i Mammo: The Mammogram You Never Had
An article in several parts
Part III and Conclusion: Mammographic Serfdom
Tofu, Turkey, and Planet X
In the mid 1980's, an arcane new technology transformed the music and recording industry. Music CD's, with digital music pressed onto their silvery surfaces, emerged from avant garde record stores like UFO's from Planet X. The public was asked to abandon its long love affair with vinyl LP's; and worse...to forgo that sweet, unstable, quirky player-box: the turntable. In its place, astonishingly soulless and siliconized, was the CD player, a computerized device as far removed from the record turntable as tofu is from a Thanksgiving turkey.
Despite aesthetic shortcomings and poorly understood technology, digital music and CD's quickly and thoroughly transformed the recording, delivery, and storage of music. It was a revolution spurred by those twin engines of the market system: consumer demand and feedback. Convenience, portability, and reproducibility were honed to consumer preference in a marketplace where competition also took care of prices. CD players -- like all new technological products -- started at prices over $1,000, but quickly were available for less than $300. These same forces drove innovation, resulting in today's market gigaton bombs: the iPod and iTunes.
Divergent Paths, Asymmetrical Outcomes
In Part I of this series I drew a parallel between the advent of industry-changing technologies in music recording and breast imaging: the music CD and Full Field Digital Mammography (FFDM).
In this example, however, the parallels diverge after introduction of the technology. FFDM stands as a technology, now five years post introduction, that boasts all of the advantages of the digital format, with very few drawbacks. Yet FFDM has neither become widespread, nor has it evolved rapidly in the years since it broke into the FDA's universe of approved devices. This, despite the fact that routine use of FFDM will mean:
- Fewer images and less radiation overall
- No lost, damaged, or mislabeled films
- New ways to detect cancer (manipulating the digital image); and
- "Double-reads" by Computer Aided Detection (CAD) software
As I wrote about in Part II of this series, "double-reading" is a highly desirable method to improve cancer detection, but it is not feasible currently. However, with digital mammography, CAD is effortlessly available* with the push of a button. After the digital mammogram is recorded, the radiologist makes a decision about the study (mainly: are there areas of suspicion?), then, with a keystroke, the image is "re-read" by the computer. The CAD software marks out, on the film, areas of question. The radiologist then observes the computer's markings to make sure there are no areas that were missed in the original interpretation. A large study recently confirmed the efficaciousness and value of these CAD over-reads. The conclusion? CAD increases the total number of breast cancers identified over a lone interpretation by a radiologist.
What power did digital music and recording have that digital mammography lacks? Why did one breakthrough technology snare the public's imagination while the other plods along, it's advantages and potentials relatively ignored?
Is it too Expensive and Less Good?
The digital mammography machine is a lot more expensive than the format it seeks to supplant. An X-ray mammogram unit can be purchased for somewhere around $70-100,000. Digital mammography units are closer to $500,000, and adding on additional workstations to view and manipulate the images further increases the cost.
There are some imaging concerns, also. Many radiologists feel that although detection of calcifications (one of the ways one finds breast cancer) with digital mammography is improved over x-rays, the perception of masses and small opacities is not as good. Also, the resolution (how well two tiny areas can be seen as separate things) of film systems is slightly better than digital systems.
Could these two factors be holding back the imammo revolution? Hardly.
Issues with new technology are not uncommon, as the example of digital music demonstrates. Neither are high prices. Usually, these market deficiencies are dealt with rapidly and efficiently by consumer demand and feedback along with manufacturer competition. Currently, the benefits of FFDM outweigh the problems standing in the way of its widespread adoption, and the issues of price and image resolution surely would quickly be resolved if digital mammography were presented to the marketplace for absorption. It reminds me of the famous Spartan threat to Laconia that went something like this: "If we breech your walls we will capture your city and enslave your people." The Laconians -- being laconic -- answered:
Out of the Loop
The reason that digital mammography remains in the starting gate, along with, in some aspects, another powerful high-tech procedure, MRI of the breast, is because of the market place distortions in medicine.
