Screening mammography has been a contentious issue, with headlines dominated by the struggle to pinpoint the ideal screening interval. Start too late or screen too infrequently and life-threatening cancers could be missed, but screen too much and overdiagnosis—and its associated costs and harms—becomes a significant risk.

This week, a major study published in CANCER poked holes in the argument that women under 50 do not need regular mammography screening. An analysis of invasive breast cancer deaths found that a majority of the deaths occurred in the minority of women who were not regularly screened, and that half of the deaths were in women under age 50.

This runs counter to the recommendation of the U.S. Preventive Services Task Force, which in 2009 said screening should be limited to women aged 50 to 74 years to limit overdiagnosis.

What led to the divergent conclusion in the CANCER study? Authors Blake Cady, MD, of Harvard Medical School in Boston, and colleagues took the typical study design and flipped it on its head. Rather than conduct a randomized trial that looked forward at outcomes after screening, Cady et al used a “failure analysis” that tracked individual cases backwards from a patient’s death to make correlations with diagnosis and screening.

Median age at diagnosis for those who died was 49 years, and 71 percent of the deaths were unscreened women, according to Cady and colleagues.

In a joint statement from the American College of Radiology (ACR) and Society of Breast Imaging, Barbara S. Monsees, MD, chair of ACR’s Breast Imaging Commission, said, “These findings should quiet those who argue that women age 40-49 do not need regular mammography screening. In fact, these women need annual screening--as do all women 40 and older. This is the message physicians should be promoting.”

Two other top stories this week dealt with the balancing act imaging plays in breast imaging. The first was a study presented Sept. 7 at the 2013 Breast Cancer Symposium that demonstrated MRI immediately before or after surgery in women with ductal carcinoma in situ was not associated with reduced recurrence or contralateral breast cancer rates.

The other interesting story came from the California Breast Density Information Group, a team of California-based breast imagers and breast cancer risk specialists, who developed a website offering guidance on breast density notification laws. While supplemental screening could benefit women with dense breasts, it could also mean substantial additional costs, and the threat of overdiagnosis or false-positive results still loom.

If you live in one of the twelve states with a breast density notification law, I urge you to check out the group’s website at www.breastdensity.info. At the pace these laws are being implemented, it’s probably not a bad idea for breast imagers in the other 38 states to take a look as well.

-Evan Godt
Editor, Health Imaging

egodt@trimedmedia.com