Abstract
After some decades of contention, one can almost despair and conclude that (paraphrasing) "the mammography debate you will have with you always." Against that sentiment, in this review I argue, after reflecting on some of the major themes of this long-standing debate, that we must begin to move beyond the narrow borders of claim and counterclaim to seek consensus on what the balance of methodologically sound and critically appraised evidence demonstrates, and also to find overlooked underlying convergences; after acknowledging the reality of some residual and non-trivial harms from mammography, to promote effective strategies for harm mitigation; and to encourage deployment of new screening modalities that will render many of the issues and concerns in the debate obsolete. To these ends, I provide a sketch of what this looking forward and beyond the current debate might look like, leveraging advantages from abbreviated breast magnetic resonance imaging technologies (such as the ultrafast and twist protocols) and from digital breast tomosynthesis-also known as three-dimensional mammography. I also locate the debate within the broader context of mammography in the real world as it plays out not for the disputants, but for the stakeholders themselves: the screening-eligible patients and the physicians in the front lines who are charged with enabling both the acts of screening and the facts of screening at their maximally objective and patient-accessible levels to facilitate informed decisions.
Highlights
To these ends, I provide a sketch of what this looking forward and beyond the current debate might look like, leveraging advantages from abbreviated breast magnetic resonance imaging technologies and from digital breast tomosynthesis— known as three-dimensional mammography
As often assumed, that survival is the best measure for judging mammographic screening[2,3]. It remains open whether claimed harms truly are disproportionate to benefits when using, for instance, a more nuanced definition of overdetection than breast cancer diagnosed but not bca expired
Benefits and harms relativized to specific bca molecular subgroups or phenotypes, because it is highly unlikely that tumours detected would behave substantially the same regardless of whether they are more indolent endocrine-positive, versus her2-positive, versus more aggressive triple-negative disease
Summary
Several core issues require closer examination: 1. The potential benefits of mammographic screening independent of whether ultimate survival is affected, including diagnosis at earlier stages, typically with smaller tumours and node negativity; reduced likelihood of aggressive treatments and morbidities; detection of high-risk lesions (most diagnosed in the screened group2) allowing for chemoprevention or magnetic resonance imaging (mri) surveillance against occult malignancies, or both; and avoidance of compromised quality of life after diagnosis of advanced disease. The potential benefits of mammographic screening independent of whether ultimate survival is affected, including diagnosis at earlier stages, typically with smaller tumours and node negativity; reduced likelihood of aggressive treatments and morbidities; detection of high-risk lesions (most diagnosed in the screened group2) allowing for chemoprevention or magnetic resonance imaging (mri) surveillance against occult malignancies, or both; and avoidance of compromised quality of life after diagnosis of advanced disease. It is not clear, as often assumed, that survival is the best (or only) measure for judging mammographic screening[2,3]. I note that it is not implausible that more aggressive bcas can lead to significant bca-specific mortality during the first 10 years without early detection and surgical removal, while some more growth-indolent cancers could incur mortality after 10–20 years of follow-up in the absence of screening, given potentially significant intra-tumour heterogeneity, with early screening detection preventing many small or well- or moderately-differentiated tumours from developing into larger, more poorly differentiated tumours, against the common claim that mammography screening primarily detects mostly indolent cancers, recognizing some propensity for dedifferentiation and worsening of tumour malignancy grade as disease progresses[8,9,10,11,12,13]
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