STATEMENT

Of

D. David Dershaw, M. D.

On Behalf of the Society for Breast Imaging

To the

Senate Committee on Health, Education, Labor and Pensions

RE: Mammography Quality Standards Act Reauthorization

April 8, 2003

Good Morning . My name is David Dershaw. I am Professor of Radiology at
Cornell University Medical College and the director of breast imaging at
Memorial Sloan-Kettering Cancer Center in New York City. I am also the
incoming president of the Society of Breast Imaging, the subspecialty
professional organization of radiologists who do mammography, and I am
testifying on the Society's behalf.

Thank you, Mr. Chairman, for inviting me to testify regarding the
reauthorization of the Mammography Quality Standards Act of 1992. It is
my belief that MQSA has played a significant role in improving the
quality of mammography. This program needs to be reauthorized so that
women can continue to benefit from high quality mammography.

Since enactment of the Mammography Quality Assurance Standards Act
(MQSA) in 1992, women in the U.S. have gained confidence in the
providers of their mammograms through the knowledge that mammography
facilities were being certified in accordance with federal standards. A
continuing decline in breast cancer death rates (almost 1/3 reduction
for invasive cancers in the 1990\'s) and increasing utilization of
mammography screening services (increased from 27% of eligible women in
the two years before 1987 to 66% in the two years before 1997) are
testaments to the success of the collaboration of radiologists,
mammography facility operators, and government regulators. This
consortium was carefully designed into the law. The improved quality of
mammography services has undoubtedly saved many lives and diminished the
anxiety of women in the United States about the quality of their
screening studies. The continued force of MQSA in maintaining this high
level of service is essential. On behalf of the Society of Breast
Imaging I again urge the reenactment of this legislation.

MAMMOGRAPHY INTERPRETIVE SKILLS ASSESMENT

Currently, MQSA requires that physicians interpreting mammograms
participate in 15 hours of Continuing Medical Education (CME) every
three years. CME is offered in a variety of ways such as attending
meetings and lectures. Although valuable in their content, these
meetings are rarely designed for radiologists to assess their skills.

The American College of Radiology has designed and tested over the past
decade the Mammography Interpretive Skills Assessment (MISA) test.

In 1999, this was made available as an interactive computer-based
CD-ROM. This offers radiologists an opportunity to participate in a
mammography self-assessment examination.

The purpose of the MISA is to provide the radiologist with an assessment
of his or her skills and to identify areas in which additional study or
skills improvement is warranted. This is not a pass/fail test or one
that is intended to certify or judge participants. The emphasis is on
self-help.

By providing the physician with seven or eight hours of CME, depending
on which CD the physician uses, physicians would be encouraged to use
the MISA for both continuing education and self-assessment. This might
be useful as a method of determining skills in addition to the data are
presently derived from the end results assessment required under MQSA
regulation.

While self-assessment testing may be of value, it should also be
recognized that there are no data to indicate that such tests provide
feedback that accurately determines competence. There is also no science
to indicate that such tests result in improvement in the quality of
medical care.

I am certain that the Committee recognizes that in order to achieve the
benefits obtained under MQSA those involved in mammography practice have
added time, effort and expense to the delivery of screening and
diagnostic mammography services because of the need to comply with
MQSA=s regulations. Although the mammography community is appreciative
of the higher standard set for its care than that generally required in
radiology or other areas of medical care, these have also imposed a
burden that has discourage some from offering these services. The
possible advantage of mandated self-evaluation, an additional regulation
that would need to be fulfilled and documented by mammography
facilities, should be weighed against the detrimental impact of
increased regulation of mammography facilities and radiologists
interpreting mammograms. Steps that might further discourage
radiologists to incorporate mammography into their careers may
accelerate the developing crisis in availability of mammography services

Radiologists interpreting mammograms are already in short supply due to
poor reimbursement rates and high litigation. It is my belief that
providing plaintiff lawyers with another potential avenue for litigation
will lead many more radiologists to turn away from mammography, thus
exacerbating the already critical access problem many women face in
receiving timely mammography services. If results of self-assessment
activities were to be subjected to discoverability in litigation cases
against physicians, the Society of Breast Imaging would strongly oppose
the incorporation of such testing into MQSA regulation.

The Committee should also recognize that the greatest threat to the
delivery of quality mammography services in the United States is the
impending shortage of radiologists, technologists and imaging facilities
to provide this service. Inadequate reimbursement persists with payments
for service often less than the cost of performing and interpreting
mammography. The most tenuous financial reimbursement is for
hospital-based services. As this is the site where most women on
Medicare and Medicaid receive their health care, the availability of
mammography to these women is the most threatened by inadequate
reimbursement.

Hospitals are also the sites where most of the training of physicians
and technologists occurs. Poor reimbursement, particularly when compared
to reimbursement levels for other radiology services, has left those
deciding what area of radiology to specialize in with an impression of
mammography as a big money loser. Along with high malpractice exposure
and considerable time and effort required to meet federal (and often
local) regulation, this negative impression works to discourage those in
training from selecting mammography as an area of specialization.

As the Committee considers reenactment of MQSA, I would like to make a
few comments about modifications that might be recommended in current
regulations.

As authorized under the original legislation and recommended by the
National Mammography Assurance Advisory Committee, regulation of
mammography services should be expanded to include stereotactic breast
biopsy and equipment used in needle localization procedures.

Furthermore, the current requirement for CME in digital mammography
beyond the initial training required before using digital mammography on
patients does not improve the quality of practice or contribute need
training to improve patient safety. This requirement is often difficult
to meet and the Committee should recommend that it be discontinued.

Thank you for the opportunity to testify. I would be happy to answer any
questions.