Unlike other markets, in medicine the consumer is unhooked from the formative and evolutionary processes. Consumers don't purchase the technology directly, nor are their preferences and desires fed back to the manufacturers and vendors. Instead, third party payers (insurance companies, HMO's, and the like) lead consumers by the nose to the mammography centers that have cut the best deal, or have the best relationship with the patient's insurance company or doctor. There is little of that essential market component: choice.
It goes further than that. Because consumers have no informed idea as to what constitutes a good mammogram, and appropriate interpretation, they cannot judge the product of this process. Is there a woman anywhere who can answer of her women's center:
Who is interpeting your mammogram?
What is the interpreter's qualifications?
Is that interpreter competent?
What type of machinery is in use?
Who is the technologist performing the study?
Is every mammogram satisfactory, or are there glitches in the process?
What degree of certainty is there as regards any particular diagnosis in any particular patient?
And most saliently: what is the track record of this facility and how is that track record documented?
If no one ever knew what good or appealing music sounded like, or the basic parameters of that decision, digital music and CD's would have gone nowhere. Likewise, with little notion of the determinents and results of quality in mammography, consumers cannot intelligently express their opinions and desires.
This is how backwards the consumer in medicine is. Not only can one not make an intelligent and rational decision between x-ray and digital mammography, most women don't even know if the mammogram they got, last year, was done competently or interpreted appropriately.
The government is aware of this gross information deficit. Their interpretation? It is the government's opinion that women are not sophisticated enough to grasp these issues and to make their own choices. That's why legislators allowed Mammactivists (disease-specific lobbyists) to foist myriad laws onto the system, mandating thousands of pages of standards and complex, byzantine rules and regulations that attempt to legislate women's centers and mammographers into quality -- a task that most economists willl tell you, is inefficient, costly, and fraught with perils.
These laws had a predictable outcome: Compliance required raising the cost of running a women's center. To offset this (un)anticipated result of do-good legislation, the government -- through Medicare, which sets reimbursement standards -- instituted price controls limiting the amount a center can collect. Add to price controls the government's later conclusion that less expensive mammography would be more widely accessible (so they lowered reimbursement even more), and the result? A product that is produced as cheaply as possible, if at all.
The final nail being driven into the coffin of FFDM is liability lawsuits. Mammography is, by most estimates, second only to childbirth as a source of litigation. Every mammographer lives in fear -- each and every moment -- of receiving THE registered letter from Torter, Sorter, and Distorter, the lawsuit lions who perform retrograde scavenging of mammograms in breast cancer cases looking to find images they believe are confusing enough to befuddle juries and bludgeon insurers into settlements.
If people were informed and had choices, new technology would spread like wildfire, and breast cancer detection would get better. Fewer women would die from breast cancer. All the groups who lobby so hard and work so fervently against this cancer plague could do more by advocating simple market reforms than is done with all the walkathons, pink ribbons, and think tank group seminars together.
Worse Than Serfdom
It is profoundly cynical to conclude that the public's intelligence and ability are insufficient to evaluate and choose in matters of health care and medical technology. This cynicism prohibits any talk of such reform; That and the entrenched lobbyists on all sides -- including physicians.
It is also sad that on the horizon -- only one politician away -- lies the pernicious spectre of nationalized health insurance. This type of reform leads in the other direction, to less choice, fewer options, and more ignorance. Read my post regarding the British mammography program whose monolithic socialist health care system, until just recently, refused to accept even the rudiments of breast cancer screening. Many, many lives surely were lost as a result.
There is only one direction less choice and less information leads. Someone once called it serfdom.
But in the case of medical technology, and mammography, it's a road to death.
*Plain film x-ray mammograms can be digitalized with the use of an analog-to-digital converter, and these images can then be subject to CAD analysis by a computer. However, the converters are expensive, involve several extra steps and additional manpower, and have not entered into widespread mainstream use.