Rebuttal: “Marketing Muscle” by Liz Szabo


We live in very interesting times.  You cannot watch an evening of television or listen to a Saturday afternoon radio show without hearing about the latest pharmaceutical new to the market that you as a consumer should talk to your doctor about.  Dr. Google will come up with a list of  100s of diagnoses to explain a search for a source of a queried symptom.  Technology has expanded genetic mapping beyond the research arena, and is now widely marketed to document familial genetic origins as well as identify genetic risks.  It also identifies genetic mutations whose role and expression are not well understood.  The information unearthed by these genetic maps has unknown real meaning, many without actionable options.  

New tools, new tests, what do they mean for the average American?  What implications do they have with regards to health and maintaining quality physical and mental well being?  The physicians named in Ms. Szabo’s article work hard to provide insight and guidance for public and publicly funded research centers.  Their work is important in establishing the cost effectiveness of new treatments, drugs and tests to help the consumer navigate.  The quotes provided in this article however are speaking to broader issues and not specifically to  3D mammography.  Dr. Woloshin’s quote correctly identifies that “there is alot of money to be made” by the health care industry with his research indicating $30 billion dollars are annually spent in marketing (right, we all see and hear the commercials).  He is an internist whose research focuses on analysis of communication of health services to the public and by corporations.  Dr. Brawley is an oncologist whose critique of mammography is finding non aggressive breast cancers and their overtreatment.  There are many types of breast cancer, not all are killers therefore they should not all be treated the same, I agree wholeheartedly with his assessment.  Not all the cancers we find on mammography will require the same surgical approach, oncology treatment and radiation therapy.  Please colleagues, this is an appropriate recommendation.  His quote regarding use of “not proven” tests or services as unethical may be appropriately applied to many of the scenarios outlined in the first paragraph. 

The good news is that mammography works, it has been tested time and time again, and I find publications where both of these researchers agree that mammography saves lives.  It is the implications that this article makes with regards to the value of 3D mammography as well as its appearance in the paper on the heels of Breast Cancer Awareness month that sadden  me.  

First, let’s discuss what mammography is not.  Mammography is not perfect.  Even 3D does not find all cancers as the article indicates the patient was told.  

Mammography IS the exam proven to find most breast cancer at a smaller and earlier stage.  It IS credited to have reduced the number of women dying from this disease by 30%.  Each new technical iteration of mammography has continued to improve its efficacy.  It has progressed from its humble beginnings of xeromammography, to film screen to digital and now 3D.   The technology innovations along each step have  improved the sensitivity of this lifesaving exam.

The 3D technology uses tomography, an old radiology technique, in an innovative way to give more information about each mammogram view without increasing the amount of radiation needed to obtain the image.  In most women this means this technology allows a more accurate depiction of the breast tissue and decreases the number of women called back for additional study.  National multi institution studies of thousands of women comparing 2D and 3D by experienced mammography doctors found 3D to increase the number of cancers found per thousand women by up to 29% (1-2 per thousand increase is statistically significant when your typical population find rate is established at 3-4 per thousand) at the same time it decreases the number of patients needing additional views or work up by 15%.

As a radiologist who reads mammography I’ve always felt strongly that women should have access to the best possible technology.  I am fully invested in the power of full field digital and its latest development, 3D mammography.  I don’t believe that myself nor my colleagues have been duped into embracing an unproven exam by fancy advertising or special dinners.  I will say it again, mammography saves lives.  So, to keep women healthy, all should have a breast cancer risk assessment by age 30 by their physicians. In order to save the most lives a woman of average risk should begin having a mammogram EVERY a year once she turns 40.  If you feel you have any risk factors, are currently experiencing a new problem or just have general questions about your breast health, I encourage you to reach out to your physician or contact our breast clinic.  You may find additional information and resources here:

Thank you, Dr. Terrell, for bringing this article to my attention!  I will continue to profess and practice the latest proven technologies when peer reviewed studies confirm value to positively impact my community.  My team and I are committed to the Society of Breast Imaging’s mantra of “diminishing the impact of breast cancer to our community”.

Dr. Nanette Evans has been a practicing radiologist in the Cross Timbers area since 1998.  She is a mammographer at The Breast Clinic at SMSC, designated as a Breast Center of Excellence by the ACR as well as radiologist at Cross Timbers Imaging, an ACR Accredited outpatient imaging facility providing advanced imaging services for our community.

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