We are committed to providing you with personalized, high-quality breast health evaluations. We’re focused on ensuring that your care is comprehensive and timely — biopsy results are usually available within 24 hours — and that our dedicated staff addresses your questions and concerns.

As Richmond’s only breast imaging facility to earn the American College of Radiology Breast Imaging Center of Excellence designation, VCU Breast Imaging is part of an interdisciplinary team at the VCU Massey Cancer Center that includes pathologists, surgical oncologists, medical oncologists, radiation oncologists, plastic surgeons, nurses and geneticists — all with specialty training in breast cancer.

STATEMENT FROM THE VCU SECTION OF BREAST IMAGING AND VCU MASSEY CANCER CENTER’S BREAST HEALTH CENTER REGARDING MAMMOGRAPHY SCREENING GUIDELINES

We recommend screening mammography annually for most women starting at age 40.  In some women at high risk for breast cancer, we recommend screening to start at age 30.  These guidelines were not established anecdotally, or whimsically, but rather are based on strong scientific evidence. 

In medicine, randomized controlled trials are considered the gold standard in evaluating the usefulness of tests such as mammography.  Seven different randomized controlled trials conducted by researchers worldwide, some of which included women ages 40 – 49, evaluated the effectiveness of mammography.

For these trials, large groups of women were randomly assigned either to undergo screening mammography or not.  Researchers followed them over a number of years to see if fewer women died of breast cancer among the group that were assigned to have screening mammography compared to those who were not.  ALL of these trials have shown that the routine use of screening mammography results in fewer women dying from breast cancer, including women ages 40 – 49.

Further supporting the routine use of screening mammography, and as predicted by these seven screening trials, is what we have seen happen to the mortality rate from breast cancer.  In the United States, the mortality rate from breast cancer was stagnant for 50 years.  However, since the routine use of screening mammography started in 1990, the death rate from breast cancer has decreased by 30 percent.  This is a dramatic result that speaks for itself.  Yet, here we are in 2009, with a federally funded task force under the auspices of the United States Preventive Services Task Force (USPSTF) suggesting that screening guidelines for breast cancer be changed significantly. 

This begs the question – “Why?” What kind of evidence has become available that would have the strength to reverse what has already been established? Why would we want to take the risk of reversing the positive trend in the breast cancer mortality rate in the United States?

This task force is recommending against the routine use of screening mammography in women ages 40 – 49.  It also recommends that screening intervals be changed from annually to every other year for women ages 50 – 74 and that screening mammography should be stopped for women over 74 years of age. 

What is the evidence used for these recommendations?  Computer modeling.  Six different computer models were used to evaluate different screening strategies.  In considering the USPSTF’s report, it is critical to recognize that computer modeling is based on the assumptions fed into the models.  To the extent that the assumptions are correct, the models may accurately predict what will happen.

For example, these investigators chose to evaluate specific “harms” against the benefits of saving lives and extending life-years through the routine use of screening mammography.  The harms they measured were (1) false-positive mammograms, (2) unnecessary biopsies and (3) overdiagnosis.  However, their models did not include other factors relative to how many biopsies are possibly patient driven rather than the result of strong mammographic findings, nor did they include the effect of our current medico-legal environment. 

With respect to “overdiagnosis,” ductal carcinoma in situ (DCIS) is discussed as though it is one disease without considering the biological variability in some of these cancers and the implications of this variation.

The authors don’t disclaim the effectiveness of mammography; in fact, they state that mammography can save lives and extend life years.  What they attempt to do, to guide health care policy, is determine the degree to which mammography accomplishes these benefits by measuring them against what they define as harms (see above) resulting from mammography.  We would suggest that, rather than drastically change what we know to be working, we look to reduce the effects from the harms they assumed for their computer models. 

Would it not be wiser to redouble our efforts to reduce anxiety among women by not “over-reading” mammograms, by shortening the time to complete evaluations, by providing rapid turn-around time on biopsies and prompt scheduling for treatment planning in those women diagnosed with breast cancer?  Is it possible that by refocusing our efforts on interpretive issues and tort reform, some of the false-positive mammograms and what the investigators call “unnecessary” biopsies could be decreased significantly?   What impact would more expert reading of mammograms and a 50 percent reduction in false-positive mammograms and biopsy rates accomplish in their modeling? 

With respect to “overdiagnosis,” this is an issue that warrants further research.  The problem is that we do not yet have a reliable way to predict the behavior of a small percentage of non-invasive breast cancers (specifically, low nuclear grade DCIS).  In some women these lesions may never progress to become invasive, but in other patients these lesions can result in metastatic disease and death.  Currently, we are unable to distinguish the “good” from the “bad” and in fact the authors concede that there needs to be more primary data on the natural history of DCIS and small invasive cancers so that more reliable conclusions can be drawn.

For the woman whose life could have been saved through the routine use of screening mammography, what do we say to her family when she dies from breast cancer because a computer model suggested that the type of harms listed above outweighed the benefit of saving her life?

While this is an interesting publication that warrants consideration and debate among researchers, we urge caution to women and their primary care providers.  Rather than use one publication, predicated on interesting computer models, to suggest changing the current norm, we encourage an approach that improves on the significant progress we have made with respect to mammography, interpretative skills and patient education.  Instead of discouraging women from annual mammography, our goal should be to assure that all women avail themselves of this potentially life-saving screening. 

While not a perfect test, mammography is one of the best and most studied in medicine.  The resulting decline in breast cancer mortality should be heralded as a testament to the effectiveness of the current guidelines.

Dr Cardenosa, screening video 1

Dr. Cardenosa, screening video 2

Dr. Cardenosa, screening video 3

Dr. Cardenosa, screening video 4

 STATEMENT FROM VCU BREAST IMAGING EXPERT REGARDING MAMMOGRAMS FOR WOMEN AGES 40 – 49

Studies and an editorial published in today’s Annals of Internal Medicine suggest that mammograms are not beneficial to women ages 40 – 49. These reports contradict volumes of science with regards to mammography’s proven record of saving and extending lives.

Gilda Cardeñosa, MD, director of breast imaging at Virginia Commonwealth University Medical Center and a world-class clinician, researcher and medical textbook author, has thoroughly reviewed the reports and provides important insight on this topic. She is also a key member of the Breast Health Center at VCU Massey Cancer Center.

Dr. Cardeñosa’s Statement:

The current best standard of care for women ages 40 – 49 who are at average risk for breast cancer is to get annual screening mammograms.

A new report runs counter to the scientific information that the worldwide breast imaging research community has acquired over the last several decades. The report relies on computer models for its data and includes many assumptions.

The gold standard for medical research is through clinical trials on human subjects in which one group of participants are randomly assigned a treatment or procedure, and another group, the control group, is not.

Data from seven randomized clinical trials have demonstrated that screening mammography in women ages 40 – 74 reduces breast cancer mortality. For the 50 years prior to the introduction of mammography in 1990, breast cancer mortality rates were flat. Since routine screening guidelines were adopted in the United States in 1990, we have seen mortality from breast cancer decrease by 30 percent.

I join many other physicians, researchers and breast cancer awareness advocates in urging women to not be alarmed by this new report, and to continue to get annual mammograms.

 

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– Excerpts from VCU Breast Imaging patient satisfaction surveys.