"The radiologist has to look at the film, look at the CAD, reconsider the film in light of looking at the CAD. This fee is supposed to be compensating them for that effort," Fenton observed.

Perhaps more importantly, some radiologists are skeptical that a business concern would significantly influence the decision to use CAD.


"I just can't picture in my practice or any practice I've been associated with, I can't imagine making a decision to incorporate a technology solely for the purpose of making extra money," Dr. Carol Lee, a radiologist at Memorial Sloan-Kettering Cancer Center in New York and chair of the American College of Radiology's Breast Imaging Commission, told DOTmed News.

"Just speaking on a personal level, CAD helps -- it's sort of like a spell-check. It gives you another look at the mammogram, and hopefully prevents you from making errors. And so I think many radiologists who use CAD view it that way," she said. (Lee currently does not use CAD in her practice.)

Hologic, a medical device company that pioneered the development of CAD for mammography and says it has the largest installed base of digital mammography systems in the world, isn't surprised by the findings, but believes CAD is supported by overwhelming clinical evidence.

"I don't find it surprising that reimbursement drives behavior. Isn't this almost always the case in medical capital equipment?" said Dr. Jim Culley, director of marketing for the Bedford, Mass.-based company.

But Culley said there are more than 40 peer-reviewed studies showing the effectiveness of CAD, which is ordered in more than 90 percent of the diagnostic workstations sold by the company.

And radiologists consulted by DOTmed suggest the bulk of the evidence points to CAD's benefits with cancer detection.

"The bottom-line is using CAD will pick up some cancers that are otherwise not picked up. There's no question about that," Lee said.

A 2004 study in the American Journal of Roentgenology found the technology resulted in a 164 percent increase in finding tiny invasive cancers, and that on average radiologists found cancers through screenings about five years earlier than with a group examined before CAD was used. And a 2006 study published in Radiology found the technology improved the cancer detection rate by around 15 percent when compared with double readings (that is, having two radiologists examine the same slide).

Possibly most significantly, a meta-analysis published in 2009 in the journal Archives of Gynecology and Obstetrics suggested that for every 100,000 women screened with CAD, 50 extra breast cancer diagnoses would be made. However, this would also lead to 1,190 more false positives, with an additional 80 healthy women biopsied.

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