Why It Can Take a Year to Get a Mammogram in the U.S.

By Abby Christopher, AlterNet. Posted December 4, 2008.

A handful of states, most recently Texas, have had some success reforming malpractice laws. In Texas, where tort-reform legislation passed in 2003, malpractice judgments for pain and suffering are capped at $750,000.

But in spite of Texas' model of success, changing medical malpractice law, subsidies for subspecialists and tort reform do not change the biggest factor driving medical malpractice lawsuits: communication breakdowns between doctors and patients.

Why Patients Sue

In many cases, women sue because some breast cancers are not detected early. Once a woman gets a later-stage diagnosis, she may ask why the cancer wasn't found sooner, in one of her annual screening mammograms. And certainly some missed diagnoses should have been caught earlier and are the result of a radiologist's negligence. But the breast isn't an easy area to screen, and mammography is not 100 percent accurate. In fact, studies estimate the error rate in mammogram screenings can range from 15 to 30 percent.

Breast cancers, commonly detected as masses and calcifications, can be tricky to spot in screenings. Some types of breast cancer resemble normal tissue nearly perfectly. Instead of forming a dense mass, they form clouds of tissue that are indistinguishable from normal breast tissue. If there is a distinct change between screenings, radiologists can find them.  But if it is the patient's first mammogram, radiologists might miss the abnormality.

Mammograms are also harder to read in some breasts than others. Generally, the denser the breast tissue, the more difficult it is to see masses. Mammographers use four densities to characterize breasts: fatty; scattered fibroglandular; heterogeneous; and very dense.

"Fatty and scattered fibroglandular are much easier to read, and heterogeneous and very dense are the hardest," according to Dr. Loretta Lawrence at the Breast Imaging Center of North Shore University Hospital, Great Neck, N.Y. "To find cancer in the densest breasts -- very dense or heterogeneous -- you're looking for a white dot in white dense tissue."

Some radiologists compare looking for cancers in dense breasts to searching for a grain of salt or sand -- one that may not even exist -- in a snowstorm.

Women under 50 typically have denser breasts, but, Lawrence says, "I've seen women at 80 with dense breasts, so you can't assume. We don't know how dense your breasts are until we see your mammogram."

Calcifications can also be a headache for mammographers. They are divided into two categories: macrocalcifications and microcalcifications. Macrocalcifications are benign, large calcium deposits that are more common in women 50 and older. However, microcalcifications, much smaller calcium deposits, may or may not be cancerous. They are trickier to detect and interpret, and therefore very often the root cause of medical malpractice suits.

According to the American Cancer Society, an area of microcalcification that is seen on a mammogram does not always mean that cancer is present. Microcalcifications may appear alone or in clusters. Their shape and layout help the radiologist judge how likely it is that cancer is present.

Still, it's hard for women to accept all that uncertainty, especially when we've been urged to believe just the opposite -- that screenings are foolproof. We've been overwhelmed by the familiar refrain, "mammograms save lives." That sort of ad campaign or simple slogan scares us into the exam room. The implication is: Get your mammogram, and you're covered. It's human nature to want it to be that easy.

"It's great that screening campaigns have raised awareness," says Dr. Berlin of Rush North Shore Medical Center and Rush Medical College. But in the course of getting through to us, the "campaigns may have unwittingly raised expectations," he says. And in some cases, this has led to serious misunderstandings. Sure, regular screenings save lives. The National Cancer Institute and the American Cancer Society, among many others, urge us to get screened annually once we hit 40.  But ask any radiologist who reads mammograms, and they'll tell you straight up, they most certainly are not infallible.

See more stories tagged with: health, breast cancer, medical malpractice, mammograms, breast cancer detection

Abby Christopher is a freelance health and health policy writer based in Portland, Oregon.

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