Editorial for “Mammography Screening of Women in Their Forties

The impact of changes in screening guidelines”


  • Rachel F. Brem MD

    Corresponding author
    1. Department of Radiology, George Washington University Medical Center, Washington, District of Columbia
    • Department of Radiology, George Washington University Medical Center, 2150 Pennsylvania Avenue NW, Washington, DC 20037
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    • Fax: (202) 741-3029

  • See referenced original article on pages 473–80, this issue.


Mammographic screening has resulted in ≤44% reduction in breast cancer mortality. Understanding what influences and motivates women to obtain mammograms is critical to achieving the highest compliance rate

Mammographic screening has resulted in up to a 44% reduction in breast cancer mortality.1, 2, 3 Therefore, it behooves us to try to understand how to best influence women to comply with mammographic screening recommendations such that we can optimize early diagnosis for improved survival. Understanding what influences and motivates women to obtain mammograms is critical in trying to achieve the highest compliance rate. This is even more important now as recent data are suggesting that for the first time in decades, the compliance rate with mammographic screening is decreasing in the United States.4

In a 3-month period in 1997, 3 divergent, highly publicized recommendations for mammographic screening in women aged 40–49 years were issued. The American Cancer Society changed its recommendation to annual screening of women ages 40–49 years, the National Cancer Institute (NCI) to screening every 1–2 years, and the United States Preventive Services Task Force maintained a recommendation for initiation of screening at the age of 50 years, thereby not changing its recommendation. Several retrospective studies evaluated the impact of these changes in recommendations. However, the needed prospective study had not been undertaken.

The investigators of the study reported in this issue of Cancer1 had a uniquely fortuitous opportunity. It was in the middle of another study being undertaken by the investigators (the Race Differences in Screening Mammography Process Study) that recommendations for screening mammography changed. Over a century ago, the great scientist Louis Pasteur said that chance favors the prepared mind. It was the prepared minds of these investigators that resulted in harnessing this unique opportunity in time to prospectively study the change in attitude. Women ages 40–49 years versus 50 years and older were studied to determine whether these changes in recommendations resulted in a change in attitude concerning the need for screening mammography. Interestingly, the study demonstrated, in a well designed, prospective manner, that changes in recommendations by the American Cancer Society and the National Cancer Institute had resulted in a significant increase in the perception of women ages 40–49 years that they should undergo screening mammography, which was not the case in other age groups to whom the change in recommendation was not targeted. Although the change in actions in these nontargeted women was not studied, the investigators point out that other researchers have demonstrated that a change in attitude results in a modification of actions, and we can assume that more women ages 40–49 years obtained mammographic screening after these changes in recommendations.

The findings of this study,1 in and of itself, are important and highly significant. It is clear that these investigators used their insight to add significantly to our understanding of the consequences of issuing recommendations for health maintenance interventions. We must applaud their insightfulness, which caused them to perform this unique study that otherwise may not have been undertaken. We have learned that when organizations held in high regard vigorously publicize recommendations for medical interventions, publicity has its intended result. However, we, as a medical community, must evaluate these findings in light of our influence on the persons to whom these types of recommendations are targeted. The recommendations of highly regarded organizations and institutions have enormous impact on the people and the health of the United States. It is not uncommon to hear or read in the media about a change in recommendation for screening or other health-related issue by an organization or institution of note. This emphasizes what a great honor and responsibility those of us in the healthcare profession have on those for whom we care. However, we must also understand the enormous responsibility that we have by virtue of the finding that our patients and the American people look to us for healthcare guidance. It is for this reason that organizations and institutions who issue health-related recommendations must do so with a great sense of responsibility and with a clear understanding of the impact that their recommendations will have. Clearly, much thought, research, and deliberation must go into these recommendations. The study reported in this issue of Cancer1 further demonstrates how far our recommendations reach, and they must be carefully evaluated by all organizations and institutions before issuance of health maintenance recommendations. This is especially true when the recommendation is to not obtain available studies that result in improved outcomes. It is crucial that before rendering a recommendation to not undergo potentially lifesaving examinations, the impact of such a recommendation is carefully, thoughtfully, and statistically evaluated and that there must be a compelling reason not to undergo such an examination, ie, mammography. Of course, if harm can occur as a result of a test, then such a recommendation is understandable. Otherwise, issuance of a recommendation to forego a lifesaving examination must be carefully, responsibly, and objectively considered. That being noted, we must always remain fiscally responsible. Nevertheless, it is an enormous disservice to patients and, with regard to screening mammography recommendations, to women when recommendations are made to not undergo screening. Yes, there are costs, but there are also lives saved, man hours of work not missed by the patient, decreases in morbidity and mortality, and an increase in data supporting the view that screening mammography saves lives, especially those of younger women. Issuance of a recommendation to either undergo or forego screening mammography carries with it an enormous responsibility. Organizations and institutions must be sure that they guide, and not misguide, those who look to them for advice. I applaud the recommendation of the American Cancer Society, the National Cancer Institute, the American College of Radiology, and the American College of Surgeons who recommend screening mammography annually for women ages 40–49 years . However, I respectfully disagree with the recommendations by the American College of Physicians and by the American College of Preventive Medicine that recommend that women younger than the age of 50 years who are not at increased risk do not obtain mammograms. Data is compelling that there is a 44% reduction in death from breast cancer in women who undergo mammographic screening. The argument that meta-analyses are not sufficiently robust to definitely demonstrate a reduction in breast cancer mortality forwarded by these organizations is not substantiated by data and also denies younger woman the opportunity for lifesaving intervention. Clearly, the study reported in Cancer1 has demonstrated that these recommendations have their intended result and that women ages 40–49 years will perceive a lesser need for mammographic screening than would optimally be needed after a recommendation to forego mammographic screening.

I strongly commend the investigators on this excellent, fortuitous, and important study.1 We now have objective proof that recommendations for health interventions do impact the beliefs of those to whom the recommendations are targeted. We must now use this information to assure, and certainly not to deny, women that they will receive optimum care for optimum survival.