BJS: Opportunistic mammo screening may be eliminated

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Mammography does not increase the breast cancer detection rate when applied as part of a triple assessment protocol in women over age 35 with single quadrant symptoms, based on study findings published in the July edition of British Journal of Surgery. Therefore, the researchers advocated for a more discriminatory approach to the triple assessment rule.

Triple assessment (clinical assessment, mammography and/or ultrasound imaging and core biopsy and/or fine needle aspiration cytology) emerged more than 30 years ago as a method for investigating breast lumps.

“Since then, new methods of investigation have been introduced such that the original ‘triple’ epithet has become misleading. In addition, the presentation of breast disease has evolved, with more women now presenting more promptly, with a wider range of symptoms and, since 1988, participating in the National Health Service Screening program,” wrote Jill Donnelly, lead clinician of the breast multidisciplinary team at Hereford County Hospital in England, and colleagues.

Donnelly and colleagues sought to re-evaluate the triple assessment rule and determine its validity in all patients and particularly in women with no abnormality clinically or on ultrasound exam (P1 U1).

The researchers enrolled 454 women (median age, 48 years) assessed as P1 U1 between October 2007 and September 2009.

At the authors’ institution, the diagnostic pathway uses ultrasound and ultrasound-guided biopsy in addition to mammography. Mammography reports, however, are not available until a few days after the ultrasound study.

“Among women with symptoms localized to one quadrant of one breast but no abnormality clinically or on ultrasonography, mammography did not increase the rate of cancer detection at the site of symptoms," Donnelly and colleagues reported. "Therefore, for the women in this study group, the mammography component of triple assessment was effectively providing ‘opportunistic’ screening.”

Thus, the authors concluded that there is "room for greater selectivity in requesting mammography, without compromising the overriding priority of not missing cancer.” They suggested raising the age threshold for including mammography in assessment of P1 U1 women to 39 years and not requesting mammography in the subset of patients between 50 and 70 years because they participate in national screening.

The change, they stated, would produce “considerable” cost savings and “should not result in symptomatic cancers being missed.” However, Donnelly and colleagues acknowledged that this revision would require clinical assessment prior to mammography. Although clinical assessment prior to mammography is the gold standard, it is not universally practiced in England.