Q&A: Mary Mahoney on Breast Density Reporting Laws and the Technologies of Tomorrow

Mary Mahoney, MD, Ben Felson Endowed Chair of Radiology and professor of radiology at the University of Cincinnati, has dedicated her life to breast imaging. Mahoney spoke with imagingBiz about what life is like as a department chair and shared her thoughts on several hot topics affecting breast imaging today.

In February, you were officially appointed the chair of UC’s department of radiology after serving as interim chair for a year and a half. How has that changed a typical day for you?

Mary Mahoney, MD: Being chair has definitely impacted the amount of clinical work that I can do, and I absolutely cherish my clinical days now because they are so much less frequent. So I do miss it, but I am enjoying the challenge of being a department chair. I think I’ve grown an enormous amount in the last year and a half I’ve been interim chair and then chair. I’ve learned so much and I feel like I’m a sponge soaking up so many things.

But I do cherish that clinical time. I still work one to two days a week clinically and it’s my opportunity to be in the reading room with our trainees, talk to my patients, and utilize that skillset. I work with my assistant very purposefully and carefully to preserve that clinical time.

Do you have any thoughts about the large number of states that now have breast density reporting laws? What are your thoughts on this development?

I think the premise of making women know about their breast density, and then having conversations with them about what this means and what might make sense in their particular situation, is all good, but with the following caveats:

It’s mandated that we tell them about it, but I don’t think it’s uniformly being handled well in terms of how those conversations are working and who is talking with the patients. And how informed are the providers having those conversations? Even in our breast center, we have a sophisticated group of clinicians saying, ‘Please, talk to us about this. What are the recommendations?’ So if you’ve got specialized clinicians in a big academic center and they are struggling with it, how are other providers dealing with this? The intent is good, but are the conversations happening in the community as informed as they should be?

And lastly, once we do have these conversations with women about what supplemental imaging they may want to consider—it may not be covered by their insurance. So what do you do with a woman who can’t afford to get whatever she chooses to do, whether it’s ultrasound, MR, or something else? I do have a bit of an issue with that.

There was some controversy when the U.S. Preventive Services Task Force (USPSTF) recommended women ages 50 to 74 get biennial mammograms and gave biennial mammograms for women ages 40 to 49 a “C” rating. What were your thoughts on those recommendations?

Oh, we could talk about this one for hours. The USPSTF does not have the leading breast experts or clinicians who are knowledgeable in this area. I don’t think their processes are as robust as they need to be in terms of their methodology. That has created issues with credibility in the breast community. Their recommendations are an outlier compared to other well respected medical organizations.

As far as our institution goes, our recommendations have not changed. As an institution, we will continue to recommend annual exams beginning at age 40.

What are some of the biggest challenges facing the breast imaging industry today? How can providers equip themselves to overcome these challenges?

It goes back to what we were just talking about. We’ve got the task force saying there are all these problems with overdiagnosis and there are all these harms with screening, and then at the same time, we’re saying mammography isn’t enough and we need to do more. So which is it? Is it too much or do we need to do more? There’s a contradiction there.

I think our challenge continues to be that we continue to be challenged. The idea that clinicians don’t know what to advise patients and patients don’t know who to listen to—you can’t underestimate the damage that does. The challenge is for us to get through this and establish, once and for all, that mammography is a very robust examination that has made a major impact in terms of mortality, and it’s been proven over and over.

Also, I’m working with our local insurance companies to get tomosynthesis to be a covered imaging tool. They keep calling it ‘experimental’ and ‘investigational,’ but it is absolutely not experimental or investigational. Insurance companies need to step up and recognize that, and I think it’s in their best interest. If we’re calling back fewer patients, that’s better for them. If we’re picking up cancer at an earlier stage, that’s got to be better for them.

And what do providers need to do? I think we just need to stay the course, keep our eye on the ball, and keep taking care of our patients.

What are some of the some of the most important trends and technologies emerging in breast imaging?

There’s a lot of different things happening. I’m a big advocate of tomosynthesis. As a health system, we offer tomosynthesis at all of our sites. I think that’s really good, and as you go back to issues of breast density and the masking effect, that’s really the strength of tomosynthesis. That’s a great imaging technique and it’s been a huge step forward in terms of expanding on the digital platform.

There are other things out there. There’s a whole lot of work being done in breast MR, looking at abbreviated protocols so we can do it much quicker. We’re trying to come up with techniques that could be useful without using contrast—there have been issues lately with gadolinium, so can we develop techniques that don’t use contrast? That would make it much more accessible to the general public, which is a step forward.

And the last one I would mention is molecular imaging. There has been continuing research going on in terms of trying to use smaller doses of the radioactive materials to try and bring radiation doses down. They’re trying to keep the sensitivity and the detection, but in smaller and smaller doses so there isn’t as much of an impact from radiation. That’s certainly a technology we want to keep an eye on.

What can practices do to make sure they stay at the forefront of these trends?

If you are in an academic environment, you are pretty much going to know what’s going on, but if you’re not, just keep up with the literature, attend the meetings, and keep up with what is happening. I do think we are doing a much better job as a specialty in terms of not jumping on technologies the second they come out. There’s more of an emphasis on outcomes research and demonstrating the effectiveness of new imaging techniques.

This text was edited for clarity and space.