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Breast disease programs and mammography training
Volume 163 Number 2
Letters
we point out in our article, the ethical significance of that potential increased cost must be addressed in the larger context of the formation <;>f public policy in the democratic process. For example, it is possible that the increased expenditure for routine ultrasonography would reduce by a greater amount other medical expenses, such as neonatal costs, and thus be cost beneficial to society. Frank A. Chervenak, MD Depm"tment of Obstetrics and Gynecology, New York HospitalCornell Medical Center, 525 East 68th St., M036, New York, NY 10021
Laurence B. McCullough, PhD Baylor College of Medicine, 6550 Fannin St., Houston, TX 77030
Judith L. Chervenak, MD Lenox Hill Hospital, New York, NY 10021
REFERENCES 1. Romero R, et al. Prenatal diagnosis of congenital anomalies. Norwalk, Connecticut: Appleton & Lange, 1988. 2. Nyberg DA, et al. Diagnostic ultrasound of fetal anomalies: text and atlas. Chicago: Year Book, 1990.
Breast disease programs and mammography training To the Editors: We are concerned about a conclusion in an article in the August 1989 issue of the JOURNAL (Gleicher N. Breast disease programs in obstetrics and gynecology: A plea for training in mammography. AM J OBSTET GYNECOL 1989;161:267-70). Dr. Gleicher concluded that gynecologists, to become interested in breast disease as part of their care of women, should undertake the performance and interpretation of mammograms. We concur with the conclusion that gynecologists should become knowledgeable about the diagnosis and management of breast disease as a part of their residency and continuing medical education. In the programs of the American Cancer Society and the joint activities of the American College of Obstetricians and Gynecologists and the American College of Radiology, we have urged strongly that more attention be given to breast cancer, a disease that will strike one American woman in 10 during her lifetime. Indeed, all our statements about breast cancer have emphasized that proper breast care begins with regular visits to a physician for physical examinations, followed at the appropriate age by periodic mammograms. It was the failure of gynecologists and other primary care physicians to uniformly use available breast cancer detection procedures that led the American Cancer Society, the National Cancer Institute, and many medical societies to embrace the concept of mammography as a screening procedure. The "walk-in" concept of screening mammography is less desirable than the standard medical approach, but it will reach many women who lack access to periodic examinations and mammography on any other basis. The incorporation of mammograms into regular ex-
689
aminations of women is an end much to be desired. Making such examinations available in a timely and convenient manner has had the attention of many clinicians in several interested medical specialties. The correlation of history, physical findings, and the results of the mammogram are ideally made by the primary physician after consultation with colleagues. However, we must suggest strongly that Gleicher's assertions that gynecologists can "pick up the art of mammography" by short courses or informal training would detract from the achievement of our shared objective and from the overall quality of care now afforded in most American cities. Many of us who have been involved for three decades in the development and proliferation of modern mammography have overcome a series of problems. These include development of a standard technique to produce a valid image, constant attention to radiation safety, a concern with repeated examinations, and the acquisition of the visual acuity needed to detect and identify early radiologic signs of breast malignancy. After all these hurdles, it remains fair to observe that good mammography is most difficult to perform and interpret. For more than a decade instruction in mammography has been part of the residency programs for diagnostic radiologists. A similar emphasis is incorporated in the training programs for radiographers. Beyond the formal training, some radiologists have sub specialized in mammography, just as others have concentrated on other areas. A vigorous set of continuing medical education opportunities provide upgrading for radiologists and radiographers about mammography. These programs are predicated on the basic skills acquired by radiologists in roentgen interpretation, radiation safety, and imaging technique. For Gleicher to suggest that gynecologists can detract from their own excellent and demanding residency programs to acquire a level of skill in a single (but intensely demanding) imaging procedure reflects a failure to appreciate the difficulties therein. For a radiologist to assume that his interest and skill in mammography, plus a few lectures or weekend courses, would qualify him to practice gynecology would be equally indefensible. In recent years many of us in medicine have been part of a ground swell movement to make both clinical and screening mammography available to American women. Radiologists have been urged to provide screening programs in their hospital departments, offices, clinics, mobile services, and other sites. They have been urged, and even mandated by the pending Medicare screening coverage rules, to reduce the fee for screening to a figure well below prevailing rates for clinical mammography. They have been urged to work with gynecologists and other colleagues to establish a referral mechanism for women with positive findings on screening examinations. The American College of Obstetricians and Gynecologists has urged its members to become part of the breast care team with surgeons, pathologists, and other physicians.
