Ironically, improvements in breast cancer therapy and screening technology are very likely diminishing the benefit of mammography screening. Therapeutic advances are reducing both the relative and absolute benefit of mammography screening on breast cancer specific mortality, while advances in imaging technology are increasing the risk of overdiagnosis and hence the risk of a small excess in mortality from unnecessary diagnostic and therapeutic interventions. Alternatives to mammography screening should be considered, particularly in older women, for whom the risk of overdiagnosis is substantial. Screening clinical breast examination (CBE) might be a good alternative, and a randomized trial comparing mammography screening versus screening CBE in older women should be considered as an important step to address the breast cancer screening dilemma. This editorial reflects on the past, present and future of breast cancer screening. Improvements in breast cancer therapy and screening technology are likely reducing the overall benefit of mammography screening, and this editorial discusses this dilemma and the direction that we should take in the future.
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