor that is found by mammographic screening that would never be evident otherwise.

Autopsy studies have found tumors in people who died of causes unrelated to the tumors. The studies indicate that lesions exist that fulfill the histologic criteria of cancer but that were not clinically apparent in the woman's lifetime. An overview of seven autopsy studies documents a median prevalence of 1.3% for undiagnosed invasive breast cancer (range, 0%-1.8%) and 8.9% for undiagnosed ductal carcinoma in situ (range, 0%-14.7%).[16,17] Finding such cancers by mammography would be overdiagnosis. Because cancers that will progress cannot be distinguished with certainty from those that will not, these tumors are often treated (with surgery and possibly with radiation, chemotherapy, and hormonal therapy). This treatment would constitute overtreatment because it would not confer a benefit to the woman.

It is difficult to determine the proportion of screen-detected cancers that are overdiagnosed. A widely accepted estimation method is to compare breast cancer incidence over time in a screened population with that of an unscreened population. Randomized screening trials are the most credible, but the period of screening versus control is limited in all the trials. If a woman complies with not being screened during the study period but gets screened afterwards, then a breast cancer that would have been found had the woman been assigned to screening would likely be found shortly thereafter. (Most of the women in the control group in the Swedish trials were assigned to receive a control mammogram at the end of the study period.) Such delayed screening will also find overdiagnosed cancers; the cumulative incidence of cancers will be similar in the two groups, irrespective of the magnitude of overdiagnosis.

Population-based studies suffer from the same problem as randomized trials, although to a lesser extent. However, the population-based studies have their own problems. Unbiased estimates would only be possible if the screened and nonscreened populations were the same except for screening, but the populations may differ in time, in geography, in culture, and by the use of postmenopausal hormone therapy. In addition, investigators differ in their assessments of overdiagnosis regarding how and whether to adjust for characteristics such as lead-time bias.[18,19] As a consequence, the magnitude of overdiagnosis due to mammographic screening is controversial, with estimates ranging from 7% to 50%.[18-21]

Several observational population-based comparisons consider breast cancer incidence before and after adoption of screening.[22-26] If there were no overdiagnosis-and other aspects of screening were unchanged-there would be a rise in incidence followed by a decrease to below the prescreening level, and the cumulative incidence would be similar. Such results have not been observed. Breast cancer incidence rates increase at the initiation of screening without a compensatory drop in later years. For example, in Sweden, the age-specific incidence rates doubled between 1986 and 2002 for all age groups participating in screening.[22] Another study in 11 rural Swedish counties showed a persistent increase in breast cancer incidence following the advent of screening.[23] A population-based study from Norway and Sweden showed increases in invasive breast cancer incidence of 54% in Norway and 45% in Sweden in women aged 50 to 69 years, following the introduction of nationwide screening programs. No corresponding decline in incidence in women older than age 69 years was ever seen.[27] Similar findings suggestive of overdiagnosis have been reported from the United Kingdom [24] and the United States.[25,26]

References

1. Kerlikowske K, Grady D, Barclay J, et al.: Positive predictive value of screening mammography by age and family history of breast cancer. JAMA 270 (20): 2444-50, 1993.  [PUBMED Abstract]
   
   
2. Elmore JG, Barton MB, Moceri VM, et al.: Ten-year risk of false positive screening mammograms and clinical breast examinations. N Engl J Med 338 (16): 1089-96, 1998.  [PUBMED Abstract]
   
   
3. Christiansen CL, Wang F, Barton MB, et al.: Predicting the cumulative risk of false-positive mammograms. J Natl Cancer Inst 92 (20): 1657-66, 2000.  [PUBMED Abstract]
   
   
4. Welch HG, Fisher ES: Diagnostic testing following screening mammography in the elderly. J Natl Cancer Inst 90 (18): 1389-92, 1998.  [PUBMED Abstract]
   
   
5. Rosen EL, Baker JA, Soo MS: Malignant lesions initially subjected to short-term mammographic follow-up. Radiology 223 (1): 221-8, 2002.  [PUBMED Abstract]
   
   
6. Feig SA, Ehrlich SM: Estimation of radiation risk from screening mammography: recent trends and comparison with expected benefits. Radiology 174 (3 Pt 1): 638-47, 1990.  [PUBMED Abstract]
   
   
7. Helzlsouer KJ, Harris EL, Parshad R, et al.: Familial clustering of breast cancer: possible interaction between DNA repair proficiency and radiation exposure in the development of breast cancer. Int J Cancer 64 (1): 14-7, 1995.  [PUBMED Abstract]
   
   
8. Swift M, Morrell D, Massey RB, et al.: Incidence of cancer in 161 families affected by ataxia-telangiectasia. N Engl J Med 325 (26): 1831-6, 1991.  [PUBMED Abstract]
   
   
9. Kopans DB: Mammography and radiation risk. In: Janower ML, Linton OW, eds.: Radiation Risk: a Primer. Reston, Va: American College of Radiology, 1996, pp 21-22.
   