690
Letters
We applaud Dr. Gleicher for his premise that gynecologists should learn more about breast disease and take a primary role in breast care. We renew our offer to work with The American College of Obstetricians and Gynecologists and with others to achieve that end , but we differ sharply with his conclusion that a gynecologist can and should become a proficient mammographer by brief and casual study. Gerald D. Dodd, MD , and Robert McLelland, MD American College of Radiology, 1891 Preston White Dr., Reston, VA
22091
Reply To the Editors: I am pleased to respond to the com-
munication by Drs. Dodd and McLelland in reference to m" article. At the same time, I am distressed about the obvious misrepresentation of my conclusions by these representatives of the American College of Radiology. I do not believe that my Clinical Opinion article ever suggested that gynecologists could or should "pick up the art of mammography by short courses of informal training." In fact, my own experience, also delineated in my article, was based on a rather extensive training process that involved didactic training as well as the attendance of courses which, in turn, were geared toward progressively increasing knowledge and reading capabilities. Most important, however, the entire program was based on a mandatory "double I'eading" process by two physicians. Since its inception this program always involved both a gynecologist and a radiologist within the framework of a multidisciplinary approach, which also included a surgeon. Although the efforts of the radiology community over three decades in popularizing and improving mammography are applauded , it must be acknowledged that radiologists have so far been unable to make mammography the Papanicolaou smear of the breast. At present only an inadequately low percentage of women have entered mammography screening programs in accordance with recommendations by the authoritative bodies as Drs. Dodd and McLelland acknowledge in their letter. To blame this fact on gynecologists and other primary care ph~sicians, as they do in their communication, is at best unfair and at worst uninformed . Gynecologists (and other primary care physicians as well) have succeeded in integrating other aspects of preventive care into their practices quite successfully. Papanicolaou smear screening is only one example. The same cannot be said for the mammography effort, mounted by the radiology community. In fact, it may be argued that this failure directly relates to who performs mammography. As stated in my article, patient convenience as well as cost considerations favor a "onestop" annual checkup for each woman. What makes more sense than to offer every woman over age 40 a mammogram at the same time as she receives her annual physical, pelvic examination, and Papanicolaou smear? The breast is a r eproductive organ, and gynecologists perform more breast examinations and di-
Augusl 1990 Am J Obstel Gynecol
agnose more cases of breast cancer than any other specialty. Laudably, Drs. Dodd and McLelland appear to fully support an integrated diagnostic approach toward women's health care. Why then do they oppose such an approach in the gynecologist'S office? How many radiologists perform breast examinations at time of mammography ? Gynecologists do. However, the emphasis should not lie with who performs mammography. There is nothing predetermined to suggest that only radiologists can perform high-quality mammogra phy. Similar arguments were heard from the radiology community when obstetricians and gynecologists started performing ultrasound scans. Today it is accepted by both communities that excellence can be found in both specialties. Although the amount of ultrasound training in obstetrics and gynecology residency programs still varies greatly, the same can be said about radiology training programs, especially in reference to obstetrics and gynecology ultrasound. I am sure that similar differences in extent and quality of training also exist in mammography training programs. Laszlo Tabar, arguably the most experienced mammographer in the world today, emphasizes this point repeatedly in his courses, which are largely attended by practicing radiologists but are open to interested gynecologists. In these superior exercises, Tabar also repeatedly makes the point that nobody is perfect in reading mammography films and strongly urges all mammography centers to double read every film . I am puzzled then about alleged quality concerns, expressed by Drs. Dodd and McLelland in reference to a program like ours that h as used a double-reading system since its inception , at a time when the majority of mammography programs administered by radiologists do not. Moreover, let us acknowledge a few additional facts. (1) Most mammograms in this country are not read by radiologists specializing in mammography. In fact, very few such specialists practice in this country (in contrast to Europe). (2) Mammography is among the least desired assignments in most radiology units. Only too often this responsibility falls on the most junior and least experienced individual and is passed on at the earliest opportunity. I and other members of our specialty applaud the willingness of the American College of Radiology to engage in a dialogue with our community. Our own departmental interest in mammography was spurred by the recognition that we as gynecologists cannot actively engage in the management of breast disease without knowledge of mammography. We therefore maintain our belief that gynecologists who manage breast problems require mammography knowledge. Obviously, this does not automatically suggest that every gynecologist with minimal mammography knowledge should read films. We require ultrasound training in our obstetrics and gynecology residency programs but not all graduating residents read their own scans. We would like to urge our radiology colleagues to accept that some
Letters
we point out in our article, the ethical significance of that potential increased cost must be addressed in the larger context of the formation <;>f public policy in the democratic process. For example, it is possible that the increased expenditure for routine ultrasonography would reduce by a greater amount other medical expenses, such as neonatal costs, and thus be cost beneficial to society. Frank A. Chervenak, MD Depm"tment of Obstetrics and Gynecology, New York HospitalCornell Medical Center, 525 East 68th St., M036, New York, NY 10021
Laurence B. McCullough, PhD Baylor College of Medicine, 6550 Fannin St., Houston, TX 77030
Judith L. Chervenak, MD Lenox Hill Hospital, New York, NY 10021
REFERENCES 1. Romero R, et al. Prenatal diagnosis of congenital anomalies. Norwalk, Connecticut: Appleton & Lange, 1988. 2. Nyberg DA, et al. Diagnostic ultrasound of fetal anomalies: text and atlas. Chicago: Year Book, 1990.
