TOWSON, MarylandMammography is still the gold standard
for the screening and diagnosis of breast cancer, but that
doesnt mean it is always done right, said Gilda
Cardenosa, MD, head of breast imaging at the Cleveland Clinic.
There is a lot of bad mammography out there, even with all the
regulations that are in place.
Speaking at the Seeking Excellence in Breast Cancer Care conference
sponsored by the Johns Hopkins Medical Institutions, Dr. Cardenosa
described in forthright terms what she feels must be done to raise
the quality of breast imaging nationwide.
One of the first steps, she said, is to keep clear the distinction
between screening and diagnostic mammography. Screening is done
on asymptomatic women, Dr. Cardenosa said. If the physician is
in any way concerned about patient symptoms or findings on the
physical examination, then the patient should receive a diagnostic,
not a screening mammogram.
Screening is only about detection and perception, she
said. If a physician receives a screening mammogram report
recommending biopsy, thats not appropriate, she
said. What is appropriate in such a situation is a simple
observation that might note, for instance, a suspicious spot,
apparent microcalcifications, or other manifestations.
She decried mammography boutiques where, for about $50, a
woman can get a basic breast scan but, chances are, inadequate review
or interpretation. The best way to look at screening mam-mograms is
not while the patient is waiting on site, she said, although some
centers advertise they do this. They say, Well give
you an answer right away! and any responsible radiologist
hearing that must wonder, Do they care if the answer is right?
Dr. Cardenosa said that it is better for the radiology specialist to
set aside several hours of quiet time, gather perhaps 50 mam-mograms,
and go through them undisturbed. During that time, all the
viewing professional needs to ask is whether the woman appears to be
normal, or if there is something in the mammogram that arouses
suspicion, she said.
The interpretation of diagnostic imaging, however, calls for a
different mind-frame. In diagnostic imaging, Dr.
Cardenosa said, I am focused only on one patient, and
whether that patients findings require biopsy or another
Who Does the Call Back?
When a screening mammogram does detect something seemingly abnormal,
the patient must be called back for further tests. Dr. Cardenosa
believes it is better to let the radiology specialist do that
directly. That way, the radiologist can elicit information from
the patient, schedule further views and tests appropriate to the
situation, and do it quickly, she said.
Physicians often disagree with her. Frequently, she said, she gets a
call from a doctor who protests, Youre taking over my
patient. Is this the right mind frame? she asked. If I
see something suspicious, Dr. Cardenosa said, I want to
call the patient back.
A Cleveland Clinic study showed that when radiologic reports are
referred back to physicians, the result is delay and lower compliance
with requests for follow-up. When the radiology program did not
call patients back directly, about 70% had their studies done within
a month, she said. When patients were called directly,
that rate rose to 92.2%.
These results suggest that another way to improve mammography is
teamwork. Many institutions talk about how their providers work
as a team, but for that to be true, they do actually have to work
together and make sure their views of any patients situation
match up, Dr. Cardenosa commented.
She said that the Cleveland Clinic has a radiology call back program
in which a secretary trained in patient communication telephones
patients within 24 hours of mammogram interpretation. When the
patient is reached by phone, an appointment is scheduled, and the
referring physician is e-mailed with specifics of the
appointment, she said.
Radiology and Biopsy
Dr. Cardenosa also emphasized the importance of adequate mammography
before breast biopsy. She said that too often surgeons do not have
the right radiologic views or guidance to know where to sample
tissue. Blindly taking patients to surgery does not make
sense, she said.
She also decried the use of needle aspiration without radiology.
If we blindly aspirate, were not going to find early
breast cancer, she said. Before we put a needle into
anything, lets look at it.
She urged the same approach for nipple discharge, because negative
cytology by itself does not rule out the presence of breast cancer.
If the ducts are cut to relieve the discharge, the patient may
come back years later with invasive carcinoma, she said.
And if a surgeon does cut and send tissue to the pathologist,
is the pathologist going to know where to find the lesion?
Finally, Dr. Cardenosa urged health care organizations to stop
treating mammography as a loss leader and the mammography
center as an unwanted stepchild. Nobody wants us around because
we lose money, she said. Third-party payers will also try
to ratchet costs down, but like any other specialty, its costly
to do right. She also said that not all radiology centers
should perform mammography. Its a specialty and requires
specialists to be done correctly.