NEJM poll: Jury still out on mammo screening

Physicians responding to a poll regarding when and if to initiate screening mammography were fairly evenly divided about beginning screening at age 40 or 50, with a significant fraction not recommending the exam, according to a clinical decisions feature published Feb. 28 in the New England Journal of Medicine.

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NEJM conducted the brief survey following publication of one screening mammography study and three invited commentaries. The initial study suggested that 30 percent of breast cancer cases detected in 2008 were overdiagnosed. One invited commentary supported initiating screening mammography at age 40, and a second argued in favor of U.S. Preventive Task Force (USPSTF) recommendations, which suggest biennial screening beginning at age 50. The final commentary argued against routine screening, citing a small benefit and substantial risk of harm.

A total of 1,240 physicians responded to the poll. “Overall, 39 percent of the readers who voted supported initiating screening at the age of 40 years, 44 percent supported initiating screening at age 50, and 17 percent did not support routine screening,” wrote James A. Colbert, MD, of Newton-Wellesley Hospital in Newton, Mass., and Jonathan N. Adler, MD, of Massachusetts General Hospital in Boston.

The authors referred to geographic disparity in the results. Physicians from Central America and South America were much more likely to support initiating screening at the age of 40. However, European respondents were divided; 45 percent recommended starting screening at age 50, and the remainder were split between initiating screening at age 40 and not recommending screening.

A total of 47 percent of physicians in the U.S. concur with the USPSTF recommendations, while 40 percent prefer initiating screening at age 40, and 13 percent not recommending the exam.

The authors shared several comments from respondents, some of whom noted that differentiating cancers that will remain indolent from aggressive disease is not possible on an individual basis. Others affirmed the benefits of a population health perspective that reduces overall disease burden and increases life expectancy.

However, many respondents recognize screening mammography’s flaws. “A number of commenters support the need for further development of novel diagnostic assays that can better detect the cancers that need treatment while sparing tens of thousands of women each year from overdiagnosis and overtreatment,” wrote Colbert and Adler.