Breast markers are important, but so is separating screening, diagnostic cases

I read with great interest the article by Dr. Richard Chesbrough, "Mammographic markers may lead to confusion and liability" (March 2005, page 27). This well-crafted article clearly articulates the need for standardization for mammographic markers. I was struck by the strict adherence to marking the breast: "Palpable abnormalities are marked with a discrete radiopaque triangle. There is no deviation from these marking devices, and every marking device placed on the breast is also noted by the technologist."

But there is a further step that should be taken: When patients with palpable abnormalities go through screening examinations, the technologist should flag these cases, since these are truly diagnostic cases.

The mindset for interpreting and providing a report for a screening examination and for a diagnostic examination is very different; while screening is an exercise in detection, the diagnostic examination is frequently an exercise in detection and diagnosis. A negative screening mammogram report conclusion might read, "No mammographic evidence of malignancy. Recommend annual screening." A true diagnostic mammogram (even though a screening mammogram was requested) should read, "No mammographic evidence of malignancy. Management of the patient's reported palpable abnormality should be based on physical examination and degree of clinical concern." Perhaps a more proactive conclusion might read, "No mammographic evidence of malignancy. Patient will be recalled for physical examination aided with ultrasound for further diagnostic evaluation, and an additional report will follow."

Providing standardization for mammographic markers is very important; however, making sure the radiologist realizes the case represents a diagnostic patient remains critical. I would strongly advise that mammographic examinations for patients with a palpable abnormality (diagnostic patients) not be commingled with screening mammographic examinations for asymptomatic patients (screening patients).

-Richard L. Ellis, M.D.

Co-director, Norma J. Vinger Center for Breast Care

Gundersen Lutheran Medical Center, La Crosse, WI