i-Mammo Part II: Breasts, Lies and Videotapes

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

Shhhh…What is the dirty little secret of mammography? Double reading picks up 15% more cancers.

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.

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[Daniel]

This is great, Katie.You clearly show the the power of story,the counrdnum of mammography in contemporary medical care, and all the grey areas in between. Because that's what we're walking through. Grey areas of confusion in obtaining accurate readings AND interpretations of something suspicious that ranged from squamous cell to the more common IDC. I could understand how mine was misread (though certainly not at the time) in l998, years before digital and better imaging technologies. But yours was much more recent.We should all be troubled by this; and we all need to continue the message making that mammography isn't everything. There are no guarantees.Thanks,jms

[Ozan]

Thank you for telling your patniets.My doctor chose not to and after 10 years of normal screening mammos and two ultrasounds, the MRI that I demanded found not one but two stage 2 invasive tumors in my left breast. The surgeon who did my mastectomy told me they had been in there fir up to 10 years and no mammogram would ever find them because if my dense breast tissue.

[Adelina]

. This matter of unesrnesacy or excessive treatment is then repeated in the penultimate paragraph: therapies such as surgery, radiation, chemo and long-term hormone pills can mean serious, long-term side effects, Warner says. What about the pathology report, what about the Oncotype Dx test? This article suggests doctors have no tools for distinguishing between types of tumors!I've seen this suggested in other articles too. It seems a dangerously misleading omission. Or am I missing the point, somehow? (Are some women rushed into treatment without adequate testing on their particular tumor?) What's your take on this?

[Maria]

I have had several since I am (slightly!) over 40 and your decpristion is spot on. Really no pain at all. I would add by experience that going when your tender in your chest area (for me a few days a month) is miserable big mistake and excruciating! Lesson learned.

[Sajid]

that a studies show self besart exams don't make a difference in preventing cancer. I was never good about them and so didn't stop because of his statement.But ..the exams by the gyne docs seem to be so fast ..I do wonder how they could really feel anything and know the difference unless extremely obvious. Actually ..i would think women would be aware of more if they consistently did the self exam. As far as radiation ..personally I've had so many abd cts ..that mammos are the least of my concerns ..unless the radiation to the besart could activate a cancer process. ?****************My direct question was going to ask about Cornell physicians and Sloan Kettering. Would it be alright if I ask here? With the understanding that you may prefer not to answer ..although it is a general ..anyone may be interested question.********************************In coming over here to see if you have e-mail I read your Ask a Simple Question post. HILARIOUS!Would it be alright if I put it up in it's entirety as my next post,link to it and tell everyone that the comments to this post are also very funny ..or something like that?Either way ..thanks for the laugh that was great!

[Michael]

Thanks TBTM. Okay ..I will still link to it. I'll just put a little teaesr because I know people don't always follow links. Ha! Although if sex is mentioned ..probably an enticer for sure.I didn't see an e-mail address. It's probably right in front of me. But where? And YOU are the one person who explained menopause ..the one day marker thing and I have since explained it to other women. Amazing that so many women don't really understand something so important.Your welcome and you have a great blog. Unbelievable that I am by definition still peri-menopausal. But I do think that this might be the last 6 month stretch toward *the* day.