Breast disease programs and mammography training To the Editors: We are concerned about a conclusion in an article in the August 1989 issue of the JOURNAL (Gleicher N. Breast disease programs in obstetrics and gynecology: A plea for training in mammography. AM J OBSTET GYNECOL 1989;161:267-70). Dr. Gleicher concluded that gynecologists, to become interested in breast disease as part of their care of women, should undertake the performance and interpretation of mammograms. We concur with the conclusion that gynecologists should become knowledgeable about the diagnosis and management of breast disease as a part of their residency and continuing medical education. In the programs of the American Cancer Society and the joint activities of the American College of Obstetricians and Gynecologists and the American College of Radiology, we have urged strongly that more attention be given to breast cancer, a disease that will strike one American woman in 10 during her lifetime. Indeed, all our statements about breast cancer have emphasized that proper breast care begins with regular visits to a physician for physical examinations, followed at the appropriate age by periodic mammograms. It was the failure of gynecologists and other primary care physicians to uniformly use available breast cancer detection procedures that led the American Cancer Society, the National Cancer Institute, and many medical societies to embrace the concept of mammography as a screening procedure. The "walk-in" concept of screening mammography is less desirable than the standard medical approach, but it will reach many women who lack access to periodic examinations and mammography on any other basis. The incorporation of mammograms into regular ex-
689
aminations of women is an end much to be desired. Making such examinations available in a timely and convenient manner has had the attention of many clinicians in several interested medical specialties. The correlation of history, physical findings, and the results of the mammogram are ideally made by the primary physician after consultation with colleagues. However, we must suggest strongly that Gleicher's assertions that gynecologists can "pick up the art of mammography" by short courses or informal training would detract from the achievement of our shared objective and from the overall quality of care now afforded in most American cities. Many of us who have been involved for three decades in the development and proliferation of modern mammography have overcome a series of problems. These include development of a standard technique to produce a valid image, constant attention to radiation safety, a concern with repeated examinations, and the acquisition of the visual acuity needed to detect and identify early radiologic signs of breast malignancy. After all these hurdles, it remains fair to observe that good mammography is most difficult to perform and interpret. For more than a decade instruction in mammography has been part of the residency programs for diagnostic radiologists. A similar emphasis is incorporated in the training programs for radiographers. Beyond the formal training, some radiologists have sub specialized in mammography, just as others have concentrated on other areas. A vigorous set of continuing medical education opportunities provide upgrading for radiologists and radiographers about mammography. These programs are predicated on the basic skills acquired by radiologists in roentgen interpretation, radiation safety, and imaging technique. For Gleicher to suggest that gynecologists can detract from their own excellent and demanding residency programs to acquire a level of skill in a single (but intensely demanding) imaging procedure reflects a failure to appreciate the difficulties therein. For a radiologist to assume that his interest and skill in mammography, plus a few lectures or weekend courses, would qualify him to practice gynecology would be equally indefensible. In recent years many of us in medicine have been part of a ground swell movement to make both clinical and screening mammography available to American women. Radiologists have been urged to provide screening programs in their hospital departments, offices, clinics, mobile services, and other sites. They have been urged, and even mandated by the pending Medicare screening coverage rules, to reduce the fee for screening to a figure well below prevailing rates for clinical mammography. They have been urged to work with gynecologists and other colleagues to establish a referral mechanism for women with positive findings on screening examinations. The American College of Obstetricians and Gynecologists has urged its members to become part of the breast care team with surgeons, pathologists, and other physicians.
