In this issue, Dr. Brenner describes asymmetric densities found on mammography. As all breast imagers know, asymmetry on mammography is a common finding and often precipitates nothing more than its causal observation. The high incidence of asymmetries and the relatively small proportion that are malignant may prompt the radiologist to be conservative, and not recommend biopsy and risk the outcome.
"I will use my power to help the sick to the best of my ability
andjudgment; I will abstain from harming or wronging any man by
it."
-Oath of Hippocrates
In this issue, Dr. Brenner describes asymmetric densities found
onmammography. As all breast imagers know, asymmetry on mammography
is a commonfinding and often precipitates nothing more than its
causal observation. Thehigh incidence of asymmetries and the
relatively small proportion that aremalignant may prompt the
radiologist to be conservative, and not recommendbiopsy and risk
the outcome.
Similarly, because they can be less frequent presentations of
cancer, othersubtle signs of malignancy must not be overlooked. All
too often in the work-upof an abnormality seen on mammography, I
hear a resident say, "I'llget a spot view to see if I can make the
density go away." With thisphilosophy, the breast imager does a
great disservice to the patient. Our roleis to diagnose breast
cancer at an early, curable stage. We try to work uplesions and
analyze them appropriately so that our positive biopsy rate is
nottoo low, but yet we do not miss small cancers. Achieving this
balance requiresexpertise, reliance on sound principles of
mammographic analysis, carefulscrutiny of the images for quality
and for abnormalities, and sometimes luck inmaking the right
judgment when the decision is difficult.
Recently, I saw a young woman who presented with an asymmetric
density anddistortion found on mammography three years earlier and
which had beendetermined by the interpreting radiologist as less
prominent with spot views.The patient was followed for three years,
with the distortion becoming larger,yet it was called unchanged.
Ultimately, she presented with advanced clinicaldisease. My
resident's comment at the time was "I think I need tochange my
approach to mammography. It shouldn't be to try to give out
goodnews, it is to recommend a biopsy if I have any doubt that a
lesion isbenign." In this patient's case, mammography did not
achieve what itis intended to do, nor what it should have done.
The statistics that we are proud to quote of a 35% mortality
reduction withscreening mammography require us to be extremely
attentive to detail and toavoid that well intentioned wish of not
giving the patient any bad news. Bybeing forthright and
recommending biopsy when appropriate, we positively impactthe
health, and subsequently the lives, of many women for the
better.
Dr. Shaw de Paredes is the Director of Breast Imaging at the
Medical Collegeof Virginia in Richmond; she is also a member of the
editorial advisory boardof this journal.