The moral dilemma of digital mammography

By Greg Freiherr, Editor, gfreiherr@cmp.com

We tend to look at technology as a problem solver. And in many instances it is. Faster, cheaper, better solutions are natural outcomes of many technological advances. They are, in fact, the major drivers of innovation. Ethical or moral imperatives seldom are. Technology may contribute to them as well, as in the case of better healthcare through more sophisticated equipment. But occasionally advancing technology has the opposite effect. It creates a moral dilemma. This is happening now in digital mammography.

In a market segment where even the most advanced film-based system typically costs less than $100,000, full-field digital mammography is an anomaly. Early adopters have to pony up four times as much to buy a digital system as an analog one. And they are doing so.

The ability to analyze digital data with specialized algorithms that optimize the image and then run the data set through a computer-aided detection system to ensure no signs of pathology are missed provides an enormous advantage in the screening and diagnostic process. But at facilities accustomed to low capital expenditures for mammography that are struggling with unreasonably low reimbursement, administrators with several mammography rooms will be hard pressed to come up with the money to swap out entire analog operations in favor of digital systems. They will likely decide to bootstrap their way to digital imaging.

That raises the issue of who gets what kind of mammogram. If one of three mammography machines is replaced by a digital system, who will decide which patients are sent for film-based exams? And on what basis?

One solution is the adoption of CR mammography, if and when it becomes available, at least as an interim step to providing digital mammograms for all patients visiting a facility. There are practical concerns in such a strategy-regarding the interpretation of images, for example. CR mammograms will look a lot different from ones obtained using digital systems. The difference in resolution, 50 microns versus 100-plus, will show more. Diagnosticians will have to keep that in mind, especially when comparing images obtained using CR and flat panels. But this is manageable. What is not acceptable is a two-tier women's healthcare system at the same facility.

And if the weight of this moral argument is not enough, administrators might want to consider the legal liability that may exist if cancer is missed in a patient assigned to a film-based system rather than the newly installed digital one. -Greg Freiherr