BURNED BY LAWSUITS AND LOW PAY, RADIOLOGISTS ARE QUITTING, MAKING WOMEN WAIT LONGER TO FIND OUT IF THEY HAVE BREAST CANCER.
For years, breast cancer specialists have quite rightly touted mammograms as the best way to detect tumors while they’re small and highly treatable
Indeed, if a tumor is caught early – while it’s 1 centimeter or less in diameter – the odds of living 16 to 20 years are better than 90 percent, according to the American Cancer Society.
But, just as women are getting the message – doubling the number of mammograms performed annually since 1985 – doctors who read the X-rays seem to be fleeing the field at an alarming rate. Caught between rising litigation over allegedly missed tumors and low reimbursement for their services, a growing number of radiologists say their field just isn’t worth the stress any more.
“I personally would not recommend that a resident or fellow work full time in breast imaging because of the likelihood of burnout,” said Dr. Ferris Hall, a radiologist at Beth Israel Deaconess Medical Center in Boston.
And Hall appears to speak for many in his profession. The retirement rate of radiologists doubled from 1995 to 1997, from 400 to 800 a year, while the number of new radiologists specializing in mammograms dropped by 80 percent, according to a study by the American College of Radiology. Lamented Hall in the September issue of the journal of the American College of Radiology: “There is a disproportionate shortage of qualified mammographers.”
For women, radiologist burnout translates into a months-long wait for routine screening at many centers – when the mammograms are available at all. A prominent clinic, run by New York University, shut down altogether recently because it was losing too much money.
“It’s ridiculous what patients have to put up with,” said a disgruntled 61-year-old Needham woman who asked that her name not be used. She was told that she would not be able to get an annual mammogram until next February – even though she has had “suspicious things that needed to be checked” on past mammograms. “I’m extremely uncomfortable about that extra five-months wait,” she said.
While no one claims the radiologist shortage is costing lives – at least, not yet – delays in getting a routine mammogram can be dangerous. The five-year survival rate for breast is confined to the breast when it is discovered, but plummets to 21.3 cancer is 96.3 percent if the tumor percent if the tumor has spread to other organs. Ironically, the mammogram crunch comes at a time when there are a number of technological advances that could make breast cancer screening more accurate, albeit more expensive.
“We are on the verge of possible significant breakthroughs in cancer detection, especially with digital mammography and MRI, or magnetic resonance imaging,” said Dr. Daniel Kopans, director of breast imaging at Massachusetts General Hospital.
Yet, far from a golden age of breast cancer screening, the signs of an impending crisis in mammography are growing:
Young doctors are avoiding the field.
Fellowships in breast imaging, an important part of the training for radiologists who want to specialize in mammograms, now go begging. “Two years ago, there were not enough fellowships for would-be mammographers,” said epidemiologist Robert Smith, director of cancer screening for the American Cancer Society. “Now, they can’t fill the ones they have.”
At the same time, overburdened radiology offices are cutting back on discount mammograms for uninsured and low-income patients. Last year, more than 2,200 facilities offered discount mammograms during a national screening day organized by the American College of Radiology; this year, half that number signed up.
“How can I offer free mammograms when I have a four- to five-month wait for my own patients?” one doctor said.
Adding to the disenchantment, technologists, the people who actually take the mammograms, are dropping out of the field as well. “Techs take a lot of abuse from patients who are scared or upset thinking they might have cancer, and they don’t get paid well,” said Linda Santos, a technologist who manages the breast imaging service at Mass. General.
Perhaps most distressing, some centers, such as the NYU clinic in New York, are simply shutting their doors. “For every patient we see, we lose money. And the more patients we see, the more money we lose. It’s very simple, really,” explained Dr. Gillian M. Newstead, NYU’s director of breast imaging.
And epidemiologist Smith of the American Cancer Society said he believes that a lot of other facilities “would love to give it up, but are compelled to keep it because of contracts with managed care groups and employers.”
Indeed, the math is not even faintly fuzzy.
Medicare, the federal insurer, pays $67.81 for a screening mammogram, of which the doctor gets less than $22 (And unlike other reimbursements, the Medicare fee for mammograms is set by federal statute; that means that raising it takes congressional action.)
Some private insurers pay a bit more, up to $90, but the costs of maintaining X-ray machinery up to stringent federal and state standards, paying technologists and keeping offices running can run $100 per mammogram, not even counting the doctor’s fee, Newstead said.
“It’s ridiculous, what they expect us to do,” said Dr. Norman Sadowsky, director of the Faulkner-Sagoff Breast Imaging and Diagnostic Centre at Faulkner Hospital.
“The result is that some radiologists are being forced out of the breast-imaging business,” said Dr. W. Max Cloud, president of the American College of Radiology and a mammographer at the Baystate Medical Center in Springfield. “We are going to see more and more facilities dropping out of breast imaging.”
Making matters worse is the growing fear of malpractice suits. A decade ago, gynecologists were the most likely to be sued for failure to diagnose breast cancer. Now it’s radiologists, according to a 1995 study by the Physician Insurers Association of America, a Maryland-based trade group of physician-owned medical malpractice companies.
