to the editor: I appreciate the attention American Family Physician has placed on preventive medicine and Healthy People 2010.¹ The article and editorial titled “Breast Cancer Diagnosis and Screening” and “Screening for Breast Cancer,” by Drs. Apantaku² and Garr,³ respectively, address important issues. However, for the sake of completeness, both authors should have addressed the controversy over screening mammography in greater detail.

In 1997, the NIH panel recommendation⁴ process became politicized and ended with the recommendation that the patient “should decide for herself” (if patient is 40 to 49 years of age), because there was no proof of benefit. Lancet published a meta-analysis performed by the Nordic Cochrane Center.⁵ The meta-analysis was conducted to see why there had not been the observed decrease in breast cancer mortality expected from the 1993 meta-analysis.⁶ The Nordic Cochrane Center found a number of serious methodologic issues with the allocation process and the reporting of results from the trials from the 1993 meta-analysis. If only the higher quality trials are used, then there appears to be no benefit from screening mammography and, indeed, it may be harmful. This was observed across all age groups.

Screening mammography is a highly charged issue and should not be refuted or dismissed on the basis of one meta-analysis. However, those interested in women's health must consider the data and determine how to proceed with guidelines for mammography. I fear that we may find mammography to be as ineffective for screening as the once-promising autologous bone marrow transplant was for treating metastatic breast cancer. As family physicians, I believe we owe the women we care for very careful consideration of this difficult issue.

to the editor: I read with great interest Dr. Apantaku's excellent review of breast cancer diagnosis.¹ I thought that the description of the various screening techniques was especially useful, but I do have a question regarding the clinical breast examination as described in the article.

It is suggested in the review to gently squeeze the nipple for discharge during the routine examination, and this technique has been advocated previously.² However, nipple discharge on palpation is found in many patients without breast pathology and has not been shown to be a prognostic factor in breast cancer.³ In one retrospective study, a group of 205 patients with evoked nipple discharge but without spontaneous discharge or mass had no evidence of carcinoma. The authors recommend routine follow-up for these patients.⁴

Does attempting to express nipple discharge further the inquiry into possible breast cancer? And would this finding without a history of spontaneous discharge or breast mass lead to any change in the routine screening protocol?

in reply: Dr. Vega, differences of opinion do exist on whether or not nipple discharge should be elicited during an examination if there is no history of spontaneous discharge. The most important issue is whether or not the patient's history is taken regarding possible discharge.

Small amounts of spontaneous nipple discharge may not be apparent to the patient. The finding of elicited (nonspontaneous) discharge would lead to a discussion with the patient of what signs to look for that might represent suspicious discharge. One might consider a cytologic smear and close follow-up for elicited, unilateral bloody discharge in a woman older than 50 years, although, admittedly, the yield would be low.

It is certainly true that the signs of a suspicious discharge are spontaneous, bloody discharge from a single duct often associated with a mass.¹ Although nipple discharge is usually insignificant, it is worrisome to the patient. Physicians can help relieve patients' anxiety by explaining the nature and origin of the discharge.

Dr. Sontheimer is correct that the entire article, if re-titled, could have discussed the controversy of whether or not women in their 40s should undergo screening mammograms. Because I could not definitively answer the question, I chose to include what I consider to be four balanced references on the subject and present other information regarding breast health.

The study by Gotzsche² produced multiple correspondence³ that adds to the ongoing debate over this topic. The reference² to screening mammography being potentially harmful refers primarily to the harm of having to go through a surgical procedure. Currently, most of these are done stereotactically with little morbidity and must be balanced against the possible benefit of survival. To compare screening mammograms with high-dose chemotherapy that resulted in a 10 percent mortality of the women undergoing the treatment is, I believe, unfair.

Breast cancer is an enormous issue in the mind of many women. With one in eight women diagnosed with breast cancer, most women have personal knowledge of a friend or relative with breast cancer. A majority of women with a family history of breast cancer have exaggerated perceptions of their risk and experience excessive anxiety.⁴ I believe that many women without family history have some anxiety. My own calculated risk for developing breast cancer in the next five years by the Gail model⁵ is 1.1. This is well below the 1.7 level recommended for consideration for chemoprevention. Even so, I have an annual sense of relief looking at my mammogram and seeing no signs of cancer.

It is important for us to educate our patients about the risks and benefits of all the procedures undertaken. It may be more expedient to tell a 40-year-old woman asking for a screening mammogram that the benefits have not been proved, than to have a discussion with every patient older than 40 years about the known risks (i.e., possible biopsy for a benign mass) versus possible benefits (i.e., finding a cancer at an earlier stage with a better prognosis for survival). Because I believe that at the present time the possible advantages outweigh the possible risks, I recommend annual screening mammograms for all women older than 40 years.