ACR Statement on Annals of Internal Medicine Harris Opinion Editorial

A recent editorial relies on obsolete, hyperbolic information. Most experts do not support¹ the delayed or less frequent breast cancer screening the article advocates.

The American College of Radiology^® (ACR^®) urges women to start annual screening at age 40² and to have a breast cancer risk assessment³ by age 25. The United States Preventive Services Task Force (USPSTF), American Cancer Society, ACR and Society of Breast Imaging agree that the most lives and years of life are saved by starting annual screening at age 40⁴.

National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results⁵ data show that, since screening became widespread in the 1980s, the U.S. breast cancer death rate in women has dropped 40%. Women screened regularly have a 47% lower risk of breast cancer death⁶ within 20 years of diagnosis than those not regularly screened. Regular mammography use cuts the risk of breast cancer death nearly in half^7,8.

NCI/Cancer Intervention and Surveillance Modeling Network models show a major decline⁹ in deaths in women screened annually vs. biennially. Swedish data shows¹⁰ chemotherapy is much more effective in screened women¹¹ vs. unscreened women.

Total reliance on outdated randomized controlled trials (RCT) to inform screening policy can cost lives. The most recent RCT started over 30 years ago¹². The first RCT is more than 60 years old¹³. All used outdated, film-screen technology, many obtained only single views of each breast and there were limited screening rounds with variable screening intervals. Today, digital mammography with tomosynthesis, which acquires dozens of views of each breast, has increased cancer detection, and a decrease in callbacks and false positives is standard.

The RCTs individually did not have adequate statistical power to evaluate breast cancer mortality benefit for women in their 40s; however, subsequent meta-analyses have shown clear mortality benefit of screening in women ages 40–49^14,15,16.

Screening risks — which are non-lethal — are overstated¹⁷ due to faulty assumptions, methodology and hyperbole in articles on which these claims are based. High overdiagnosis claims are not well-founded¹⁷. Such claims based on modeling studies are inflated¹⁸. Well-designed studies provide an overall breast cancer overdiagnosis estimate of 10% or less^19,20,21. Screening-detected breast cancers do not disappear or regress if left untreated²².

So-called false positive exams (recalls from screening) are usually resolved by the woman coming back to get additional mammographic views, ultrasound or MRI. Anxiety from an inconclusive mammogram result or false positive is brief, with no lasting health effects²³. Nearly all women who have had a false positive exam still endorse regular screening²⁴.

Foregoing or delaying screening — resulting in breast cancer not being discovered until at an advanced stage — is often lethal. Screening only women ages 50–74 every other year may result in up to 10,000 additional, and unnecessary, breast cancer deaths²⁵ in the United States each year. Thousands more would likely endure extensive surgery, mastectomies and chemotherapy for advanced cancers.

References:

