Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: TUESDAY, November 8, 1994 TAG: 9411090041
SECTION: EXTRA PAGE: 1 EDITION: METRO
SOURCE: RICHARD A. KNOX BOSTON GLOBE
DATELINE: LENGTH: Long
That is not supposed to happen. Any abnormal mammogram should be promptly followed by further tests - mammograms taken from different angles or with special attention to the suspicious area, perhaps an ultrasound exam to determine if a suspected tumor is solid or fluid-filled, and possibly a biopsy, or retrieval of a tissue sample by a needle or through surgery.
Six months later, Elizabeth felt a lump. It turned out to be stage II breast cancer - and it had spread to a nearby lymph node. After a ``lumpectomy,'' radiation and chemotherapy, she hopes she has beaten the disease, but is left wondering ``if maybe some red lights should have gone off'' when the first mammogram was abnormal.
Immediate follow-up of an abnormal mammogram sounds like common sense. But when it comes to mammography - performed on American women 24 million times a year - even more basic lapses in proper procedure are not rare.
It is no accident that failure to diagnose breast cancer promptly results in more medical malpractice awards and settlements than any other cause.
Sometimes women are never told anything about the results of their mammograms - normal or abnormal. ``Failing to communicate mammography results is a common problem,'' notes an expert federal panel that last week issued an A-to-Z guide on how to ensure quality in performing this critical diagnostic test.
Iris Allen, 40, of Weymouth, had a different kind of problem. She had a mammogram four years ago, after she felt a lump in her breast, but the doctor who interpreted the X-ray film reported that he saw nothing abnormal. Eight months later, when she was diagnosed with advanced breast cancer that had spread to her bones, the original mammogram was retrieved, she said, and the evidence of a tumor was there all along.
``This is where a botched mammogram leads,'' Allen said Friday from her bed at Brigham and Women's Hospital, where she is undergoing experimental treatment for metastasized cancer.
``As far as I'm concerned, if a mammogram is not being done correctly, it's worse than not having one at all,'' says Suzanne Cocca, a Boston lawyer who has studied mammography quality-control.``It's very dangerous to offer the procedure without guaranteeing quality.''
But American women will soon have reason to feel more confidence in mammography. Oct 1 was the effective date of a rigorous U.S. law that makes mammography the only diagnostic imaging test subject to federal quality standards.
It is now illegal for any of the nation's 10,600 mammography facilities to operate without a federal certificate, which must be updated annually. About half are already fully accredited; 40 percent have provisional certificates and must win formal accreditation within six months or go out of business.
The 170-page guidelines issued last week do not have the force of law. But the panel that drafted them hopes to set a new standard for everyone - receptionists and technicians as well as radiologists, primary care doctors who recommend the test and for patients themselves.
``Health providers should know and understand the complexity involved in getting a high-quality mammogram. There are many steps in the chain where a mammogram can go wrong, and some can be quite subtle,'' says Amy Langer of the National Alliance of Breast Cancer Organizations and a consumer representative on the 15-member panel.
``Second, we hope to make consumers more involved in the process of followup. They must understand they're in charge of their health.''
Mammography has become such a part of the medical landscape that neither physicians nor patients think much about its limits.
The technology is the best medicine has to detect breast tumors before they can be felt by either a woman or her care givers, and it has vastly improved in both sensitivity and safety in the past decade. But it is far from foolproof.
Because it has the potential to unmask tumors while they are localized, screening mammography ``is the only modality that can decrease cancer mortality of any kind,'' says Dr. Lawrence W. Bassett of the University of California at Los Angeles, who chaired the federal panel. ``That's why we want it to work well. We don't want it to be harmful.''
The potential benefit is enormous. The often-cited figure is that mammography, if widely and properly applied, could reduce breast cancer deaths mortality by 30 percent - saving 13,800 lives a year in this country.
That statistic is derived from a Swedish study of nearly 170,000 women over age 40, some of whom were offered mammography every two or three years, depending on their age, and others not offered the test. In 1992, after an average follow-up of nearly 11 years, the groups that were screened had 30 percent fewer breast cancer deaths.
That kind of evidence has led to aggressive campaigns to offer mammography widely.
Despite those efforts, U.S. breast cancer mortality has not changed much for decades; the reason may be the lag in mortality statistics - and possibly the highly variable quality of mammography.
``Much of our accomplishment with mammography is not yet apparent because we are detecting cancers that would not have declared themselves for another 10 or 15 years,'' said Dr. A. Alan Semene of Faulkner Hospital's Sagoff Breast Center.
In trumpeting the benefits, however, screening advocates have not educated doctors and patients about mammography's limits. Even the best quality mammograms miss about one in 10 breast tumors.
by CNB