ACR Comments on JAMA Article on Screening Mammography - 10/23/2003
The October 2003 Journal of the American Medical Association (JAMA) article, "Comparison of Screening Mammography in the United States and the United Kingdom," could easily be read as concluding that mammography performed in the United Kingdom is superior to that performed in the United States.
The American College of Radiology is committed to mammography as a tool to save lives. While it is important to have a recall rate that does not cause excessive patient anxiety or undue cost, the ACR believes the primary focus of mammography is to detect breast cancer early enough to produce a mortality benefit for those undergoing the exam.
As a result, the College believes that the JAMA article downplays important realities about mammography in the two countries. For example, the article fails to note that more cases of early, curable breast cancer are detected in the United States than in the United Kingdom. Above all else, the purpose of a breast cancer screening program is to decrease the death rate from breast cancer. It is the rate of detection of small early-stage, node-negative tumors that translates into saved lives.
In addition, litigation for missed breast cancer is much rarer in the United Kingdom and, thus, less of a driver for additional testing. According to a 1997 survey published by the Physician Insurers Association of America and the ACR, mammography is the most prevalent procedure for which claims are filed against radiologists. Furthermore, an error in the diagnosis of breast cancer is the most prevalent patient condition for which claims are generated against physicians.1 As the authors of this JAMA article present, this current environment provides "a strong incentive to increase sensitivity at the expense of specificity, possibly leading U.S. radiologists to recall women when they identify a finding with a low likelihood of cancer."
The ACR agrees that efforts should be made to improve mammographic screening in the United States by lowering the recall rate without substantially lowering the cancer detection rate. Meeting this challenge, however, will require careful evaluation of current complex issues. The challenge will not be met unless the American public is willing to accept a higher rate of false-negative results, the profession is willing to expose itself to increased malpractice claims for missed cancers, the insurance industry is willing to absorb these claims, and society is prepared to lose mammography facilities and professionals, possibly decreasing access to mammography for all women in the United States.
References:
1. Physician Insurers Association of America, American College of Radiology. Practice Standards Claims Survey. Rockville, Md: Physician Insurers Association of America; 1997.