A 2001 report from the Institute of Medicine (IOM) and the National Research Council (NRC) concluded that, although it is an imperfect technology, x-ray film mammography is still the best screening tool available for the early detection of breast cancer.
Now the report has a sequelalso a product of the IOM and NRCthat reaffirms this view and builds on the content of the previous volume by focusing on how the deployment of the technology could be improved. "For the immediate future, broader and better use of (conventional) mammography holds the greatest potential to save lives," concluded the committee behind the most recent report, "Saving Women's Lives: Strategies for Improving Breast Cancer Detection and Diagnosis," which was released earlier this summer.
The committee's primary suggestion is that the United States would do well to adopt some features of screening programs from abroad. In Great Britain, for example, the National Health Service contacts all women of suitable ages individually every 3 years to offer them the opportunity to be screened without charge. In the United States, by contrast, there is no annual "invitation system," and millions of women, lacking the health insurance to pay for it, are not screened who should be.
Training ancillary health workers to read mammograms is another idea the new report applauds. In the United States, radiologists with breast imaging credentials have been shown to be the most proficient at this job. However, only 12% of the radiologists who interpret mammograms are specialists, and a further shortage of them looms as the demand for their servicesdriven by the aging of baby boom generation womenis poised to grow. Although the American College of Radiology is opposed to letting non-radiologists read mammogramspreferring that general radiologists do itstudies in England found that technologists outperformed them at this task.
Measures to address the uneven quality of U.S. mammography were of special interest to the committee that wrote the report. One such measurealready mandated in the Swedish, Dutch, and Australian screening programswould require that all mammograms be examined by two expert sets of eyes. Another measure, the norm in Sweden, the Netherlands, and Great Britain, would have the films read at centralized high-volume facilities. Such arrangements are rare to nonexistent in the United States, but screening programs abroad that use either or both strategies are less likely to be error prone than those that do not and in particular are more likely to have lower rates of false-positive readings.
More specifically, false-positive readings and their consequent follow-up (usually including biopsy) are harrowing for women andat about $500 per caseare expensive. Some 40 million women a year are screened in the United States, and the false-positive rate, which is currently about 10%, has been adding about $200 million to the nation's health care costs. Thus, the report estimates that, if an overhaul of the screening infrastructure halved the number of women who falsely tested positive (which data from other countries suggest is feasible), $100 million could be saved annually.
The report also calls for better education of the public and the media who communicate with it about breast cancer, noting that women under 50 tend to overestimate their risk of the disease, whereas older women underestimate it. Besides that, most women misunderstand or overestimate the benefits of mammography. And, because susceptibility to the disease varies not only by age but also by other factors, the report advocates research aimed at defining risk factors more precisely.
Not the least of the report's concerns, moreover, is ductal carcinoma in situ (DCIS), a condition readily detected by screening mammography that many health care professionals, as well as patients and the general public, do not realize is, as the report notes, "far less grave... than a diagnosis of invasive breast cancer."
At the heart of this misunderstanding is that virtually everyone in whom DCIS is discovered is treated aggressively because there is no way to tell the majority of it that is harmless apart from the minority that is potentially life-threatening. "We don't want to detect disease that will never really kill people," said Jeffrey Marks, Ph.D., of Duke University, who served on the committee that prepared the report. "But the current reality leaves us no choice."
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As for the future of breast cancer detection, the committee foresees incremental improvements but little chance of imminent drastic change. "A single breakthrough technology that will revolutionize the early detection of breast cancer is not likely in the next few years...," the report stated. "No breast cancer screening tool (to date) has better sensitivity and specificity than screening film mammography."
Meanwhile, the greater worry, according to the report, is a dearth of funding for studies specifically designed to shed light on whether a medical product or technique is well suited for non-research settings, stacks up well against other measures that serve the same purpose, consistently performs well over time, and turns out to be cost-effective. The clinical trials the National Institutes of Health supports do not answer these questions, the report states, and neither do many trials sponsored by private industry to satisfy U.S. requirements for product approvals.
Although the committee acknowledges that this shortcoming is applicable to virtually every aspect of health care, the gist of its message is that reform of the entire situation is long overdue and that rigorous assessment of strategies for the detection, diagnosis, and treatment of breast cancer is as good a place as any to begin.
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