iMammo: The Mammogram You Never Had
An article in several parts
Yesterday, 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?
Today, in Part II:
Breasts, Lies, and Videotapes:
The Iron Triumvirate and the Dirty Secret of Mammography
I've Got A Secret
A double reading means that a mammogram is looked at twice, by two different radiologists.
This “secret” is well known in the imaging community, and was established in the early 1990’s when a study of 11,000 mammograms confirmed that: Double reading detected 15% more cancer cases. The author's conclusion to that study?
"Independent double reading does significantly increase sensitivity of mammography screening."
If having a mammogram interpreted twice prevents 15 more women -- on top of every 100 found -- from having their breast cancer remain undiagnosed, why aren't all mammograms double-read?
Answer: It's impossible.
Have you heard of the "crisis" in mammography? What is this crisis? Well, since every woman over the age of forty needs a mammogram every year, there is a never ending -- and right now constantly enlarging -- pool of women needing mammography. There are tens of millions of mammograms that need to be done every year. However, increasingly, doctors, hospitals, and clinics are dropping the procedure from their repertoire of imaging studies. It is getting harder and harder to get routine mammograms scheduled, done, interpreted and acted upon in a timely fashion. Eh? How can that be?
The Confederacy of Dunces
There are three large, important, forces of influence that shape the face of mammography in the United States. Ten seconds to guess them.
Did you say the millions of women over age 40? Wrong.
Did you say physicians, scientists, or mammographers? Wrong.
The ruling Iron Troika of mammography consists of: The government, Mammactivists, and Torters. These are the groups that, in reality, have the most influence over how mammography gets done -- or not done -- in the United States. The "crisis" in mammography is directly related to the perverse influence of these three groups on that procedure.
In a previous post I wrote about Mammactivists Killing the Mammogram. Burdensome, expensive, superfluous and redundant anti-market legislation promulgated by "disease-specific" breast cancer lobbyists and approved by weak-kneed legislators has created thousands of pages of regulations controlling the entire process of mammography, from the building the machine is in, to the developing fluid used in the photographic process.
To comply with these regulations (the laws, that is) is expensive and time-consuming. These costs -- added to all the other fixed overhead of a women's center -- make mammography a money loser.
Medicare -- run by the federal government -- has, over the years, slashed the reimbursement for obtaining and interpreting mammograms under the claim that if the examination is too expensive, fewer women will obtain it.
Add to these factors the ever present Torters (go here if you are unfamiliar with this beast) who have turned mammography interpretation into one of the greatest liability risks in all of health care, and...voila! A crisis exists.
Low reimbursement, burdensome federal regulations and the constant threat of lawsuits make mammography an undesirable task for any radiologist. As a result, only a small percentage of radiologists will interpret mammography. In many communities it is hard enough to find one radiologist who will interpret mammography, let alone another radiologist to reread the thousands of mammograms done in any given center each year.
Ineluctable Cell Logic
This is a breast cancer cell. Some of these cells double every 120 days. So a cancer that is barely visible and highly curable -- say 3mm -- today, could have a dramatically worse prognosis in a year, at over 2 cm.
The Iron Troikites all claim that what they do is for the "good" of women.
- Mammactivists claim that their legislation helps protect women from substandard equipment, facilities and doctors
- The government claims that by forcing lower reimbursements, they are allowing more women access to mammography
- Torters snap away about how liability lawsuits protect women from bad doctors
What, actually, are the consequences of their good intentions? The "Iron" in their title stands for irony because, the consequences of these good intentions are:
- Radiologists are being driven away from women's imaging
- Clinics are closing their doors
- Mammograms are not double-read which would detect 15 more cancers in addition to every hundred breast cancers found...meaning, if these women are lucky their missed cancers (that could have been detected this year) will only grow "a little" before next year's mammogram
- New, more expensive technology-- such as digital mammography and MRI of the breast -- is adopted slowly and limitedly
In the next installment I'll discuss how digital mammography and the breast MRI fall victim to the final irony of the Troika.