By Dr. Samuel Epstein

The updated Federal guidelines, announced by Health and Human Services Secretary Tommy Thompson on February 21, strongly recommending annual mammography for women over the age of 40, are unlikely to resolve the current headline debate.

The guidelines, surprisingly based on an unpublished analysis by an independent advisory board, ignore evidence on the risks of breast cancer from mammography. Furthermore, they dismiss evidence on the effectiveness of breast self examination (BSE) combined with annual clinical breast examination (CBE).

Screening mammography poses significant and cumulative risks of radiation, particularly for premenopausal women, of which women remain uninformed. The routine practice of taking four films of each breast annually results in approximately 1 rad (radiation absorbed dose) exposure.

This is about 1,000 times greater than exposure from a chest x-ray which is broadly focused on the entire chest rather than narrowly on the breast. The premenopausal breast is highly sensitive to radiation, each 1 rad exposure increasing breast cancer risk by about 1 percent, with a cumulative 10 percent increased risk for each breast over a decade's screening.

Radiation risks are further increased, by some four-fold, for the 1 to 2 percent of women who are unknowing silent carriers of the A-T (ataxia-telangiectasia) gene. By some estimates, this accounts for up to 20 percent of all breast cancers diagnosed annually. All these risks are greater for women in their thirties who are being encouraged to undergo "baseline screening," for which there is no evidence of any future relevance.

Since 1928, physicians have been warned to handle "cancerous breasts with care -- for fear of accidentally disseminating cells" and spreading the cancer. Nevertheless, mammography entails tight and often painful breast compression, particularly in premenopausal women. This may lead to distant and lethal spread of malignant cells by rupturing small blood vessels in or around small undetected breast cancers.

Another serious danger of mammography is the fact that mammography centers are being overbooked as a result of aggressive promotion of premenopausal screening. Resultingly, patients referred for diagnostic mammography, because of suspicious clinical or other findings, are now experiencing potentially life-threatening delays, of up to several months, before they can be examined.

The advisory panel's dismissal of BSE and CBE is inconsistent with the results of a September 2000 publication by leading University of Toronto epidemiologists.

Based on a unique individually randomized control trial on breast cancer mortality in some 40,000 women, it was concluded that monthly BSE following brief training coupled with annual CBE by a trained health care professional is a least as effective as screening mammography in detecting small tumors.

National networks of BSE and CBE clinics staffed by trained nurses should be established to replace screening mammography. Apart from their minimal costs, such clinics would empower women and free them from increasing dependence on industrialized medicine and complicit medical institutions.

It should further be pointed out that the new Federal guidelines ignore the growing and inflationary costs of mammography. Screening all premenopausal women, some 20 million annually, would cost about $2.5 billion, about 14 percent of estimated Medicare spending on prescription drugs.

These costs would be increased some four-fold if the highly profitable machine and film industries succeed in replacing film machines, costing about $100,000 each, with the latest high-tech digital machines costing about $400,000 each. These have been recently approved by the FDA although there is no evidence of improved effectiveness.

Finally, it may be noted that no nation other than the U.S. recommends routine screening of premenopausal women.

Samuel S. Epstein, M.D.

Professor Emeritus Environmental Medicine
University of Illinois at Chicago School of Public Health
and Chairman, Cancer Prevention Coalition

Published in the LA Times February 25, 2002