“Failure to diagnose breast cancer is the number-one allegation against all doctors, in Massachusetts and nationally,” said Martha Byington, a loss-prevention specialist at the Risk Management Foundation, which insures Harvard doctors and hospitals.
Part of the trend toward naming radiologists in breast cancer lawsuits is undoubtedly due to rising public expectations for mammography, despite the fact that mammograms can be extremely difficult to read. Indeed, with hindsight – that is, after a diagnosis of breast cancer – radiologists say they can often look back at old mammograms and pick up tell-tale signs of cancer that, on first reading, did not raise a red flag.
Still, there is no question the rise in litigiousness and high monetary awards in malpractice cases is scaring radiologists. Last year, for instance, a Topsfield woman was awarded $5.5 million after a jury decided her doctors at Beverly Radiology Associates failed to detect her breast cancer on mammograms taken in 1989 and 1992. Since then, the parties in the case have reached a settlement for an undisclosed sum.
In June, a woman from the Bronx in New York sued her doctors for not catching her breast cancer on a mammogram, after the state health commissioner in May suspended the doctors’ licenses for poor breast cancer screening practices, including the use of mammograms done with the wrong film and the wrong machine. Other high-profile cases in Hawaii and Florida have also resulted in significant monetary awards.
One result of such cases, Byington noted, is that “physicians are practicing more cautiously now and they do order more tests, for which they may not get paid.” And that, of course, compounds the problems for mammographers.
“The legal climate in which radiologists work is potentially severe,” said Dr. R. James Brenner, director of breast imaging at the John Wayne Cancer Institute in Santa Monica, Calif., and head of a new task force convened by the radiology college to document the growing problems in mammography.
The bottom line, said one Massachusetts radiologist who has been sued for failing to find breast cancer on a mammogram, is: “If given the option, many radiologists would not do mammograms anymore. It’s just too stressful.”
Judy Foreman is a Lecturer on Medicine at Harvard Medical School. Her column appears every other week. Past columns are available on www.myhealthsense.com.
SIDEBAR: Imaging Systems Improve Accuracy
Were it not for the economic and legal problems now facing mammographers, these would be exciting times in breast imaging. A number of advances in imaging technology could make breast cancer detection considerably more accurate than mammograms, which miss about 15 percent of cancers.
“We hope that these techniques will help us detect cancers that are not visible on mammograms and can’t be felt,” said Dr. Daniel Kopans, director of breast imaging at Massachusetts General Hospital.
Traditional mammograms, which take an X-ray photo of the breast, remain the overwhelming majority of the 30 million breast images made in the United States annually. But that may soon change, especially as digital film and magnetic resonance images become more available – and affordable.
Digital mammography, in which an X-ray image of breast tissue is captured electronically instead of on film, gives the radiologist far more flexibility in how he or she views the image. A film mammogram that is too dark or too light cannot be significantly altered.
But, with digital mammography, the image can be manipulated on a computer to heighten contrast and tease out details of suspicious areas.
“The excitement about digital is not just that you can manipulate the image but that we will be able to do things with X-ray imaging that we have never been able to do before,” Kopans said. Most importantly, he said, radiologists will be able to look at sequential levels of breast tissue, in essence becoming able to spot tumors that would otherwise be hidden.
The big drawback is that a digital mammography machine can cost roughly $750,000. “It’s very, very expensive,” said Dr. Kevin Hughes, director of the breast centers at the Lahey Clinic in Peabody and Burlington. Even so, he predicted, the number of centers that will have it will go up year by year.
A number of centers are also beginning to use a variant of digital mammography called CAD, or computer-aided detection. With this technique, a film image of the breast is converted to a digital image so that a computer can read it. In essence, this system enables a mammographer to improve accuracy by doing a double read: The radiologist reads the standard X-ray, then the computer checks the digital image and highlights suspicious areas.
“MRI [magnetic resonance imaging] scans are also pretty exciting,” said Dr. Norman Sadowsky, director of the Faulkner-Sagoff Breast Imaging and Diagnostic Centre at Faulkner Hospital, who is using the technique for certain patients.
Because MRI scans involve an injection of a substance that heightens the contrast between normal and abnormal tissue, and because the machines cost $500,000 to $2 million, they aren’t likely to be used soon for standard screening of healthy women.
But researchers are already using MRI to test women at high risk of breast cancer whose breasts are dense or whose breasts are difficult to image on regular mammograms for other reasons. MRIs are also beginning to be used to define the extent of cancer in a woman whose mammogram clearly shows a tumor. MRI already appears to be the best way doctors have of determining how large a tumor is.
Ultrasound, too, is increasingly being used as an adjunct to standard screening in women who have suspicious mammograms. In ultrasound, sound waves are bounced off breast tissue to detect abnormalities. The images generated are less effective than standard mammograms at picking up areas of calcification that might need further testing, which means they probably wont be used for initially screening healthy women. But they are very good at differentiating between a harmless, fluid-filled cyst and a cancer, Hughes said.
Other techniques also are in the works. At Lahey, researchers are studying several heat-based tests for breast cancer detection, including a technique called computerized thermal imaging, which uses low levels of electrical current to detect the heat signature of the breast. The idea is that cancerous lumps have more blood flow and therefore become hotter than normal tissue. Whether that translates into an accurate detection test is not yet clear.