Last week the American Medical Association (AMA) recommended that all American women start having regular mammograms for breast-cancer detection at age 40. The AMA thus joined the National Cancer Institute and American Cancer Society in making this recommendation. The AMA had been reluctant to endorse this proposal for the past several years. Why the change now?

Has new evidence on the benefits of such screening recently emerged? Is there good reason to recommend this routine breast-cancer screening for all women at such a relatively early age? Will this recommendation save lives?

While it is hardly politically correct these days to say so, the bottom-line answers here are not reassuring: There is no evidence that such routine screening is justified, no evidence that earlier screening will prevent deaths from breast cancer — and there are many reasons why screening women in their 40′s who have no risk factors for breast cancer will cause unnecessary costs and undesirable physical and emotional consequences.

While one might argue, “Well, if it is just money at stake, then why not test all women early — even if you only prevent a few breast cancer deaths? What’s the downside risk?” But the realities are these:

Because breast cancers are relatively rare are in women under age 50, we would be testing more than 20 million women (in the 40 to 49 age range) to find very few cancers.

According to the American Association for Cancer Research, reading younger women’s mammograms is much more difficult than reading those of older women. The breasts of women in their 40′s have less fatty tissue and more glandular tissue than those of older women, and glandular tissue provides less contrast with tumors on mammogram.

Breast cancer that develops in women aged 40 to 49 tends to progress more rapidly than breast cancer that develops in older women. But mammography may not be much of a lifesaver for these women with aggressive tumors, for by the time such tumors are detected by mammography it is usually too late for effective treatment.

The less common a disease, the greater the possibility that a positive result on routine screening will be false — that a diagnosis of breast cancer will be made, when in fact there is no cancer. These “false positives” — as well as the identification of large numbers of precancerous lesions and of noninvasive lesions, such as ductal carcinoma in situ (DCIS) — will turn millions of young women into patients, subject to follow-up X-ray exams and other procedures (such as biopsies). Thus, there is a real risk of overtreatment.

And while advocates for early, routine screening might argue that “its only about money,” it has been estimated that if all of the more than 20 million women age 40 to 49 in the Unites States were to undergo screening mammography this year at $l25 per test, the total cost would be $2.5 billion — a figure higher than the entire annual budget of the National Cancer Institute!

Are there not better and more effective ways for us to spend our preventive-medicine dollars — and save more lives?

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