While the widespread use of mammography would lead the average person to believe that this matter has already been settled, the authors assert that this is simply not the case. In their review of the issue, they note:

Breast cancer screening and mammography have almost become synonymous in the public perception, yet this should not necessarily be the case. Ideally, a screening tool for breast cancer would reduce mortality from breast cancer while having a low false alarm rate and being relatively cheap.

Clinical breast examination is also relatively simple and inexpensive, but its effectiveness in reducing mortality from breast cancer has not been directly tested in a randomized trial. Mammography is complex, expensive, and only partially effective.

We believe that there is sufficient circumstantial evidence to suggest that clinical breast examination is as effective as mammography in reducing mortality from breast cancer and that the time has come to compare these two screening methods directly in a randomized trial.

The authors conclude with the following summary points:

• The goal of breast screening is to prevent death and not simply to detect cancers by mammography

• Mammography does detect some cancers "early," but many of these are not potentially lethal and their detection causes needless anxiety

• Clinical breast examination is more likely to detect cancers that are potentially lethal

• Results of a recent Canadian study suggest that mammographic detection of cancers that are not palpable does not affect mortality
  

• New British guidelines on informed consent state that women should be informed of the drawbacks of mammography as well as its potential benefits

In an emailed response to the article, Dr. BC Boyd of the University of the West Indies, voices his hesitation at promoting universal mammograms to his patients:

Medicine can sometimes be like women's (and men's) fashions - certain features become "in vogue"! (Note the waning interest now in the PSA). Mammography, I believe, is now in vogue My arguments to my patients (and my colleagues) continue to be:

1) The uncertain value of mammography in reducing the mortality from breast cancer

2) The extraordinary discomfort involved in the procedure (some would say unacceptable)

3) The psychological trauma which accompanies the request for diagnostic biopsy and surgery (where the radiological diagnosis is in doubt)

4) The continued anxiety raised when a routine mammography reveals a "lesion" that is diagnosed as non-malignant

5) The extensive costs required for the special training of adequate numbers of radiologists in this field

6) The doubtful cost effectiveness of this procedure where priorities in health care must be taken into account -particularly in the presence of "structural adjustments" demanded by the World Bank

British Medical Journal, October 28, 2000; 321: 1071-1073