Mammography in the media:
covering the absence of consensus


No one disputes that regular mammography is useful to screen for breast cancer in women in their 50s. Similarly, everyone agrees that women in their 30s do not need regular mammograms unless they are at increased risk for breast cancer. But the middle ground is a battleground: For the past four years, health organizations ranging from the American Cancer Society to the American College of Obstetrics and Gynecology and the American Academy of Family Practice have expressed varying opinions on whether annual mammograms help save the lives of women in their 40s. What is the public to do when experts don't agree and great minds refuse to think alike?

A meta-analysis of several studies1 found that regular mammograms decreased mortality from breast cancer in women in their 40s, but this reduction did not come into effect until they were in their 50s and could be due to later mammograms. In addition, younger breasts tend to be more fibrous and more likely to hide tumors from mammography. There is the added risk that regular mammograms could lull women into false security, leading them to ignore regular breast self-examination. However, the meta-analysis shows that regular mammograms for women in their 40s may prolong the lives of one or two women out of 1,000. Of note, most women in their 40s who participated in the trials were actually between 45 and 50; thus, we have few data on women in their early 40s.

In January, a panel advising the National Institutes of Health chose not to recommend regular mammography for women in their 40s. The director of the NIH immediately asked a National Cancer Institute panel to review this decision, and one member of the NIH panel resigned over it. The upshot -- at this writing -- was that the National Cancer Advisory Board, which advises the NCI, recommended that women in their 40s get mammograms every year or every other year, while the American Cancer Society recommends annual mammograms. The public was left with a view of disagreement between people who should be united in giving advice. The controversy and the sometimes contentious meetings -- the original NIH meeting lasted until the wee hours, and at least one partisan of early screening used the word "murder" to describe any approach less vigilant -- received wide coverage in the daily press, wire services, and news weeklies. Pugnacious metaphors proliferated: Newsweek referred to the situation as "The Mammogram War," and Science called it "The Breast-Screening Brawl."

Some news outlets, including Newsweek and Reuters, correctly noted that the NIH panel actually said the decision on when to start mammograms should be left to patients and their physicians. Others, including the Associated Press, noted the money factor: that managed care could turn a recommendation into a mandate and deny coverage to women in their 40s who want mammograms. Considering the confusion on the part of the medical establishment, the medical reporting establishment didn't do too bad a job, says Dr. Judith S. Jacobson, assistant professor of clinical public health at Columbia. "I don't have any specific criticism of the press coverage," she said. She singles out the handling of the issue in the New York Times as a balanced representation of both points of view.

Dr. Jacobson notes, however, that the public may have been oversold on the benefits of mammography, which may not only miss tumors but also perhaps lead to overtreatment of some that might never cause clinical problems, especially in younger women. The public also may not have been informed of the distinction between early detection of tumors and reducing deaths due to breast cancer, which do not necessarily go hand in hand, she says.

"I read the public and professional literature and don't know what the public got out of it," saysDr. Karen Antman, director of the Herbert Irving Comprehensive Cancer Center at Columbia. But reporting on the controversy and telling the public about dissent among experts, she adds, is not necessarily bad: "I'm not as disturbed by the ambiguity. It is OK that the public knows we disagree." Women should consult with their doctors and make decisions based on their family history and other risk factors, as the NIH recommended in January, Dr. Antman notes. "It might be that we can avoid screening in women in their early 40s who are at low risk," she says. "Nevertheless, most women oncologists I know in their 40s get regular mammographic screening."

Kenneth Goldstein, professor emeritus of journalism at Columbia, believes the press did not present the material well. "They never went into the numbers well enough," he says. Women will now not know what to do or think, he believes, because they may not have received all the information they need. One point missed was the need for training: Although several news articles reported the difficulties in reading mammograms in younger women, few pointed out that more training would be needed on the part of the clinicians reading those mammograms to prevent misdiagnosis.

Prof. Goldstein notes that both sides in the controversy are propelled by action groups who are committed to their point of view. Such groups are loud and get listened to, he says. "Then we have a dogfight in the press and then it will blow over, with some kind of compromise." --Valerie DeBenedette

1. Smart CR, Hendrick RE, Rutledge JH 3rd, Smith RA. Benefit of mammography screening in women ages 40 to 49 years: current evidence from randomized controlled trials. Cancer 1995; 75(7):1619-26.
VALERIE DeBENEDETTE writes frequently on medical topics. Her work has appeared in 21stC, National Cancer Bulletin, Cosmetic Dermatology, Drug Topics, The Physician and Sportsmedicine, and the Gannett Suburban Newspapers. She is the author of Caffeine (Springfield, N.J.: Enslow, 1996).