   
10. Suleiman OH, Spelic DC, McCrohan JL, et al.: Mammography in the 1990s: the United States and Canada. Radiology 210 (2): 345-51, 1999.  [PUBMED Abstract]
    
    
11. Lerman C, Trock B, Rimer BK, et al.: Psychological side effects of breast cancer screening. Health Psychol 10 (4): 259-67, 1991.  [PUBMED Abstract]
    
    
12. Gram IT, Lund E, Slenker SE: Quality of life following a false positive mammogram. Br J Cancer 62 (6): 1018-22, 1990.  [PUBMED Abstract]
    
    
13. Burman ML, Taplin SH, Herta DF, et al.: Effect of false-positive mammograms on interval breast cancer screening in a health maintenance organization. Ann Intern Med 131 (1): 1-6, 1999.  [PUBMED Abstract]
    
    
14. Pisano ED, Earp J, Schell M, et al.: Screening behavior of women after a false-positive mammogram. Radiology 208 (1): 245-9, 1998.  [PUBMED Abstract]
    
    
15. Brewer NT, Salz T, Lillie SE: Systematic review: the long-term effects of false-positive mammograms. Ann Intern Med 146 (7): 502-10, 2007.  [PUBMED Abstract]
    
    
16. Welch HG, Black WC: Using autopsy series to estimate the disease "reservoir" for ductal carcinoma in situ of the breast: how much more breast cancer can we find? Ann Intern Med 127 (11): 1023-8, 1997.  [PUBMED Abstract]
    
    
17. Black WC, Welch HG: Advances in diagnostic imaging and overestimations of disease prevalence and the benefits of therapy. N Engl J Med 328 (17): 1237-43, 1993.  [PUBMED Abstract]
    
    
18. Duffy SW, Lynge E, Jonsson H, et al.: Complexities in the estimation of overdiagnosis in breast cancer screening. Br J Cancer 99 (7): 1176-8, 2008.  [PUBMED Abstract]
    
    
19. Gøtzsche PC, Jørgensen KJ, Maehlen J, et al.: Estimation of lead time and overdiagnosis in breast cancer screening. Br J Cancer 100 (1): 219; author reply 220, 2009.  [PUBMED Abstract]
    
    
20. Gøtzsche PC, Nielsen M: Screening for breast cancer with mammography. Cochrane Database Syst Rev (4): CD001877, 2006.  [PUBMED Abstract]
    
    
21. Zackrisson S, Andersson I, Janzon L, et al.: Rate of over-diagnosis of breast cancer 15 years after end of Malmö mammographic screening trial: follow-up study. BMJ 332 (7543): 689-92, 2006.  [PUBMED Abstract]
    
    
22. Hemminki K, Rawal R, Bermejo JL: Mammographic screening is dramatically changing age-incidence data for breast cancer. J Clin Oncol 22 (22): 4652-3, 2004.  [PUBMED Abstract]
    
    
23. Jonsson H, Johansson R, Lenner P: Increased incidence of invasive breast cancer after the introduction of service screening with mammography in Sweden. Int J Cancer 117 (5): 842-7, 2005.  [PUBMED Abstract]
    
    
24. Johnson A, Shekhdar J: Breast cancer incidence: what do the figures mean? J Eval Clin Pract 11 (1): 27-31, 2005.  [PUBMED Abstract]
    
    
25. White E, Lee CY, Kristal AR: Evaluation of the increase in breast cancer incidence in relation to mammography use. J Natl Cancer Inst 82 (19): 1546-52, 1990.  [PUBMED Abstract]
    
    
26. Feuer EJ, Wun LM: How much of the recent rise in breast cancer incidence can be explained by increases in mammography utilization? A dynamic population model approach. Am J Epidemiol 136 (12): 1423-36, 1992.  [PUBMED Abstract]
    
    
27. Zahl PH, Strand BH, Maehlen J: Incidence of breast cancer in Norway and Sweden during introduction of nationwide screening: prospective cohort study. BMJ 328 (7445): 921-4, 2004.  [PUBMED Abstract]