Should women stop getting mammograms? Imaging experts explain

The standard recommendation in the U.S. once a woman is between the ages of 40 and 50, getting an annual mammogram exam should become regular routine. The hope for this worldwide movement that began in the 1970's was to prevent more women from developing advanced breast cancer, however a new article published by TIME reveals why some medical experts believe it's time to end mammograms altogether.  

On Dec. 6, TIME published "It's Time to End Mammograms, Some Experts Say", explicating different study findings and medical imaging experts' opinions about the annual exam 65 percent women in the United States between the ages of 40 and 50 receive every year, according to a report by the Centers for Disease Control and Prevention (CDC).  

Mammography picks up changed breast tissue surrounding tumors, not the actual tumors themselves, the article states. Therefore, advanced or growing breast cancers that don't have simultaneously changing breast tissue may not get noticed by mammograms in time.  

A recent study published in the September issue of BMJ has left many imaging experts uncertain about whether mammography exams are effective enough to continue to perform, spearheading the TIME article. The study shows that mammography did not prove to be effective in reducing the number of deaths or advanced breast cancer diagnoses in 8 million Dutch women over a period of 23 years (between 1989 and 2012).   

According to study results, although the women received mammograms every other year, researchers instead found that the mammograms led to overdiagnosis 60 percent of the time.  

"I don't think the accumulating data shows that continuing mammography screening is a good solution," lead researcher of the study Phillippe Autier from the University of Strathclyde Institute of Global Public Health in Glasgow, UK told TIME.  

The researchers found that there was no notable decrease of stage 2 to stage 4 breast cancers over the 23 year period, however early stage in situ cancers increased by 4 percent each year. Additionally, Autier and his colleagues calculated that 59 percent of lesions detected were overdiagnosed and received unnecessary treatment. 

Autier, who has supported the use of mammograms throughout his career, now believes that mammography is not an ideal solution to prevent and protect women from breast cancer because over diagnosis outweighs the difference mammography makes in mortality rates. Although not against screening for cancer in general, he thinks there needs to be more effective ways to detect breast cancer.  

"Doctors need to be more upfront in discussing the pros and cons of mammography with their patients and informing them that data suggests the test may not be as effective as doctors once thought," Autier told TIME. "Based on their own personal risk for cancer, women should make their own decisions about whether they should get regular screening."  

However, there are experts who strongly disagree with Autier, including Robert Smith, vice president of cancer screening at the American Cancer Society. Smith told TIME that a current problem latched onto this debate is that not all women eligible for mammograms chose to get them or continue to receive them regularly. Smith also noted that mammography attendance rates haven proven to naturally decline over time, therefore Autier's study could not accurately detect an increase in breast cancer cases over the 23year period.  

"If breast cancer rates overall were rising in the study period, then little change in the diagnosis of advanced cancer could still mean that rates of advanced disease were declining, since more cancers were being reported," according to the article.  

According to the American Cancer Society, breast cancer mortality has declined by 40 percent as of 2017, yet treatments that are better at detecting breast cancer earlier than mammograms may be responsible, Smith added.  

Autier's study and conclusion is not the only one of its kind, with a growing number of other population studies across the world and other medical experts supporting Autier's conclusion.  

"We certainly need better screening mechanisms for breast cancer. I think there are innovations out there and people capable of bringing those innovations to fruition, that hopefully five to ten years from now will have those advances that then will either supplant mammograms or will augment the specificity of mammograms, so we're not getting the number of false positive interventions that are so troublesome today," said Lloyd Minor, MD, dean of Stanford's School of Medicine, in a panel at this year's Fortune Brainstorm Health annual conference.   

Minor explained that until recently, the degree of advancement diagnostics has been nowhere close to that of therapeutics.  

However, as medicine shifts from striclty fee-for-service (FFS) payment models to a value-based reimbursement infrastructure, value of diagnostic care will be a top priority and based on both the quality of payment systems and science itself, explains Shelley Hwang, MD, MPH, surgical oncologist at the Davis Ambulatory Surgical Center at Duke Cancer Center and Duke University Hospital and one of TIME's 100 most influential people of 2016.  

"It's a cultural problem, it's a focus problem, and it's easier to focus on a discreet issue; one gene, one targeted therapy. Prevention is really big, but if we organize ourselves around trying to tackle this problem, I have no doubt that we can. We have the ingenuity, the know-how, and now the technology and big data, all of which can be applied to tackle this problem. But I think that infrastructure and society, the way science works, is not set up to reward people who look at prevention rather than targeted therapy."  

Ultimately, the rest of medical imaging community is now left to decide: should mammograms stay...or should they go?