THE BREAST IS CLOSE TO THE HEART

Two recent reports from the randomized Canadian National Breast Screening Study give 7-year mortality results for 1) breast cancer screening with physical examination and mammography among women ages 40 to 49, and 2) assess the incremental effect of mammography to that of a careful clinical breast examination in women ages 50 to 59. Among women ages 40 to 49, breast cancer screening produced no reduction in mortality (relative risk 1.36; 95% CI, 0.84 to 2.21). The results of this study are similar to that of four previous studies but are different from those of the early Health Insurance Plan study. Groups recommending breast cancer screening in women under age 50 should review their recommendations. Among women ages 50 to 59, the Canadian study found that in the first 7 years of follow-up, mammography did not confer additional mortality benefit over that of a careful, standardized physical examination (relative risk, 0.97; 95%, CI, 0.62 to 1.52). However, the authors indicate that longer follow-up may detect mortality benefit. Meanwhile, physicians should improve their clinical breast examination skills. A paper by Coleman and colleagues in this issue shows that even among older women, in whom the need to screen for breast cancer is universally accepted, practice is poor, with 41% to 65% of women surveyed in five different communities across the United States during 1991 reporting no mammogram in the previous year. Internists must incorporate routine breast cancer screening into patient care.