Mammo 'triage' should give way to diagnosis

The value of mammography has been heavily oversold, and radiology is beginning to pay the price. Despite their high spatial resolution, rendered by small focal spots and breast compression, mammograms have never contained the morphologic or functional information needed to make a specific diagnosis of cancer, no matter how expert the reader-and in many instances, readers are astoundingly good.

In fact, mammography has always been a triage procedure, determining whether to biopsy or follow up using imaging. For that purpose, it has been a fairly miserable failure: Approximately 80% of biopsies in the U.S. and 60% in Europe prove to be benign, imposing a huge load of emotional and physical distress for hundreds of thousands of women. Adding CAD, digital imaging, and/or image manipulation to this compounds the problem: You simply find more lesions to triage, most of which turn out to be false positives with yet another increase in "unnecessary" biopsies.

The reason for residents' diminishing interest in mammography is not simply poor financial rewards or litigation, largely due to the widespread erroneous belief that mammography is 95% accurate in detecting cancers, but to the fact that mammography, despite our carefully learned diagnostic skills, remains just a triage procedure, whether we call it that or not. This is not a very satisfactory career choice.

Luckily for us, the ACR has realized that molecular imaging is the direction in which we should be heading, and that applies in spades to mammography. Let's not try to resuscitate it. Let it fade into the sunset, to be replaced with more definitive diagnostic techniques, and spend the money on molecular imaging research in breast cancer.

Eric N.C. Milne, M.D., FRCR, FRCP

Professor emeritus of radiology and medicine

University of California, Irvine