For all of my years involved with radiology, I have been a strong supporter for mammography, both for clinical uses and for screening. In my assignments with the American College of Radiology (ACR), I helped encourage mammographic technique by publicizing its development and publicizing the value of periodic mammographic screening. I was not part of the science. Rather, I was part of the promotion which gained the support of the ACR, the Public Health Service, the trainers of radiologists and technologists, the manufacturers of x-ray film and equipment, other medical societies, and the science and medical writers who told the public about the value of early detection of breast cancer.
I also support mammography because of the reality that women in my family have had breast cancer. Most of them succumbed before the rise of mammography because of the lateness and imprecision of their diagnosis and the difficulty and fallibility of surgical correction.
For all of the years in the half-century of reliable mammography growth, there have been physicians, statisticians, bureaucrats, and a few politicians who have denounced mammograms as unreliable and unjustifiable. Even some of the societies that have accepted their clinical usefulness have denounced screening. Others have rejected beginning to screen before women reach their menopause or in a yearly basis to pick up early growth.
Last November, the report by the US Preventive Services Task Force (USPSTF) that recommended only screening biannually after age 50 stirred the old controversy. The report was taken by most reporters as a changed government position. Those who made that assertion had failed to read the disclaimer at the end of the report.
“Recommendations made by the USPSTF are independent of the US government. They should not be construed as an official position of the Agency for Health Care Research and Quality (its sponsor) or the Department of Health and Human Services.” Publication of the report caused a thundering rebuttal. The secretary of the Department of Health and Human Services, Kathleen Sibelius, asserted that her department did not agree with the USPSTF position and women should continue screening mammography from age 40 and on a yearly basis. A spokesman for President Obama stated that neither government programs or private health insurance companies should refuse to pay for screening mammograms as before, from age 40 and annually. The American Cancer Society rallied in favor of continuing breast screening as before. And so did the American College of Radiology. So did the Susan B. Komen Foundation for the Cure.
Within a few days, a spokeswoman for the task force, Diana Petitti, admitted that the report was not well stated. The report acknowledged that breast cancer was the most prevalent cancer for women. The task force did not oppose screening women in their 40s, if women talked to their doctors about it. In its recommendations, the task force made no recognition of the reality that some women are more susceptible to beast cancer than others and that those with familial histories and tendencies toward lumps should be screened early and regularly. Later, in its discussions, the USPSTF acknowledged that “there is convincing evidence that screening with film mammography reduces breast cancer mortality.” Then, the report goes on to assert that mammography is not perfect and that false-positive findings are not acceptable. It also asserts that some breast cancers are not likely to be mortal and thus their detection is wasteful. How to tell which is which is not defined by the task force.
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Screening for breast cancer with mammography has been shown to decrease mortality from breast cancer, and mammography is the mainstay of screening for clinically occult disease. Mammography, however, has well recognized limitations, and recently, other imaging including ultrasound and magnetic resonance imaging have been used as adjunctive screening tools, mainly for women who may be at increased risk for the development of breast cancer. The Society of Breast Imaging and the Breast Imaging Commission of the ACR are issuing these recommendations to provide guidance to patients and clinicians on the use of imaging to screen for breast cancer. Whenever possible, the recommendations are based on available evidence. Where evidence is lacking, the recommendations are based on consensus opinions of the fellows and executive committee of the Society of Breast Imaging and the members of the breast imaging commission of the ACR.
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