If you know someone who needed to find an excuse to avoid or put off a recommended mammography exam, then the pair of recent articles in The New York Times may have done the trick. These articles (June 27 and 28) follow the recent well-publicized scientific analysis concerning the public health value of mammography, which significantly muddied the waters in the minds of many women. Now the latest articles, which were obviously researched and written over an extended time period, explore the limitations of mainstream mammography exams in the U.S. today. While the future tools, technologies and benefits of mammography were not fully developed (or barely mentioned), the skill of the radiologist was certainly brought to the forefront, and seriously called into question.
Based on what we know today, there is almost no way to ascertain the skill of the radiologist who will read the next mammogram either your own, or that of your wife, mother, sister, etc. This scenario is really not so different than your interest in knowing the skill of your GP, ob-gyn, orthopedic surgeon, auto mechanic, plumber, toaster repairman you get the picture. Most people rely on word-of-mouth reports to seek out someone with experience and no black marks on their record, avoiding the obvious bad apples. This issue is not just a scientific debate that ends with the words This suggests further studies it is a serious subject, since this involves public health policy and efforts over two decades to encourage women to utilize mammography to detect breast cancer at its earliest stages.
So, now that we know a mammogram may be read by someone with the minimum experience of 480 cases per year. What options do public officials and the ACR have at hand to deal with this real crisis in public confidence for one of the highest profile medical procedures in the world? Is there anything that the ACR or that luminary radiologists can say or do that will either restore confidence or lead to an improvement in the practice of mammography?
Well, here are some thoughts for the radiologists who have a serious interest and long-standing commitment to saving lives. First, lets hear from the pioneers out there (yes, those with the arrows in the back) about some of the leading-edge techniques and technologies as they apply to this problem.
What is the appropriate role of computer assisted detection? It looks to me like it should be required use by a radiologist for interpreting mammograms. Some of the studies show nearly identical results for a single radiologist using CAD vs. double reading of mammograms. Guess which one of these second readers may be considered more reliable, less expensive and producing identical results on case number 1, 100 and 10,000, even at 2am in the morning? CAD should be more widely discussed (and used) than it is today. There are some10,000 mammography centers in the U.S. and only about 5 percent have CAD. OK, CAD may not be perfect, but its certainly much better than any single radiologist working alone. When was the last time you hit spellcheck on your Word document and something wasnt highlighted? Anyone care to step up to the plate and try to outread one of these systems?
Mammography has well-known, but not widely publicized, limits especially for women with dense breasts, and masses in particular. The next generation of ultrasound is being developed for adjunct work with mammography to specifically address the patients for whom x-ray mammography is not sufficient to provide a clean bill of health from breast cancer screening.
Detailed work-ups appear to be a perfect fit for this tool that provides extensive soft tissue images. It seems particularly suited for women with risk factors.
Radiologist report cards
This is one step that creates a mountain of controversy. It may, in fact, do the most to restore confidence in mammography by the general public. The side effects of this significant move are probably real fewer radiologists will read mammography, and there may be less availability of mammograms services. But, the benefits seem to outweigh this restoring public confidence so that women seek the service for the health benefits that are promised. This seems to be one of the most important topics for radiologists and the ACR to tackle before RSNA this year and dont let it wind up like the recent baseball All-Star game, where the commissioner and managers agree to a tie game with no winners. Patients with a potential disease deserve better than a guess when it comes to quality healthcare.
Doug Orr, president of J&M Group (Ridgefield, Conn.), consults with medical device companies in strategy and business development for emerging growth markets, notably radiology and cardiology. Comments and suggestions can be sent to [email protected].