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On Mammography, Evidence, And Why We Need To Improve Breast Cancer Screening

This article is more than 8 years old.

Yesterday I had a discussion with an old friend about medical evidence. “There’s none to support mammography,” she told me. “It’s just not that good.”

At some level, I know she’s right. It’s true that there is no proof.* So the question – about a lack of data – turns to this: Can something be true, can a medical intervention or dietary change or whatever you might not be looking at the right way be helpful or even very helpful, when studies haven’t demonstrated it to be so? And the answer is yes, of course.

A lack of evidence doesn’t mean something is untrue. It could be that we (in this case medical scientists, epidemiologists, radiologists, statisticians) have failed to measure the right endpoints, or simply failed to measure what’s right about early detection of invasive breast cancer.

What’s worse than no information is misinformation. My issue with the mammography infographics (and recent published reviews from which those are generated) is that they misrepresent current risks and benefits.

Perhaps the most accurate assessment of mammography today is that we just don’t have or know the numbers. The fact is, there is no good trial of mammography using current radiology systems in the context of modern pathology and minimalist treatment approaches. And there is none underway. What we do have is an excellent correlation, likely but not certainly causative in large part, between screening since the 1980s and improved survival after breast cancer. And common sense.

When faced with a lack of information about a potential life-limiting health concern, you might just shrug your shoulders and do nothing. There are few busy women I know who are looking to learn they have breast cancer. Not checking is way easier. Which is why wisdom and experience are so important, and why some occasional, dare-I-say maternalistic nudging to get checked makes sense, and why oncologists’ expertise is valuable to the public at large.

Because if you understand how breast cancer works and that it’s far, far easier to deal with before it spreads, then you’d realize why early detection helps, why it has to help. Which leads me to my friend’s second point – about the quality of mammography – and more generally about the quality of breast cancer screening.

If how we check for breast cancer isn't good enough, which I agree it’s not, then we need to make it better. For the immediate future, ways to improve screening include more training of specialized radiologists with what machines they use, and electronic transmission of images to experts for review.

The reason I favor mammography now is because it’s the best thing we’ve got. That is the reality. Waiting for prevention is not going to help women today. Worse than harping on screening’s limits is ignoring the problem, minimizing its impact, or pretending that invasive breast cancer is no big deal.

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*I mean proof in the strictest sense, as in demonstration of cause and effect or a clear outcome in a randomized controlled trial. (Even then, studies and trials can be rigged.) Many published reports on breast cancer screening are wrong and misleading, as I have written before. To be clear: For mammography, there is plenty of evidence and good reason to conclude that the procedure is beneficial. - ES, April 24

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