Mammography pioneer reviews field's progress over past quarter-century

November 1, 2006

The article and editorial on screening mammography in the September 2006 issue ("Screening mammography: Practitioners consider Europe in the quest for better quality," page 28, and "Centers of excellence could improve mammography's quality profile," page 5) are both comprehensive and well done. Permit me a few comments.

I practiced mammography from 1955 to 2005 and chaired the American College of Radiology Committee on Mammography from 1980 to 1991. The committee included a world class group of radiologists. In 1987, we developed the ACR guidelines for screening mammography and the ACR Mammography Accreditation Program in response to our perceived need for improvements in mammography technique, interpretation, and results. Qualifications and technique were well defined, but accuracy measurements were elusive, due to concerns about setting a precedent over other areas of radiology. Consequently, only a recommendation for a follow-up effort was made.

We did not foresee some of the logistical and economic problems that occurred with the accreditation program, but its success led to the passage of the Mammography Quality Standards Act. We also developed the ACR BI-RADS system of standardized reporting. There were many other accomplishments of these exceptionally talented radiologists.

There is considerable opinion that ours is an increasingly dysfunctional healthcare system. The issues involved include access, delivery, quality, results, and costs.

Regarding screening mammography, some of these issues have been addressed in Sweden, the U.K., and in the U.S. with screen-film mammograms acquired in mobile vans and batch-interpreted elsewhere.

Our experience with this at the University of North Carolina in the early 1980s was very successful in terms of mission, service, and the goodwill it generated. Unfortunately, logistical and financial problems forced us to discontinue the service.

Digital mammography could overcome most of those problems. Ours is a huge country, mostly urban but still with a widely dispersed population. With digital mammography, it is feasible to acquire images in remote locations that are staffed only with qualified radiologic technologists and transmit those images to qualified radiologists at centralized facilities for interpretation.

The evidence is strong that screening results improve with full-time breast imagers, and I believe full-time breast imagers produce the best results. Most general radiologists in the U.S. would rather not do mammography because it is difficult, litigious, not profitable, and boring-and not necessarily in that order. Stress or burnout is another consideration.

I have avoided the costs issue even though it involves all of the others, either directly or indirectly, because it requires a separate dialogue. Briefly, I believe we need universal national health insurance for all, run by the federal government and paid for with taxes like Medicare (social insurance), copayments, deductibles, and catastrophic coverage.

Thank you for your fine discussion of screening mammography.

-Robert McLelland, M.D., FACR, Emeritus Clinical Professor of Radiology, University of North Carolina