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was that mammography was ineffective in detecting breast cancer, he notes. However, in an era of digital breast tomosyn- thesis that can detect about 40 percent more breast cancers at sma ller sizes tha n reg ula r dig ita l ma mmog raphy, this argument is now rarely heard. More recent ly, some have questioned t he i mpor t a nce of screening ma mmog raphy a s more adva nced therapies become available. "In previous eva luations, we obser ved some benefit from advancements in therapy among women who did not participate in mammography screenings, but our data showed very clearly that modern therapies are no substitute for early detection," says Robert A. Smith, PhD, Vice President of Cancer Screening at the American Cancer Society and a member of Dr. Tabár's research team. "It's our position that the argument around what is contributing more to saving lives — imaging or therapy — is really misplaced because we are steadily making improvements to each. That being said, our study showed that women who choose to pa r ticipate in ma mmog raphy screening benefit substantia lly more from existing, state-of-the-art therapies than women who do not." A nother common concern is that screening mammogra- phy leads to overdiag nosis. W hile the exact preva lence of overdiagnosis cannot be tested in a clinica l tria l, as it would require physicians to abstain from treating cancerous lesions, some of the strongest studies ava ilable demonstrate that only 1 to 10 percent of breast cancers detected by screening mammography are overdiagnosed. " There is a lso no ev idence that brea st ca ncers resolve without treatment," says Dana H. Smetherman, MD, MPH, MBA, FACR, Chair of the American College of Radiology Breast Imaging Commission. "That means that screening less often or starting screening at a later age does not reduce the chance of overdiagnosis because the indolent cancer will simply be found on the next screening mammogram." Others question whether potentia l discomfort and anxiety related to screening mammography are worth the benefits. According to Dr. Baker, these concerns are misguided, as well. "As someone who sees a nd spea ks to women about their brea st imag ing concerns ever y day, I ca n ag ree that they feel anxious," he says. "However, they aren't anxious about screening ma mmogra ms. They a re a nxious that they may have breast cancer." BEYOND THE DEBATE Researchers say additiona l enhancements to breast cancer screening are vita l. Future investigation could include studies on how to detect benig n lesions in order to minimize biopsies of nonletha l growths, better identify women at high risk for breast cancer, decrease discomfor t associated with screening ma mmog- raphy a nd develop more effective methods to screen dense breast tissue. According to Dr. Smetherman, further research could foster consensus on screening recommendations among agencies and organizations such as the U.S. Preventive Services Task Force, A merica n Ca ncer Society a nd A merica n College of Radiology. Consistent recommendations regarding who should be screened and how often may reduce confusion, which can discourage patients from asking for reg ular mammograms and physicians from recommending them. "Physicians need to ta lk with their patients about the ben- efits and limitations of mammography screening, stress its importance, and play an active role in ensuring patients get mammograms regularly," Smith says. "There is no substitute for finding breast cancer early in its natura l history." n " Most breast cancer deaths are caused by advanced, late stage, palpable cancers that have spread to vital organs. Early detection through mammography screening dramatically reduces the incidence of advanced breast cancer in an entire population. As a result, significantly fewer women die." — LÁSZLÓ TABÁR, MD, FACR (HON), PROFESSOR EMERITUS OF RADIOLOGY AT THE UNIVERSITY OF UPPSALA SCHOOL OF MEDICINE M D N E W S . C O M /// M D N E W S L O N G I S L A N D ■ 2 019 2 3 SPECIAL CLINICAL SECTION: RADIOLOGY

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