What’s next? Revisiting the Swiss Medical Board mammo recommendations

Despite the Swiss Medical Board’s recommendation to move away from systematic mammography screening earlier this year, there is not enough evidence to completely abolish such screening programs, according to a pair of Swiss physicians who published an editorial online Aug. 25 in JAMA Internal Medicine.

The board’s recommendations do offer some lessons to take to heart, however, such as being more transparent with patients who are likely confused by conflicted guidelines, suggested Arnaud Chiolero, MD, PhD, of the Institute of Social and Preventive Medicine, Lausanne University Hospital, and Nicolas Rodondi, MD, MAS, of the Department of General Internal Medicine, Bern University Hospital.

“In these mammography wars, rational thinking can be easily lost. It is, for example, troubling to note that ‘experts’ reach different opinions based on the same evidence. Women, physicians, and policy makers are puzzled by these contradictions,” wrote the authors.

“Although the interpretation of evidence is a scientific endeavor, the interpretation of evidence should not be confused with the formulation of recommendations. Indeed, recommendations about what to do should take into account economic, social, historical, and contextual realities.”

The Swiss Medical Board’s arguments for reigning in mammography screening were based mainly on the assertion that the absolute reduction in breast cancer mortality was low, while the potential for adverse consequences was substantial. The board also called attention to the fact that most evidence supporting the benefits of mammography is decades old.

In light of these valid concerns, Chiolero and Rodondi argued that while screening programs should continue, there are a few things that can be done to improve care. First, they noted that the value of mammography screening has been oversold and that harms haven’t been sufficiently acknowledged. “The fact of the matter is that some women benefit from screening mammography but others do not; some women are harmed but others are not. Health professionals and organizations providing mammography screening should provide women with information that is complete but easy to understand. They should avoid paternalistic persuasion to maximize the uptake of screening.”

Chiolero and Rodondi then called for updated evidence about screening mammography to replace existing studies, many of which are more than 30 years old and relied on different techniques. They also argued that mortality is not the only important outcome, and that new trials should also assess the rates of mastectomy, disease-free survival and other quality of life measures.

Lastly, the authors called on organized screening mammography programs to continue while the new evidence is being collected. In the absence of these organized programs, there would be a rise in opportunistic screening that is often performed more frequently than recommended and associated with a greater number of false-positives, wrote Chiolero and Rodondi.

“Regardless of whether the controversy over screening mammography diminishes or continues, women will continue to undergo breast cancer screening. They should be offered this screening in the best possible conditions.”