Too Many Breast Cancer Tests?

Mammogram Testing, Surgical Biopsies Sometimes Unnecessary

From the WebMD Archives

Oct. 21, 2003 -- Unnecessary mammogram testing and too many breast cancer biopsies are being done in the U.S. - causing women unnecessary worry, according to a controversial new study.

"Our study shows that in the U.S., there are twice as many diagnostic procedures, and two to three times as many surgical biopsies in the U.S. as in the U.K ... yet the cancer rates were almost identical," says researcher Rebecca Smith-Bindman, MD, a radiologist with the University of California-San Francisco.

U.S. vs. U.K.

In her study, Smith-Bindman compares a host of mammogram testing statistics in the U.S. and the U.K. -- involving nearly six million mammograms performed over a three-year period, the largest study thus far of the issue.

The study appears in the current Journal of the American Medical Association.

The findings:

  • American women got called back twice as often for repeat mammogram testing, compared to British women.
  • American women were two times as likely to get a more invasive surgical biopsy as opposed to a biopsy involving a needle to extract breast tissue for analysis.
  • Normal results from biopsies (showing no cancer) were twice as high in the U.S.
  • Numbers of cancers detected were very similar in the U.K. and the U.S.


"We have known that the recall rate was higher in the U.S., but ... we found it comes with no benefit, that it does not bring more cancers detected," Smith-Bindman tells WebMD.

The cost of so many procedures is one issue. "But the more substantial cost is the emotional costs and women's willingness to come back for screening mammography," she says. "When they have been put through the anxiety and surgery, to find they have no cancer, she's less willing to come back."

Clearly, fear of malpractice is a factor -- although a recent study found more fear than actual lawsuits, she adds.

She would like to see more "double reading" of mammogram films, a common practice in the U.K. It means that two radiologists in the same center read the same film, essentially giving a second opinion on the results.

Some evidence shows that double reading "raises detection rates and decreases recall rates," she writes.


Otis Brawley, MD, associate director of the Winship Cancer Institute at Emory University School of Medicine in Atlanta, says the matter is not so straightforward.

As younger women have been encouraged to get mammogram testing, interpreting mammograms has become a much riskier profession, he tells WebMD. Forty-year-old breasts are denser and more difficult to "read" than older breasts. When an abnormality shows up, however subtle it may be, more tests are ordered.

Indeed, "more tests is the only way a radiologist can be protected from malpractice," he tells WebMD. "I don't believe that any radiologist has ever been sued because they called someone back for additional tests."

In fact, radiologists turn away from mammogram testing as a specialty, because of malpractice fears.

There are areas in the U.S. where it's difficult to get a mammogram at all, Brawley tells WebMD. "In New York City, it's very, very difficult because so few radiologists are willing to do it. It's a combination of legalities and the fact that mammography doesn't pay very well. There are a number of mammography fellowship training programs looking for radiologists. That's very, very unfortunate for the consumer."


Mammogram testing is indeed beneficial, "especially for women in their 50s and 60s, and unfortunately we're creating a system where it's becoming less and less available to them," he says.

To avoid getting call-backs for a second mammogram, avoid mobile vans and centers where no radiologist is on site -- where the film is usually developed and read the next day after never seeing the patient, he suggests. "Those centers do not provide as good [mammogram testing] as a center where a radiologist is on site."

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SOURCES: Smith-Bindman, R. Journal of the American Medical Association, Oct. 22/29; vol 290: pp. 2139-2137. Rebecca Smith-Bindman, MD, a radiologist with the University of California-San Francisco. Otis Brawley, MD, associate director of the Winship Cancer Institute at Emory University School of Medicine in Atlanta.
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