Respect the Past, Embrace the Future

The ACR Commission on Breast Imaging will continue to prioritize
cost-effective, efficient care for every woman.


I recently read Under Our Skin by NFL veteran tight end Benjamin Watson. U.S. District Judge Madeline H. Haikala (my former high school classmate) required all parties in a school desegregation case to read Watson’s autobiographical reflection on race in our country. Although there is much to ponder in Under Our Skin, I was particularly impressed by Watson’s sincere efforts to seek understanding by seeing the world through the eyes of those whose opinions differ from his own. As I outline my vision for the ACR Commission on Breast Imaging, I am not only shamelessly appropriating Watson’s format, but also trying to adopt at least some of his philosophy.
 I’m honored. Many have described themselves as standing on the shoulders of giants. It certainly feels that way as the chair of the Commission on Breast Imaging. My predecessors, including immediate past chair Debra L. Monticciolo, MD, FACR, literally wrote the book and helped develop the Mammography Quality Standards Act, the ACR BI-RADS® lexicon, ACR accreditation, and the body of evidence that proved the value of screening mammography to decrease breast cancer mortality. Breast imaging is a model of ACR’s Imaging 3.0® initiative and has led the way in value-based care for radiology. The revaluation of mammography CPT® codes provides a powerful example of how payment policy can reflect the benefit radiologists add by directly communicating with patients. I am humbled to follow in the footsteps of these incredible leaders.
I’m frustrated. Despite our many achievements, breast imaging regularly finds itself in the crosshairs. Naysayers suggest radiologists will be replaced by AI and that big data will make our knowledge and skills obsolete. Despite the evidence that annual screening mammography beginning at age 40 saves the most lives, some outside our specialty focus on the short-term anxiety of being recalled after screening and are relentless in their efforts to de-emphasize and disprove the lifesaving benefit of mammography.
I’m motivated. Shortly after I was appointed chair of the Commission on Breast Imaging, an ACR member challenged a rating in the ACR Appropriateness Criteria® for stage I breast cancer and was understandably concerned about the potential ramifications of that rating on reimbursement. Many breast imagers need only look to their own practices to see examples of the consequences of payment policy. On a daily basis, our patients decide whether to delay and even forgo breast imaging procedures because they cannot afford the deductibles and co-payments for services that are not fully reimbursed by payers. The Commission on Breast Imaging must help our members and patients navigate the rocky economic terrain of the current U.S. healthcare system.
I’m enlightened. In August, I traveled to San Francisco with several Ochsner Health System colleagues to meet with venture capitalists, technology companies, and healthcare startups for a “Silicon Valley immersion.” Although these entrepreneurs were respectful of our medical expertise and eager for our opinions, they were also candid in their assessment that our healthcare system is encumbered with barriers and not responsive to the needs of patients and providers. As a result, our obstacles have become their business opportunities to relieve'friction and eliminate pain points for patients, who they view as consumers.
I’m concerned. The United States has the highest total cost and per capita expense for healthcare in the world, but this has not resulted in universally best-in-class health outcomes. Although the most lives are saved by beginning annual screening mammography at age 40, the majority of women will never be diagnosed with breast cancer. Current evidence does not give us the insights we need to determine who will (and who will not) benefit from early detection of breast cancer. Big data and AI may be the keys that allow us to tailor screening strategies to each woman and customize treatment for maximum benefit. While we focus on the one woman in eight who will be diagnosed with breast cancer in her lifetime, we must not forget the other seven.
I’m optimistic. So, what is my vision for the Commission on Breast Imaging? We should respect the past, but also embrace the future. We must build on the rigorous methodology and evidence our predecessors have given us and, using the power of technology, move forward to provide the most cost-effective, least harmful, and most efficacious breast care for every woman and those who care about her.
By Dana H. Smetherman, MD, MPH, MBA, FACR, Chair of the ACR Commission on Breast Imaging

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