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Looking
beyond the X-rays
By
Melissa Healy
Los Angeles Times,
May 19, 2003
In
1992, Congress passed the first-ever act aimed at bringing the nation's
10,000-plus mammography practices up to a single technical standard. Now,
the Mammography Quality Standards Act has expired. But as Congress moves
to renew a statute that has helped make early breast cancer detection far
more widespread, lawmakers have taken on a tougher task than the first
time around.
This time, they aim to bring the skill of the physicians who read and
interpret mammograms up to a single national standard as well.
It's a tricky mission, and not just because a physician's skill is harder
to measure and regulate than the power and image clarity of X-ray
machines. Radiologists who specialize in mammography seem to be leaving
the field in droves, and medical students pondering which specialty to
pursue are avoiding it.
Among the factors are insurance reimbursement rates that don't cover costs
and a rising rate of malpractice suits against those who fail to catch
malignant tumors in their earliest stages. Doctors, patient advocate
groups and lawmakers agree that any effort to regulate these doctors must
do so without worsening the stampede.
"Radiologists are in short supply. Breast imagers are in even shorter
supply," Dr. Leonard Berlin told a Senate committee recently.
"This downward trend will continue and waiting times will continue to
increase for women seeking timely mammography services unless Congress
acts responsibly" in mandating regulations, said Berlin, who chairs
the radiology department at Rush North Shore Medical Center in Skokie,
Ill.
In the decade since Congress acted, breast cancer diagnosis has made
significant strides. In the early 1980s, only 13% of women in the U.S. got
mammograms and the average size of a tumor when it was detected was 3
centimeters. By the late 1990s, 60% of American women were screened for
breast cancer with mammograms, and the average size of a tumor when it was
discovered was 2 centimeters.
Earlier detection, combined with better treatments and broader public
awareness, has paid off with better rates of survival: In the last decade,
the death rate from breast cancer in the United States has declined 2%
every year.
Lawmakers' concerns about inconsistencies and the often poor quality of
mammography across the country appear to have been well founded. Before
the quality act was passed, the American College of Radiology reported
that about four in 10 mammography units in the U.S. met that professional
association's quality standards. By 1997, 82% were up to those standards,
and in 2002, 99% met them.
But the interpretation of a mammogram's shadowy images remains perhaps as
much art as science. At last month's hearing, Berlin cited research
showing that 15% to 20% of cancers "are not visualized" on
mammograms. As many as 70% of breast cancers, he added, "can at least
partially be observed on previous studies [that were] read as
normal." Those numbers mean that doctors miss cancers altogether or
do not recognize them until they have grown larger and harder to treat
effectively.
Diane Balma of the Susan G. Komen Breast Cancer Foundation, an advocate
for breast cancer patients, calls the variations "very, very
troubling." And Sen. Barbara A. Mikulski (D-Md.), asserting that
"incorrect readings remain a strong concern," made clear in
recent hearings that the reauthorization process should be used to drive
down the numbers of missed cancers.
In reauthorizing the act, probably for five years, lawmakers are expected
to mandate that doctors who read and interpret mammograms undertake a
self-assessment program that would sharpen their interpretation skills,
expose them to mammograms showing more and different forms that breast
cancers can take and identify areas in which they need to improve.
Although such mandatory self-assessment programs would add to a
physician's workload, Berlin asserts that radiologists would not have a
problem. They would have a problem if the results of the
self-assessment programs were to become publicly available or — more to
the point — available to patients and their attorneys pressing
malpractice suits against doctors who read mammograms.
If such test results were to become "discoverable" in legal
proceedings, doctors fear, the rate of malpractice suits, which has grown
steadily in recent years, would explode. And if they did, so would
malpractice insurance premiums and, with them, the cost of providing
mammograms. And with that, physicians who can pick other specialties would
vote, increasingly, with their feet.
That prospect has patient advocate groups — groups that otherwise might
be inclined to embrace new strictures to weed out doctors who are poor
performers — worried as well.
"We do not want something that is designed to enhance [physician]
quality to be punitive," Balma said. "It would be
counterproductive" to adopt policies that would drive people from the
field.
But although Balma acknowledges the effect of malpractice suits, Komen
Foundation experts believe that insurance payments that are too low may be
more decisive in driving away practitioners. When a woman insured by
Medicare has her breast X-rayed to check for a suspicious mass, the
federal government will pay less than $70 to a hospital and about $76 to a
clinic, with the reading physician receiving a bit less than $36 in either
case. In many cases, it costs a mammography clinic more than $100 per
mammogram just to make the images.
And since Medicare reimbursement rates set a benchmark for most private
insurers, small fees for the work of interpreting mammograms have become
the norm throughout such practices. In the reauthorization of the
Mammography Quality Standards Act, Mikulski has proposed to direct the
federal government to conduct studies on the effect of its reimbursement
rates for mammograms.
Berlin underscores that whatever the legislation contains, patients must
understand a simple truth.
"Many believe that mammography is infallible, that it is a matter of
simply looking at black and white shadows on an X-ray film, of going
through a simple mathematical calculation, and that thus all radiologists
should arrive at the same interpretation," he told senators.
"Alas, such is not the case. Shadows on mammograms are far more often
varying shades of gray, normal glandular and connective tissues often
obscure suspicious abnormalities and many suspicious abnormalities often
masquerade as normal structures."
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