Breast cancer screening: controversy of impact

Few medical issues have been as controversial--or as political, at least in the United States-as the role of mammographic screening for breast cancer. The advantages of finding a cancer early seem obvious. Indeed, randomized trials evaluating screening mammography demonstrate a reduction in breast cancer mortality, but the benefits are less than one would hope. Moreover, the randomized trials are themselves subject to criticism, including that they are irrelevant in the modern era because most were conducted before chemotherapy and hormonal therapy became widely used. In this article I chronicle the evidence and controversies regarding mammographic screening, including attempts to assess the relative contributions of screening and therapy in the substantial decreases in breast cancer mortality that have been observed in many countries over the last 20-25 years. I emphasize the trade-off between harms and benefits depending on the woman's age and other risk factors. I also discuss ways for communicating the associated risks to women who have to decide whether screening (and what screening strategy) is right for them.