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Looking beyond the X-rays

In renewing the Mammography Quality Standards Act, Congress focuses on doctors' skills.

May 19, 2003|Melissa Healy | Times Staff Writer

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.

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