"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.