Screening for breast cancer in pre-menopausal women. Who should decide?

The recent UICC meeting on breast cancer screening in pre-menopausal women showed that experts disagree: some would recommend that screening begin at age 40, others would postpone it until after age 50 (Eckhardt et al., 1994). There is full consensus that screening at ages 40 to 49 may detect a substantial fraction of breast-cancer cases before their clinical manifestation, but the trials carried out have not indicated a significant reduction in subsequent mortality. As stated in the report of the UICC meeting, "this issue is too large for it to remain only the concern of experts." In our opinion, women should be provided with full information to enable them to decide themselves what is better for them. This means that the available scientific evidence both on benefits and on risks should be made quantitatively explicit. As recently reviewed by Hurley and Kaldor (1992), potential benefits include saved lives, increased use of conservative therapies, and reassurance of women without pre-clinical cancer; risks include radiation-induced breast cancer, unnecessary investigations for false positives, useless early diagnosis and treatment, diagnosis and treatment of lesions not requiring treatment (over-diagnosis), false reassurance, and psychological and social morbidity such as anxiety and the stigmatization of women with positive diagnosis.