March 15, 2021

JAMA Breast Cancer Screening Research Article and Editorial Misleading and Ignore Disparities

The research letter by Patel et al, and accompanying editorial by Habib et al, published March 15 in the Journal of the American Medical Association (JAMA) Internal Medicine contain serious omissions of fact. The claim that facilities offering mammograms to women ages 40 and older are operating counter to recommendations of “national societies” is misleading at best.

Also, to assert that financial incentives may be driving local site screening recommendations – with no evidence to back the claim – is outrageous and insulting to the medical professionals working to save lives from the nation’s second leading cancer killer in women.

The national medical societies most expert in breast cancer diagnosis and care, including the American College of Radiology® (ACR®), Society of Breast Imaging (SBI) and American Society of Breast Surgeons recommend that women start getting annual mammograms at age 40. Similarly, the American College of Obstetricians and Gynecologists recommends women start mammography at age 40 and get tested every one-to-two years.

The Patel research letter confirms what a previously published JAMA study already found - that breast cancer experts in the United States (U.S.) largely do not support delayed or less frequent screening – as called for by the U.S. Preventive Services Task Force (USPSTF) and American Cancer Society (ACS). This makes sense – as the ACS, USPSTF, ACR and SBI all agree that the most lives are saved by annual screening starting at age 40.

Mammography Saves Lives

National Cancer Institute Surveillance, Epidemiology, and End Results data show that, since mammography became widespread in the 1980s, the United States breast cancer death rate in women, unchanged for the prior 50 years, has dropped 40%.

A study in Cancer showed that women screened regularly for breast cancer have a 47% lower risk of breast cancer death within 20 years of diagnosis than those not regularly screened. Large studies -- Otto et al and Coldman et al -- show that regular mammography use cuts the risk of breast cancer death nearly in half.

Moving Away from Starting Annual Screening at Age 40 = More Breast Cancer Deaths

National Cancer Institute/Cancer Intervention and Surveillance Modeling Network models show a major decline in deaths among women screened annually vs. every other year (biennially). Screening only women ages 50 to 74 every other year may result in up to 10,000 additional, and unnecessary, breast cancer deaths in the US each year. Thousands more would likely endure extensive surgery, mastectomies and chemotherapy for advanced cancers.

Later/Less Frequent Screening Fails Groups At Greater Risk Of Early Breast Cancer Development and Death

African American women are 42% more likely to die from breast cancer than white women. In fact, since 1990, breast cancer death rates only dropped 23% in African American women — compared to a 37% drop in whites. A higher proportion of non-white women are diagnosed with breast cancer before age 50 than white women.

Women who live in rural areas are less likely to be screened and more likely to die of breast cancer than those who live in metropolitan areas. The breast cancer death rate is also declining more slowly in rural areas than in larger cities. Restricted screening may increase racial and regional disparities in breast cancer outcomes.

Coverage Denials Based on USPSTF Recommendations Could Take Away Women’s Choice

More disturbingly, the 2009/2016 USPSTF recommendations are the basis for insurance coverage determinations under the Affordable Care Act. If there was no current federal moratorium on use of those guidelines for insurance coverage, patients under 50 who need or want screening mammograms or yearly testing would have to pay out of pocket. This may place underserved populations at an even greater disadvantage. That can’t be allowed to happen.

Mammography Harms Overstated

Screening risks are overstated due to faulty assumptions, methodology and hyperbole in articles on which such claims are based. An article in The Oncologist shows that studies with high overdiagnosis claims are not well-founded. American Cancer Society findings re-confirmed that overdiagnosis claims based on modeling studies are inflated. A British Medical Journal study, using direct patient data, shows that breast cancer overdiagnosis is approximately 2%. Screening-detected breast cancers do not disappear or regress if left untreated.

A JAMA study shows that understandable anxiety from inconclusive mammogram results or false positives is brief with no lasting health effects. Research shows that nearly all women who have a false-positive exam still endorse regular screening and want to know their status.

Time to Move On from Flawed Mammography Restrictions

Short-term anxiety from initial screening test results, which are often resolved in a few days, and overstated overdiagnosis claims do not outweigh the thousands of lives saved each year through annual mammography screening starting at age 40.

For more information regarding mammography and breast cancer screening visit, and