THE MAMMOGRAPHY DEBATE: A CLOSER LOOK

            In two recent articles published in the New York Times, the debate surrounding the efficacy and usefulness of mammograms has received intense media scrutiny. The issue is not whether mammograms are a helpful tool in detecting breast cancer, but rather whether it is necessary to require higher standards of accuracy in interpreting the x-ray films.

            The first article investigated the range of physician ability to accurately decipher mammogram films in order to diagnose cancer. Radiologists miss more tumors than was previously assumed. “Many of them simply lack the ability to discern the elusive signs of breast cancer in the shadows and swirls of a mammogram, widely regarded as the hardest task in all of radiology.” Recent studies discussed in the article reveal an increasingly high number of false negative diagnoses, as some doctors fail to detect the early stages of cancer in mammograms because they do not read large numbers of mammograms over the course of a year. This inaccuracy has caused high levels of patient anxiety and thousands of malpractice suits when, upon later investigation, cancer has been found, but was overlooked in the original mammograms.

            Inexperience, rushed evaluations, and lack of reassessment of skills have been cited as key challenges to developing adequate technical skills to accurately read mammograms. Low patient volume, in particular, is a leading cause of doctors’ inaccuracy as many well-trained specialists still only see a handful of cancer patients a year. The incidence of mis-readings is significantly lower in care providers who see a large number of mammograms per year. According to a recent study published by the National Cancer Institute (NCI), doctors who read 1,200 or feweer mammograms per year averaged an accuracy rate of 65%, while those who read more than 3,600 achieved a rate of 76%.

            The central issue of debate is whether the United States government should create a means by which higher standards of accuracycan be ensured. Two proposed ideas are to require higher numbers of mammogram readings per year and to create a system to consistently evaluate doctors’ capabilities. In other countries, such as the U.K. and Canada, doctors are required to read at least 2,500 mammograms per year, while the FDA only requires 960 every two years. While some states have developed accreditation review programs, there is no existing national program, making it difficult for these states to enforce their policies. The situation is complicated by the overlapping jurisdictions under whch this kind of regulation would fall. Yet another form of evaluation and oversight might make busy, over burdened physicians bristle.

            A possible solution to this dilemma has been developed by Dr. Kim A. Adcock, chief of radiology at Kaiser Permanente in Colorado. Coupling Kaiser’s existing patient tracking system with medical outcome data, Dr. Adcock found that he could statistically monitor the accuracy of his colleagues’ initial diagnoses. When a pattern of misread mammograms is identified, the doctor’s work is more thoroughly reviewed, and often a recommendation concerning their status as an employee of the hospital is made. In addition, the doctor’s other patient files are reviewed to make certain that other cancers had not been overlooked. The accuracy rate of this Denver team has risen more than 10% since Dr. Adcock began his monitoring system, and similar programs are being developed in clinics throughout the United States.

            The intense scrutiny that mammogram procedures have received is a matter of concern for care providers. Many in the breast cancer community fear that the critical attention and negative publicity given to mammography will dissuade women from pursuing the procedure at all. Early detection of breast cancer is an important component of prevention and treatment, and mammograms are one opportunity for early detection. A higher degree of accuracy in mammogram procedures would be beneficial, however the standardization and regulation of that accuracy could interfere with the doctors’ ability to provide care for their patients.

            The effects of this recent media interest about mammography and physician abilities are unclear. Perhaps discussions generated by media attention will improve the training, oversight, and evaluation of the mammography field and help doctors improve their skills. Ultimately, the goal of all policy changes and improvements in the system are to prevent future incidents of late diagnoses due to misread mammograms with overlooked or undetected tumors.