i-Mammo: The Mammogram You Never Had

iMammo: The Mammogram You Never Had

This is an article in two parts. Today, in Part I:

The Music of Digital Mammography

• What is digital (computerized) mammography?
• How does digital mammography compare with traditional (x-ray film) mammography?
• What are the advantages of digital; mammography?

Tomorrow, in Part II:

The Fellowship of the Ring: Digital Mammography, Cancer Detection and Consumer Choice

• The dirty little secret of mammography: We could find 15% more cancers every year.
• If digital mammography is so great why don't you know more about it?
• Why don't you have it?
• Consumer choice in medicine: The role of feedback and consumer choice in the adoption of expensive, beneficial new technology

From Part I:

"As a radiologist who has read mammograms for fifteen years, I cannot tell you how many times I have had to deal with a woman’s entire twenty year folder of mammograms that has been completely lost.

Not to mention the uncountable times I’ve opened a patient’s mammogram x-ray folder to find someone else’s mammograms mixed in with the folder, or the wrong name flashed onto the patient’s film, or films degraded by age, humidity or insects!"

Part I:

The Music of Digital Mammography

Make It New

In the mid 1980’s, a small display of weird and untamed jewel boxes began to crop up in an obscure corner of Manhattan’s Tower Records.

There were always people standing around the odd kiosk. Curious shoppers opened and closed the hard plastic cases (this was before the world was catastrophically altered forever by the advent of shrink-wrapped merchandise); and, occasionally, someone would stick an index finger down, bringing back a small shiny silver disc: the CD.

The whisperers in the corners were saying something bizarre and unfathomable: One day CD's would replace the beloved vinyl LP record album. To most, this seemed patent nonsense. After all, vinyl reproduced a sound that was warm and complex. The CD screeched music that was tinny, cold, shallow, and bright. Worse, the Paleolithic disc players were more like toasters than turntables: no cartridges or needles or platters…the entire system totally without character or class.The CD was ridiculed and dismissed along with the digital music it so outrageously produced from the zeroes and ones pressed into its sectors.

In just a few years the marketplace had spoken. Manufactures heeded criticisms and beefed up the sound. Hundreds of competitors -- high and low end -- vied to establish themselves all along the chain of production and sales as the entire audio industry rushed to backfit the convenience and portability of CD's with consumer taste, preference and choice. In an historic flash, the vinyl LP was a memory as quaint as the fedora.

Parallel Collision

Much the same story has played out, on a parallel course, in the history of breast imaging and mammography. Digital mammography, once a freakish technology relegated to pre-biopsy localization, has emerged on the imaging scene with full-field technology, boasting all the power of the digital technique and format. Only this time the technology has penetrated the market with less ferocity, an important catalyst to the adoption process missing: the consumer. Standing on the third-party-payer sideline, removed from the all-important feedback loop, the consumer power of the end-user is divorced from the marketplace evolution of a medical technology whose time has come.

Last month, in the American Journal of Roentgenology (abstract), researchers from the George Washington University published a powerful study demonstrating one of the great benefits of Full Field Digital Mammography (FFDM); namely, the opportunity, with the click of a mouse button, to have a computer recheck the mammogram and alert the radiologist to areas of mass or abnormal calcium that may have been overlooked. These are areas under suspicion for cancer. This technology, Computer Aided Detection (CAD) serves as a “second look” at the mammogram. “Second-looks” have long been highly recommended by the literature as a way to improve cancer detection. However, before digital imaging, a second-look required a second radiologist to read the mammogram. The high liability risk, burdensome Federal regulations, and low reimbursement that saddle mammography make it hard enough to find any radiologist to read a mammogram once. Twice is almost out of the question. But with FFDM, a second read is a mouse click away.

What are the other advantages of FFDM?

Buggy Whips and Cameras

Standard mammograms are x-rays and they are analogous to the old style cameras you used to take photographs with, only replace LIGHT with X-RAYS. An x-ray is generated and it passes through the breast taking a “picture” on a piece of photographic film on the other side of the breast. If you take a bad photo (or a bad mammogram, which is a common occurrence) you can either live with the obscured image or you can repeat the photo.