1. Radhakrishnan A, Nowak S, Parker A et al. Physician Breast Cancer Screening Recommendations Following Guideline Changes. JAMA Intern Med. 2017.
2. Monticciolo, D, Malak S, Friedewald S, Eby P, Newell M, Moy L, Destounis S, Leung J, Hendrick RE, Smetherman D. Breast Cancer Screening Recommendations Inclusive of All Women at Average Risk: Update from the ACR and Society of Breast Imaging. Journal of American College of Radiology. 2023. 
3. Monticciolo D, Newell M, Moy L, Lee C, Destounis S. Breast Cancer Screening for Women at Higher-Than-Average Risk: Updated Recommendations from the ACR. Journal of the American College of Radiology. 2023.
4. Arleo E, Hendrick RE, Helvie M, Sickles E, Comparison of recommendations for screening mammography using CISNET models. Cancer. 2017.
5. National Cancer Institute. Cancer Stat Facts: Female Breast Cancer. 2024.
6. Tabar L, Dean P, Chen Hsiu-Hsi T, Yen Ming-Fang A, Chen Li-Sheng S, Fann Chiang-Yuan J, Chiu, Yueh-Hsia S et al. The incidence of fatal breast cancer measures the increased effectiveness of therapy in women participating in mammography screening. Cancer. 2018.
7. Otto S, Fracheboud J, Verbeek A, Boer R, Reijerink-Verheij J, Otten J, Broeders M, de Koning H. Mammography Screening and Risk of Breast Cancer Death: A Population -Based Case-Control Study. American Association for Cancer Research Journals. 2012.
8. Coldman A, Philips N, Wilson C, Decker K, Chiarelli A, Brisson J, Zhang B, Payne J, Doyle G, Rukshanda A. Pan-Canadian Study of Mammography Screening and Mortality from Breast Cancer. Journal of the National Cancer Institute. 2014, 
9. Hendrick RE, Helvie M. United States Preventive Service Task Force screening mammography recommendations: science ignored. American Journal of Roentgenology. 2011.
10. Duffy, S, Tabar L, Yen Ming-Fang A, Dean P, Smith R, et al. Mammography screening reduces rates of advanced and fatal breast cancers: Results in 549,091 women. Cancer. 2020.
11. Tabar L, Dean P, Chen Hsiu-Hsi T, Yen Ming-Fang A. et al. The incidence of fatal breast cancer measures the increased effectiveness of therapy in women participating in mammography screening. Cancer. 2018.
12. Moss S. A trial to study the effect on breast cancer mortality of annual mammographic screening in women starting at age 40. Trial Steering Group. J Med Screen. 1999;6(3):144-8.
13. Habbema JD, van Oortmarssen GJ, van Putten DJ, Lubbe JT, van der Maas PJ. Age-specific reduction in breast cancer mortality by screening: an analysis of the results of the Health Insurance Plan of Greater New York study. J Natl Cancer Inst. 1986;77(2):317–20.
14. Hendrick RE, Smith RA, Rutledge JH, Smart CR. Benefit of screening mammography in women ages 40-49: a new meta-analysis of randomized controlled trials. Journal of the National Cancer Institute Monograph 22: 87-92, 1997.
15. Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 2009; 151: 727-37.
16. Smart CR, Hendrick RE, Rutledge JA, Smith RA. Benefit of mammography screening in women 40-49: current evidence from randomized screening trials. Cancer 75: 1619-1626; 1995.
17. Kopans D. Arguments Against Mammography Screening Continue to be Based on Faulty Science. The Oncologist 2014: Vol. 19(2):  107–112.
18. Oeffinger K, Fontham E, Ruth, E et al. Breast Cancer Screening for Women at Average Risk 2014 Guideline Update from the American Cancer Society. JAMA. 2015. 
19. Kopans DB. Point: the New England Journal of Medicine article suggesting overdiagnosis from mammography screening is scientifically incorrect and should be withdrawn. J Am Coll Radiology 2013; 10:317–319.
20. Hendrick RE. Obligate overdiagnosis due to mammographic screening: a direct estimate for U.S. women. Radiology. 2018;287(2):391-397.
21. Duffy SW, Agbaje O, Tabar L, et al. Overdiagnosis and overtreatment of breast cancer: estimates of overdiagnosis from two trials of mammographic screening for breast cancer. Breast Cancer Res. 2005;7(6):258-265.
22. Arleo, E, Monticciolo D, Monsees B, McGinty G, Sickles E. Persistent Untreated Screening-Detected Breast Cancer: An Argument Against Delaying Screening or Increasing the Interval Between Screenings. Journal of American College of Radiology. 2017.
23. Tosteson A, Fryback D, Hammond C et al. Consequences of False-Positive Screening Mammograms. JAMA Intern Med. 2014.
24. Schwartz L, Woloshin S, Fowler F et al. Enthusiasm for Cancer Screening in the United States. JAMA. 2009.
25. Hendrick RE, Helvie M. United States Preventive Services Task Force Screening Mammography Recommendations: Science Ignored. American Journal of Roentgenology. 2011.