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APPENDIX B 136 Discussion At this time, there is little doubt that breast cancer screening by clinical examination and mammography has the potential of reducing mortality from breast cancer for women aged 50 and above. Most studies have not shown a clear benefit from mammography in women aged 40-49. Studies that will provide important information on this topic are in progress.48 In the meantime, it is unclear whether the effects on breast cancer mortality achieved by screening women aged 40-49 are of sufficient magnitude to justify the costs and potential adverse effects from false- positive results that may occur as a result of widespread screening.34 Until more definitive data become available, it is reasonable to concentrate the large effort and expense associated with mammography on women in the age group for which benefit has been most clearly demonstrated: those aged 50 and above. Annual clinical breast examination is a prudent recommendation for women aged 40-49. Conclusions about the cost-effectiveness of mammography have not been universally accepted. Charges vary greatly in the United States, but in 1984 they averaged about $80-$100 per procedure.30 For screening mammography to be widely used, it is likely that this charge would have to be reduced to $50 or less.49 Even if only $50 were charged per mammogram, surveying all of the women in the United States over 40 years of age would cost more than $2 billion a year.50 Others have drawn attention to the additional costs of biopsies performed on the basis of false-positive mammography results.30 There are also concerns about the availability of the large numbers of trained radiologists needed to interpret additional screening examinations.50,51 Wide variation is found in the quality and consistency of mammography, as well as in the accuracy of interpretation, radiation exposure, and cost.15,16,17,18,30 Radiation exposure during routine mammography is frequently much higher than the optimal doses or the minimal achievable doses usually quoted.17,18,19 All of the above caveats about mammography argue for caution in the recommendation of mammographic screening, as well as for the selection of mammographers who maintain only the highest standards of quality. The accuracy of BSE as currently practiced appears to be considerably inferior to that of the combination of clinical breast examination and mammography. False- positive BSE, especially among younger women in whom breast cancer is uncommon, can lead to needless anxiety and expense. With the present state of knowledge, it is difficult to make a recommendation about the inclusion or exclusion of teaching BSE during the periodic health examination. The WHO policy, neither recommending