Nahleh and colleagues recently updated ASCO guidelines regarding the frequency of breast screening following a diagnosis of primary breast cancer and recommended annual mammography for most patients.1 Presumably, the benefit of mammography will come from finding recurrences earlier, e.g., smaller and node-negative.There are no data reported from a randomized trial to support the recommendation of screening vs no screening, but there are some data that show that the frequency of screening does not impact survival.2 Rather than lament the lack of data from randomized trials, the authors might consider addressing this question from another angle.Decades ago, Fisher et al showed that mastectomy did not improve survival compared with lumpectomy, although the rate of invasive ipsilateral recurrence was much higher with lumpectomy.3We and others have shown that experiencing a local invasive recurrence increases mortality, but we now accept that preventing such recurrence through surgery or radiotherapy does not reduce mortality.4 More recently, we have shown that experiencing a contralateral breast cancer increases mortality by twofold, but preventing contralateral cancer with bilateral mastectomy does not impact mortality.5
Finally, we and others have shown that the development of an ipsilateral invasive recurrence after ductal carcinoma in situ (DCIS) increases mortality by as much as 20-fold and that these recurrences can be prevented by mastectomy, but breast cancer survival for patients with DCIS treated with lumpectomy and mastectomy is about the same,6,7
These SEER data suggest that preventing invasive recurrences after DCIS does not save lives.This leads me to ask “If preventing invasive recurrences does not prevent deaths, why should screening for [invasive recurrences] be any better?”One could argue that screening finds recurrences earlier when they are smaller and easier to treat, but if this is the underlying value of screening, then one could argue in favor of more extensive surgery to prevent recurrences altogether and de-escalate treatment.
— By Steven A. Narod, MD, FRCPC, FRSC
DISCLOSURE: Dr. Narod reported no conflicts of interest.
Dr. Narod is affiliated with Women’s College Research Institute and is a Professor of Epidemiology at the Dalla Lana School of Public Health at the University of Toronto in Ontario.
REFERENCES
1. Nahleh Z, Alfano CM, et al: Breast cancer follow-up and surveillance after primary treatment: ASCO Guideline update. J Clin Oncol. July 16, 2026 (early release online).
2. Dunn JA, Donnelly P, et al: Annual vs less frequent mammographic surveillance in people with breast cancer 50 years and older in the UK.Lancet 405:396-407, 2025.
3. Fisher B, Anderson S, Bryant J, et al: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347:1233-1241, 2002.
4. Sopik V, Nofech-Mozes S, Sun P, Narod SA: The relationship between local recurrence and death in early-stage breast cancer. Breast Cancer Res Treat 155:175-185, 2016.
5. Giannakeas V, Lim DW, Narod SA: Bilateral mastectomy and breast cancer mortality. JAMA Oncol 10:1228-1236, 2024.
6. Narod SA, Iqbal J, et al: Breast cancer mortality after a diagnosis of ductal carcinoma in situ. JAMA Oncol 1:888-96, 2015.
7. Wapnir IL, Dignam JJ, Fisher B, et al: NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst 103:478-488, 2011.
