Politicians and dense breasts: Here are 2 questions to ask

Recently, Ohio became the 20th state to pass a law mandating that hospitals and clinics performing mammography screening to notify a patient in writing if results suggest something known as “dense breast tissue.”   Standard mammography creates a 2-D image of breast tissue.  In general, this is sufficient for screening purposes.  However, especially in younger patients, the presence of dense breast parenchyma can lead to higher false negative readings and more indeterminate results that may lead to higher rates of invasive biopsies.

A newer imaging technology, called digital tomosynthesis, creates highly focused 3-D images of breast tissue.  Initial research seems to suggest that this can improve both early detection rates of smaller cancers and eliminate the need for unnecessary biopsy procedures on clinically insignificant findings.  The law passed in December is supposed to prompt patients to ask their respective health care providers about the need for follow-up digital tomosynthesis.

Several questions are begging to be asked:

1. Why don’t we just screen everyone with 3-D digital mammography?  Well, it’s an issue of cost, of course.  For most women, standard 2-D mammography is sufficient.  The 3-D machines cost twice as much, and some insurance companies will give patients a hard time about coverage.  Most tertiary care centers and dedicated breast cancer facilities have the technology, but universal availability is a problem.  Rural and critical access hospitals simply cannot afford to invest in an expensive new technology that may only be intermittently indicated.  In the long haul, as costs inevitable plateau and decrease, it is certain that 3-D digital mammography represents the future.  But for now, we run the risk of creating tiered levels of care, depending on where one lives.

2. Why is this being handled by the state legislative bodies?  Wouldn’t it make more sense for medical decision-making protocols to come from, like, oh, I don’t know, trained health care professionals rather than laymen elected officials?  Wouldn’t a consensus statement from the American Society of Breast Surgeons, or a similar entity, make more sense?  Do we not have enough laws on the books?  What would be the consequences of violations of such a law?   Criminal prosecution, in addition to any tort liability?  Doctors and hospital administrators cuffed and read their Miranda rights in the physician lounge?  Will this set the precedent for future legislation guiding physician/patient communication paradigms?

When I take out a patient’s colon cancer, the expected standard of care surveillance recommendation would be for that patient to get another colonoscopy one year after surgery.  What if I don’t document that recommendation exactly as per state guidelines?  What if the patient is either non-compliant or never received the written notification because of a change in address?   Am I criminally liable?

It all just strikes me as unnecessary and absurd.  It ought to be enough to expect doctors and health care providers to be professionally responsible and to fulfill basic standard of care requirements.  Deviations from these standards put one at risk of malpractice litigation.  There’s enough negative reinforcement in that threat alone.

Jeffrey Parks is a general surgeon who blogs at his self-titled site, Jeffrey Parks, MD.

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