Bold or bad? Experts say eradicate breast screening programs

Mammography screening programs should be eradicated, all forms of mammography should be evaluated and clear, balanced information about the benefits and harms of screening should be disseminated to women, according to two members of the Swiss Medical Board in an editorial published by the New England Journal of Medicine on April 16.

Co-authors Nikola Biller-Andorno, MD, PhD, a medical ethicist of the University of Zurich and Peter Jüni, MD, a clinical epidemiologist of the University of Bern, were members of an expert panel that assessed mammography under the Swiss Board in 2013. After the board’s recommendations were released in a report on Feb. 2, controversy ensued. Many called their recommendations unethical and contended that their assertions contradicted the global consensus from leading experts in the field.

Biller-Andorno and Jüni reiterated the report’s recommendations in their editorial. “It is easy to promote mammography screening if the majority of women believe that it prevents or reduces the risk of getting breast cancer and saves many lives through early detection of aggressive tumors,” they wrote. “We would be in favor of mammography screening if these beliefs were valid. Unfortunately, they are not, and we believe that women need to be told so.”

The authors cited three major reasons for their concerns regarding breast cancer screening. They first noted that the ongoing debate over mammography’s efficacy is mainly based on reanalyses of archaic trials. “Could the modest benefit of mammography screening in terms of breast-cancer mortality that was shown in trials initiated between 1963 and 1991 still be detected in a trial conducted today?” the board members questioned in their editorial.

Beyond reliance on outdated studies, they also pointed to uncertainty that surrounds the benefits and harms of screening. They referenced the recent controversial follow-up to the Canadian Breast Cancer Screening Study, writing: “The relative risk reduction of approximately 20% in breast-cancer mortality associated with mammography that is currently described by most expert panels came at the price of a considerable diagnostic cascade, with repeat mammography, subsequent biopsies, and overdiagnosis of breast cancers—cancers that would never have become clinically apparent.”

Lastly, they were disconcerted by the vast disconnect between women’s perceptions of the benefits of mammography and those expected in reality. If the benefits of mammography are grossly overestimated, then women are not able to make informed decisions about screening, argued Biller-Andorno and Jüni.

“From an ethical perspective, a public health program that does not clearly produce more benefits than harms is hard to justify. Providing clear, unbiased information, promoting appropriate care, and preventing overdiagnosis and overtreatment would be a better choice,” they concluded.