American women who get routine mammograms are more likely to be called back for additional tests than women in other countries, even though such caution does not result in more cases of breast cancer being found, a new study has found.
"Higher callback rates would be fine if we had evidence we're getting more bang for the buck," said Dr. Joann Elmore, lead author of research published Wednesday in the Journal of the National Cancer Institute. "But we're not."
Previous research has shown that false-positive results--abnormal or inconclusive mammograms in women who do not have breast cancer--lead to millions of costly tests every year, including hundreds of thousands of invasive biopsies, as well as incalculable anxiety until the suspicion of breast cancer is dispelled.
Interpreting mammograms, which are specialized X-rays of the breast, is a fairly subjective process and even highly experienced radiologists frequently disagree on what the images show.
Experts have long suspected that U.S. radiologists "overread" mammograms compared with their colleagues in other countries, at least in part for fear of being sued.
The new study confirms the disparity but is cautious about assigning blame.
bag Shoulder L' AUTRE CHOSE Maroon Still, the authors say they have adjusted for most of the other factors that could lead to higher false-positive rates and hint strongly that America's litigious culture is implicated.
"I think the fear of a medical malpractice suit is a big factor," said Elmore, associate professor of medicine at the University of Washington in Seattle. "That is a big difference between the U.S. and other health care systems.BARRETT Rucksack amp; bumbag NEIL Black XSvUxx
"We know the No. 1 cause of malpractice claims in the U.S. is failure to detect cancer."
Dr. Leonard Berlin, chairman of radiology at Rush North Shore Medical Center in Skokie, was more blunt:
"I think Elmore's study confirms that radiologists in the U.S. tend to overread mammograms. ... And I believe the reason is defensive medicine--the threat of malpractice litigation if a radiologist fails to flag anything that's even remotely suspicious."
Berlin said intervention is considered the capstone of medicine in this country: "People expect doctors to do something."
Maroon CHOSE Shoulder bag L' AUTRE Obstetricians do not get sued for doing Caesarean sections, he said, only for not doing them. Likewise, radiologists do not get sued for suggesting unnecessary biopsies--"but heaven forbid if they don't order a biopsy and the area turns out to be cancer."
Research has shown that American women accept a high rate of false-positive results, believing such caution is the price they have to pay not to miss anything.
According to one of Elmore's earlier studies, one in every two U.S. women will have at least one false positive after 10 years of annual screening.
But mammography is an imperfect test.
According to the National Cancer Institute, it misses about 20 percent of all breast cancers and flags a huge number of suspicious spots that turn out to be harmless--but not before the patient has gone through a battery of additional tests and many sleepless nights.
bag AUTRE CHOSE Shoulder L' Maroon Elmore's new study also showed that American mammographers do not detect any more cases of breast cancer, nor do they detect cancer at earlier stages, than their counterparts in such countries as Australia, the Netherlands, Italy or Britain.
The study analyzed data from 32 community-based mammography programs in six U.S. states and 16 other countries. The percentage of mammograms considered suspicious varied dramatically, from 15 percent in Texas to 1.2 percent in the Netherlands.
bag AUTRE Maroon Shoulder L' CHOSE On average, the percentage of mammograms deemed suspicious by U.S. screening programs was 2 to 4 percentage points higher than in other countries, even after adjusting for such factors as age of women screened and number of radiologists reading each mammogram.
According to the U.S. Agency for Health Care Policy and Research, mammographers should aim for a recall rate of no more than 10 percent.
bag Shoulder Maroon AUTRE L' CHOSE At that rate, about 3 million U.S. women are called back every year, although the cases of breast cancer diagnosed number 250,000.
L' Maroon AUTRE bag CHOSE Shoulder By comparison, the desired recall level in Europe is less than 5 percent.
Studies from the U.S. and Sweden have estimated that for every $1 million spent on mammograms, another $260,000 to $330,000 is spent on follow-ups that turn up nothing. In the U.S. an estimated $3 billion to $4 billion a year is spent on mammograms.
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Tips to avoid false readings
Mammograms flag suspicious spots that often turn out not to be cancerous--but not until the patient has endured the cost, inconvenience and anxiety of additional tests. Breast cancer screening experts offer these tips for avoiding "false positives":
AUTRE CHOSE Maroon bag Shoulder L' - Make sure your mammography facility is certified by the U.S. Food and Drug Administration.
- Find out if the facility has a radiologist who specializes in breast imaging. In general, those who read a high volume of mammograms are more accurate.
Unless you always have your mammograms done at the same site, request and keep your films and make them available for comparison. Radiologists may interpret something as abnormal when they do not have earlier films that show the same irregularity.
- If possible, go to a radiologist who knows you and your primary-care physician.
- When a radiologist finds something questionable, especially if a biopsy is recommended, consider seeking a second opinion. Get another mammogram or ask a radiologist at another facility to perform an "outside reading" of your film.