Digital images also use x-rays (and the dose is low – about the same as a mammogram) but a bad image does not have to be repeated. Think of your digital camera at home, and what you can do with the images on the computer. It’s the same case with FFDM. The radiologist simply adjusts the settings on a computer and fixes the problem. So, the first benefit is:

• Fewer repeat mammograms

therefore less radiation exposure to the breast

Being able to manipulate the image (changing contrast, density, magnification and orientation), also lets one study the breast more thoroughly, changing parameters to try and better detect a cancer that may be hiding, or nested, in a confusing array of breast opacities. So digital mammography affords the radiologist

• New ways to detect hiding cancers

therefore potentially improving survival rates

Just as a PC’s iTunes folder – with thousands of songs – has replaced the giant shelves needed to hold and store LP records, digital mammograms can be kept and backed-up on secure computer servers: No more lost, mislabeled, mixed-up, and unretrieveable x-ray mammograms.

As a radiologist who has read mammograms for fifteen years, I cannot tell you how many times I have had to deal with a woman’s entire twenty-year folder of mammograms that has been completely lost.

Not to mention the uncountable times I’ve opened a patient’s mammogram x-ray folder to find someone else’s mammograms mixed in with the folder, or the wrong name flashed onto the patient’s film, or films physically degraded by age, humidity or insects! Digital mammography offers:

• Storage and retrieval is safe, secure, accurate and ample

Tomorrow: Part II and the conclusion of iMammo: The Mammogram You Never Had

Includes:

• The dirty little secret of mammography: we could find 15% more cancers on mammograms every year…but we don’t. Why?
• If digital mammography is so great why doesn’t everyone offer it?
• If digital mammography is so great why don’t you know anything about it?

Comments

[curious]

OK, this sounds interesting. Does digital mamography exist yet? Where?

[concerned]

CBB: Dr. John Bailer has claimed that mammography causes breast cancer. Do you agree?

[cardioNP]

As a former cath lab nurse I have seen the differences in cines vs digital angio images and as a primary care NP, have viewed CXRs on a PACS system at the VA - so was quite aware of how digital images could be magnified and manipulated. Thus, I was an informed consumer when I went for my first mammogram 3 years ago when I turned 40. I was at UCLA outpt radiology - when the rad tech started to do my imaging I asked if it was digital. She said no. I asked to have the digital mammo done - she said something to the effect of "why?, it hasn't been shown to be any better". I insisted on digital imaging and she reluctantly moved me to the room where the digital machine was. Since I have relocated to No. CA, guess I will have to request a copy of the CD. I would recommend that all women request a copy of the CD to keep themselves - especially if you anticipate job changes or relocations that may affect your insurance or where your subsequent studies are performed. That way you can have your images readily available for comparison should there be a new lesion or questionable area on subsequent imaging.

[CodeBlueBlogMD]

curious: stay tuned for next post

concerned:

Since mammmography involves x-ray radiation, and this is a known cancer-causing agent, many people have worried a lot about whether mammography causes cancer.

There are a lot of tricky ways people use to prove that mammography causes cancer. The most common is to estimate the average dose a person in Hiroshima received during the WWII bombing, then calculate the % of people who got cancer after Hiroshima, then calculate the risk of cancer per given dose.

This figure is then extrapolated to mammography and YOUR risk of cancer is calculated for the dose you receive.

This method is obviously only a risk assessment, and not proof of causation.

All that being said, large important studies -- done very carefully -- have shown that mammography saves lives.

But your concerns are important. All women (all PEOPLE) need to wake up and understand that x-rays are cancer-causing agents. And the radiation for x-rays is a CUMULATIVE agent. The effects of radiation ADD up in your body and never go backwards. So your lifetime exposure is important.

Most people never receive enough of this radiation to be a concern, but no x-ray or CT scan (which also uses x-rays) should ever be taken lightly.

Finally, modern mammography machines use a clever technique that generates "soft" x-rays which are less harmful.

Bottom line? You are much, much more likely to die from breast cancer than to suffer any effect from mammography. An informed person would never skip a mammogram for fear of risking cancer caused by the procedure.

CNP:

Stay tuned. Digital mammo machines are 8x more expensive. Right now, the imaging community says the cancer detection rates are equal, but all things considered, I feel, FFDM is more desirable,and there is NO doubt that ten years from now people will be using their plain x-ray analog systems as door stops.

[concerned]

Many women with normal breasts undergo a sometimes painful and stressful mammogram, followed by other tests or an expensive and unpleasant biopsy. It is possible that some women may even undergo unnesessary breast removal, though I hope that this is rare. On occasion such unexpected medical bills lead to uninsurability or even bankruptcy.
Biopsies are expensive. How much does a breast MRI cost?

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