Dr Wilkinson’s commentary, “Breast density notification. Are family doctors prepared to counsel patients on risks and management?” in the November issue of Canadian Family Physician outlines why and how she believes family physicians should counsel women on breast density.1 While I agree with Dr Wilkinson that family physicians need to be prepared to counsel women with denser breasts, the counselling she suggests appears not to take into account all the available evidence.
Dr Wilkinson asserts that women with dense breasts have an increased risk of breast cancer and therefore need additional screening. She is correct that dense breasts increase the risk of breast cancer diagnosis,2 but should screening decisions not be based on the ability to reduce mortality and morbidity rather than the risk of diagnosis? A diagnosis of cancer is not relevant if it will never cause any harm. For instance, for prostate cancer men have an increased risk, and screening will diagnose more prostate cancer. Yet, screening is not recommended as it is unlikely to improve mortality and is associated with substantial harm.3
Based on current evidence, more intensive screening of women with dense breasts may be comparable to screening for prostate cancer. Most large observational studies suggest that dense breasts are not associated with an increase in breast cancer mortality4-11; only 3 Swedish studies suggest an association.12-14 Moreover, while a combination of mammography and sonography or yearly mammograms increase the diagnosis of breast cancer for women with dense breasts, there is a lack of evidence about whether it improves survival.15-17 There is, however, evidence that this additional screening may be harmful because of false-positive findings, overdiagnosis, and mental health sequelae.17-19
Having had patients, friends, and family members heartbreakingly pass away from breast cancer, I would wholeheartedly support increased screening if the evidence supported it, but the current evidence is equivocal. It is important that women be informed of the nuance between the risk of diagnosis and the risk of mortality and the evidence for both the benefit and harm of additional screening. The 9-point checklist Dr Wilkinson provides for “shared decision making” is unlikely to accomplish this. The updated Canadian Task Force on Preventive Health Care recommendations, expected in 2024, will hopefully provide a more balanced approach.
Footnotes
Competing interests
None declared
The opinions expressed in letters are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
- Copyright © 2024 the College of Family Physicians of Canada
References
In this issue
Jump to section
Related Articles
Cited By...
- No citing articles found.