Why British Doctors May Read Mammograms Better

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Critics of the new health reform law say their worst fear is that the U.S. medical system will become more like the one in the United Kingdom. But what if this was a good thing?

A new study suggests that in one area of health care — reading mammograms — the British way may be better. There, radiologists are permitted to interpret “screening mammograms” — those performed on women without symptoms or signs of cancer — only if they review at least 5,000 per year. The U.S. minimum threshold, enforced by the Food and Drug Administration (FDA), is just 960 screening or “diagnostic mammograms” — the latter refers to mammograms conducted after an abnormal screening mammogram or other symptoms — every two years. The result, say researchers, is that the rate of false positives — women erroneously told they have cancer or signs of cancer — is far higher in the U.S. than in the U.K. In addition to causing psychological distress in women and invasive follow up procedures like biopsies, false positives in mammography cost some $1.6 billion per year, according to the study, which was spearheaded by researchers at Group Health and largely funded by the American Cancer Society and National Cancer Institute.

This counterintuitive finding — that asking doctors to do more leads to fewer errors —could be applied to other screening tests. “You could imagine this for colonoscopy,” says Diana Buist of Group Health, the study’s lead author. Mammography is unique among screening tests in that the federal government requires doctors interpreting mammograms to do so a minimum number of times to legally continue the practice. This is thanks to the Mammography Quality Standards Act (MQSA) of 1992, which set guidelines for the field of mammography after widespread variation in the quality of mammograms and breast cancer treatment was discovered.

The Group Health study also shows how much American health care practitioners could learn from how care is delivered in other countries. While the heated political rhetoric around health care in Washington depicts foreign health care as inferior, this is not always — or even usually — the case, says Buist. Health care in places like the U.K. and Canada is sometimes better quality and is in many cases, much less expensive. “At some point, we are going to have to come to grips with how to maintain our quality while lowering costs,” says Buist. “This is an example of how you can have the same quality and lower costs.”

According to the study, some $5.2 billion is spent every year in the U.S. on breast cancer screening and on false positive costs. Based on the simulation generated by the Group Health study, if the FDA minimum threshold for mammograms per radiologist was increased to 1,500 per year — triple the current level — costs would decrease by $21.8 to $46.4 million. This is precisely the kind of complex analysis and policy change that could reduce costs while increasing quality, two outcomes that are not — contrary to what many believe — mutually exclusive.

This sort of “comparative effectiveness research” — examining data and outcomes to design medical protocols — is a primary goal of the new Affordable Care Act. The law will establish a center for such research and fund large-scale demonstrations. The American Recovery and Reinvestment Act — the stimulus — also provided more than $1 billion for comparative effectiveness research. Group Health, an integrated care delivery and insurance system in Washington State, received some of this grant funding.

So when it comes to diagnostic testing, does practice makes (nearly) perfect? Possibly, says Buist. Radiologists who read more mammograms may be better at identifying lesions that are not cancer and do not post health risks to women. But in addition, radiologists who enjoy reading mammograms and who are successful at it may choose to take on a higher caseload.

There is also a potential downside to increasing the FDA threshold. If radiologists are required to read more mammograms in order to legally continue the practice, it’s possible some may decide to eliminate this slice of their work altogether. This could decrease access to mammography, particularly in rural areas where radiologists are few. This possible problem could be mitigated, however, with the use of telemedicine. In the U.K., says Buist, radiologists who read mammograms are often concentrated in high-volume centers. With digital mammography in the U.S., screening results could be e-mailed to radiologists far away who could spend large chunks of time reading image after image. They could, in theory, easily reach an FDA threshold as high as 1,500 mammograms per year.