690
Letters
We applaud Dr. Gleicher for his premise that gynecologists should learn more about breast disease and take a primary role in breast care. We renew our offer to work with The American College of Obstetricians and Gynecologists and with others to achieve that end , but we differ sharply with his conclusion that a gynecologist can and should become a proficient mammographer by brief and casual study. Gerald D. Dodd, MD , and Robert McLelland, MD American College of Radiology, 1891 Preston White Dr., Reston, VA
22091
Reply To the Editors: I am pleased to respond to the com-
munication by Drs. Dodd and McLelland in reference to m" article. At the same time, I am distressed about the obvious misrepresentation of my conclusions by these representatives of the American College of Radiology. I do not believe that my Clinical Opinion article ever suggested that gynecologists could or should "pick up the art of mammography by short courses of informal training." In fact, my own experience, also delineated in my article, was based on a rather extensive training process that involved didactic training as well as the attendance of courses which, in turn, were geared toward progressively increasing knowledge and reading capabilities. Most important, however, the entire program was based on a mandatory "double I'eading" process by two physicians. Since its inception this program always involved both a gynecologist and a radiologist within the framework of a multidisciplinary approach, which also included a surgeon. Although the efforts of the radiology community over three decades in popularizing and improving mammography are applauded , it must be acknowledged that radiologists have so far been unable to make mammography the Papanicolaou smear of the breast. At present only an inadequately low percentage of women have entered mammography screening programs in accordance with recommendations by the authoritative bodies as Drs. Dodd and McLelland acknowledge in their letter. To blame this fact on gynecologists and other primary care ph~sicians, as they do in their communication, is at best unfair and at worst uninformed . Gynecologists (and other primary care physicians as well) have succeeded in integrating other aspects of preventive care into their practices quite successfully. Papanicolaou smear screening is only one example. The same cannot be said for the mammography effort, mounted by the radiology community. In fact, it may be argued that this failure directly relates to who performs mammography. As stated in my article, patient convenience as well as cost considerations favor a "onestop" annual checkup for each woman. What makes more sense than to offer every woman over age 40 a mammogram at the same time as she receives her annual physical, pelvic examination, and Papanicolaou smear? The breast is a r eproductive organ, and gynecologists perform more breast examinations and di-
Augusl 1990 Am J Obstel Gynecol
agnose more cases of breast cancer than any other specialty. Laudably, Drs. Dodd and McLelland appear to fully support an integrated diagnostic approach toward women's health care. Why then do they oppose such an approach in the gynecologist'S office? How many radiologists perform breast examinations at time of mammography ? Gynecologists do. However, the emphasis should not lie with who performs mammography. There is nothing predetermined to suggest that only radiologists can perform high-quality mammogra phy. Similar arguments were heard from the radiology community when obstetricians and gynecologists started performing ultrasound scans. Today it is accepted by both communities that excellence can be found in both specialties. Although the amount of ultrasound training in obstetrics and gynecology residency programs still varies greatly, the same can be said about radiology training programs, especially in reference to obstetrics and gynecology ultrasound. I am sure that similar differences in extent and quality of training also exist in mammography training programs. Laszlo Tabar, arguably the most experienced mammographer in the world today, emphasizes this point repeatedly in his courses, which are largely attended by practicing radiologists but are open to interested gynecologists. In these superior exercises, Tabar also repeatedly makes the point that nobody is perfect in reading mammography films and strongly urges all mammography centers to double read every film . I am puzzled then about alleged quality concerns, expressed by Drs. Dodd and McLelland in reference to a program like ours that h as used a double-reading system since its inception , at a time when the majority of mammography programs administered by radiologists do not. Moreover, let us acknowledge a few additional facts. (1) Most mammograms in this country are not read by radiologists specializing in mammography. In fact, very few such specialists practice in this country (in contrast to Europe). (2) Mammography is among the least desired assignments in most radiology units. Only too often this responsibility falls on the most junior and least experienced individual and is passed on at the earliest opportunity. I and other members of our specialty applaud the willingness of the American College of Radiology to engage in a dialogue with our community. Our own departmental interest in mammography was spurred by the recognition that we as gynecologists cannot actively engage in the management of breast disease without knowledge of mammography. We therefore maintain our belief that gynecologists who manage breast problems require mammography knowledge. Obviously, this does not automatically suggest that every gynecologist with minimal mammography knowledge should read films. We require ultrasound training in our obstetrics and gynecology residency programs but not all graduating residents read their own scans. We would like to urge our radiology colleagues to accept that some