Is the Future of the Mammogram in Jeopardy?

By Diane Cochran, The Billings Gazette. Posted June 6, 2007.

Reprinted with permission from The Billings (Montana) Gazette.

Searching for a snowman in a blizzard. Spotting a star on a cloudy night.

That's how radiologists describe looking for cancer on a mammogram.

It's white on white -- white tumors on white breast tissue -- and it can be very difficult to see, even for the most experienced eye.

Mammography is arguably the most difficult thing radiologists do, but it is also one of radiology's most common and most important practices.

"This saves more lives than anything else we do," said Dr. Joseph Dillard, a radiologist with Eastern Radiological Associates in Billings.

Even so, Dillard and hundreds of other radiologists across the country have begun refusing to read mammograms, a trend some say could eventually limit women's access to the cancer screening tests.

Reliable statistics are hard to find, but one U.S. study published in 2005 found that 30 percent of positions for radiologists who read mammograms were vacant. Radiologists also interpret X-rays, ultrasounds, CT scans and MRI exams.

The same study, reported in the journal Cancer, found that 63 percent of radiology practices with mammography fellowships had unfilled fellowship positions. Fellowships are programs that provide specialized training in specific areas of medicine.

At Eastern Radiological Associates, which is affiliated with St. Vincent Healthcare, three of seven radiologists are willing to interpret mammograms. At Billings Clinic, five of nine will do it.

Meanwhile, the number of certified mammography facilities is declining.

There were about 11 percent fewer places to get mammograms in the United States in 2006 than there were six years earlier, according to the government. That's 1,101 fewer mammography centers across the country.

So, what gives?

In short, radiologists are afraid of being sued, and there's evidence that they have more reason to worry than providers in other areas of medicine.

Missed breast cancer is the most common basis for medical malpractice lawsuits in the United States, according to the Physician Insurers Association of America, a trade group of medical malpractice insurance carriers.

And it's among the most expensive kind of malpractice cases. In a seven-year period ending in 2002, PIAA members spent almost $200 million on breast cancer malpractice cases. That was $30 million more than was spent during the previous six years.

But, experts say, the problem is not inept radiologists, although there are certainly some of those.

Instead, the problem is a misconception about the effectiveness of mammography.

"It's not a foolproof test," said Dr. Kathleen Ryan, also a radiologist with Eastern Radiological Associates. "Unfortunately, many women think it is."

Finding detectable cancers with mammography, radiologists say, is challenging enough. A breast does not have a standard anatomy in the way other parts of the body do, and breast cancers don't always look the same.

"Every woman's breast is like a fingerprint almost," Dillard said. "They're all different, and then we're trying to find something that always looks different."

But not every cancer can be seen on a mammogram. In fact, because of their structural makeup, as many as 20 percent of breast cancers are invisible on the screening test.

Many women don't realize that. Thanks to public information campaigns led by the American Cancer Society and other groups, which have been undeniably valuable in raising awareness about breast cancer, many people think a negative result on a mammogram means a woman is cancer-free.

"The public expects mammograms to be perfect," said Dr. Leonard Berlin, chairman of the radiology department at Rush North Shore Medical Center in Skokie, Ill. "That is the medical profession's fault. ... Mammography has been overpromoted. It's been oversold."

Berlin, recognized among his peers as an expert on mammography malpractice, also teaches radiology at Rush Medical College in Chicago and is a member of the Radiological Society of North America.

He and others argue that while mammography can and sometimes does save lives, it often detects cancers that are so slow-growing that they could not be considered life-threatening.

Women could live out their lives with some of the cancers identified by mammography and never be the wiser, Berlin said. Or they could be treated later on, after the cancer has grown and is found during a physical exam, with the same prognosis.

Mammography also gets credit for prolonging lives when it shouldn't, some experts say. In a phenomenon called lead-time bias, a mammogram can falsely appear to lengthen a woman's post-cancer survival when all it really does is lengthen the amount of time she is aware of her cancer.

Experts explain lead-time bias like this: Say the same cancer begins growing in two women's breasts today. The first woman has a mammogram next month, which reveals the cancer and leads to treatment.

The second woman doesn't get a mammogram until next year. Her cancer is also detected, and she also gets treated.

If both women die two years from now, it could look like the first woman lived longer with breast cancer -- almost two years -- than did the second woman.

For its part, the American Cancer Society acknowledges that mammography is not the end-all, be-all of breast cancer detection.

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