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Ontario should be lauded for junking obsolete mammography equipment

Ontario is junking one-quarter of its mammography screening equipment at a cost of $25-million.

Despite the price and the seeming waste, this is great news.

It is a victory for evidence-based health care. It also sends an important message that quality matters in a country that too often values volume over quality.

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Let's just hope that the philosophy is not limited strictly to the politically sensitive area of breast cancer, and that this thinking will be applied broadly.

Ontario, like most jurisdictions, uses three forms of technology to screen for breast cancer: computed radiography (CR), screen-film mammography (X-rays) and direct radiography (DR).

A study published on Tuesday in the medical journal Radiology showed that X-rays and DR identified cancers at about the same rate – 4.8 and 4.9 per 1,000 respectively. The detection rate for CR was 3.4 per 1,000.

This suggests strongly that CR is 20 per cent less effective at detecting breast cancer tumours.

In real, practical terms, that means one cancer will be missed in every 1,000 women screened using computed radiography. That is not an acceptable variance, even though it is unlikely to cause any real harm.

Ontario Health Minister Deb Matthews acted swiftly, saying the province's 76 CR machines will be scrapped. That leaves 188 DR devices and 52 film-based x-ray machines, and those numbers will have to be bolstered.

This is how public policy should work: You discover a shortcoming in care, you reveal the problem, and you fix it.

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It is questionable whether this kind of decision should have to be made by the Minister of Health. In a $48-billion-a-year provincial health system, the bureaucracy should be able to make $25-million decisions.

One can also question whether the decision was made quickly enough. The data showing poor results with CR have been available since November, but no action was announced until the research was published in a medical journal. The Ontario Association of Radiologists cast doubt on the quality of CR technology as far back as 2010.

Now that the right decision has been made – scrap the inferior equipment – the danger is escalation of demands and costs. The OAR already wants $74-million in new equipment, not $25-million, and is arguing that all screening be done with a technology called full-field digital mammography. It is far more expensive and produces only marginally better results.

That's always the challenge in health care: Balancing effectiveness and cost. Investing in quality treatment but not erring on the side of overtreatment. Mammography is just a tiny piece of that puzzle.

We clamour constantly for the latest treatments, we demand state-of-the-art technology, we want promising drugs while they are still in the experimental stage, we yearn for the most modern infrastructure, and we scour the Internet for the latest tidbits of health information, hoping to remain ahead of the curve.

But new drugs and technologies are often oversold: Their benefits are exaggerated and their risks played down. The costs are invariably far greater than what they are replacing.

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In far too many cases, old drugs and technologies are not replaced but supplemented with new medications and devices, and that drives up costs unnecessarily.

In short, we do not deal with obsolescence very well. And we do very poorly at implementing new research findings.

If there is a take-home message from the findings on computed radiography, it is that assessing existing drugs and technologies as rigorously as new ones is beneficial. We also need to focus our attention on variations in care delivery and make it a priority to close gaps.

Ensuring quality health care and maximizing patient safety requires not only learning new techniques and adopting new methods, it requires unlearning and abandoning the so-called tried-and true interventions.

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About the Author
Public health reporter

André Picard is a health reporter and columnist at The Globe and Mail, where he has been a staff writer since 1987. He is also the author of three bestselling books.André has received much acclaim for his writing. More


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