In the Beginning…(Screening Mammograms)
Wow! My very first blog! Where should I start? After agonizing over this decision for several days, I thought: why not start at the beginning, with screening?
Let me begin by stating, unequivocally, that the screening mammogram is the most important study in breast cancer. I know, it doesn't pay enough, is "boring," carries a large medical legal risk, and isn't very "high tech," but none of that alters its importance to women, or to anyone in the chain of care for breast disease.
All cancers are biologic processes, meaning that they grow over time. Screening mammography allows us to intercept breast cancers while they are pre-clinical in size, and the evidence is clear that, where breast cancer is concerned, smaller is better. In fact, most of the decrease in mortality rate from breast cancer has been attributed to screening mammography for this reason.
There is, however, an interesting phenomenon that one observes with most good comprehensive breast centers, and that is a disproportionate number of diagnostic patients when contrasted with the "native" screening population. Even after discounting for clinical referrals and short interval follow-up patients, the number of diagnostic patients exceeds the number of screening recalls by a substantial percentage. Unfortunately, if you dig deeper, you will find that that this body of patients tends to have larger cancers and even cancers that are apparent on the screening priors that the patient brings with her.
What we are seeing here is the effect of the commoditization of the screening mammogram, and it is dangerous. Commoditization reflects the erroneous perception by both third party payers, and by many of our referring physicians that all mammograms are equal, when nothing could be further from the truth. Unfortunately the consequence of this misperception is costly, both in terms of pure economics, and in the delayed diagnosis of treatable cancers.
What to do? If you are a woman, choose wisely and well. Pick your breast radiologist with care, from subspecialists who focus on breast imaging, who interpret large numbers of mammograms each year, and who keep up and improve their skills by regularly attending professional meetings and seminars devoted to breast imaging. If you are a center that is facing the commoditization challenge, stay tuned for the next edition of this blog.