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NCI Remains Committed to Current Mammography Guidelines

National Cancer Institute

In a world too often given to ambiguity and equivocation, let me begin here as I began my testimony before Congress several months ago on this same important public health issue.

The National Cancer Institute (NCI) remains dedicated to evaluating all information on the early detection of breast cancer and to continuously improving the diagnosis and treatment of this disease to save lives. With this principle ever present during the recent controversy over mammography screening, we reaffirm the following recommendation:

Beginning in their 40s, women should be screened for breast cancer with mammography every 1 to 2 years.

Clearly, we are not alone in our recommendation. Despite nuances in language—between American Cancer Society (ACS) and NCI guidelines, for instance—there remains remarkable agreement that mammography screening for women should begin in their 40s.

The recent media firestorm offered an opportunity to reevaluate and reaffirm this message to millions of women threatened by breast cancer, and to retell the story of how such conclusions are reached—and what they ultimately mean in our broader strategy to save lives and eliminate suffering.

As Begg outlines in his article [1], from the 1960s through the 1980s, seven randomized clinical trials with more than 400,000 participants were conducted to determine whether mammography—when used as a screening tool for women with no symptoms or signs of breast cancer—would result in decreased mortality from breast cancer.

These data have subsequently been examined and reexamined—by organizations like the NCI, the ACS, the American College of Radiology, and others. Such in-depth reviews ultimately led to NCI and ACS issuing the recommendation in 1997 that mammography was beneficial to women starting at age 40.

I won't belabor the specific problems in the conclusion reached in the Gøtzsche and Olsen analysis [2]. We are in agreement with Begg that the reviewers did not provide evidence that mammography does not save lives, but merely concluded—after discarding a number of studies they believed had flaws—that evidence for a positive effect was insufficient. NCI's bottom line is that after careful and serious deliberation, we remain convinced that the weight of the evidence continues to show that mammography saves lives through early detection—which permits treatment of the disease at an earlier stage. This conclusion is shared by the U.S. Preventive Services Task Force [3], an independent panel of private-sector experts in prevention and primary care sponsored by the Agency for Healthcare Research and Quality.

While we are far from declaring victory over breast cancer, recent trends demonstrate that we are headed in the right direction. In the past ten years, overall mortality rates from breast cancer have continued to fall. We first saw this encouraging trend in 1989 with a decreasing death rate of 1.4% per year. More recently, the decrease has sharpened to 3.2% per year. Of course, it is important to understand that this decline is not the result of mammography alone, but statistical modeling indicates that stage shift due to screening makes a substantial contribution. It is a combination of factors that has driven—and must continue to drive—this promising trend.

Everyone agrees that mammography detects early tumors when they are smaller, detects more tumors, and gives a woman more options for earlier treatment. These benefits are substantial in themselves. But mammography is only one factor in the equation that has set us on the present course. Advances in therapy—for instance, the use of adjuvant therapy including hormonal and chemotherapy, and chemoprevention such as tamoxifen—are also playing a role in turning the tables on this disease.

In addition to continuing to monitor and evaluate new information and better treatment options, NCI is increasing its efforts to learn how best to communicate the message. This is an important element that is far too often overlooked. For while the majority of informed women continue to follow the current guidelines—with or without controversy—it is clear that we need to increase efforts to reach women of low income and limited education who are not following any mammography guidelines because they have less access to information about it.

As readers of The Oncologist are all too familiar, cancer is a complex disease. Our solutions to this menace are likewise complex, but also deliberate.

As scientists and clinicians, we examine, we evaluate, we learn, and we intervene—and through it all, we continue to drive forward toward our goal to save lives and eliminate suffering. This has been the story with our on-going struggle against breast cancer. And this story will continue to guide our strategy to use every proven method—in combination with other factors—until we ultimately succeed.

Andrew C. von Eschenbach, M.D.

REFERENCES

1. Colin B Begg. The Mammography Controversy. The Oncologist 2002;7:174–176.[Free Full Text]
2. Olsen O, Gøtzsche PC. Cochrane review on screening for breast cancer with mammography. Lancet 2001;358:1340–1342.[CrossRef][Medline]
3. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, Revised Edition. Washington, DC: Office of Disease Prevention and Health Promotion; 2002.

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