The initial results of the much-anticipated Digital Mammographic Imaging Screening Trial (DMIST) released online in The New England Journal of Medicine are in, and the evidence confirms that the digital technology is as reliable as film for detecting breast cancer. In and of itself, this could be good news for many people.

First, consider the practical aspects. For all radiology departments intent on eliminating the scourge of film, everyone on the sidelines waiting for the data just got the green light to proceed. Second, there are the rewards for those vendors that have invested in developing the technology and shepherding it through the arduous process of Food and Drug Administration approval. DMIST just eliminated one of the major sales objections: "We're waiting for the data." Then there are the patient logistics. There are few studies for which a prior is more important, and digital mammography will encourage patients to keep their mammographic priors at hand on a CD. The DMIST results could even promote access by encouraging the establishment of telemammography services at a time when providers who offer mammography are disappearing.

But the even bigger news is that digital mammography in fact proved significantly better than film for detecting cancer in women younger than 50 years old; women classified as having heterogenously dense or extremely dense breasts; and premenopausal or perimenopausal women. Many of the cancers detected in the trial by digital mammography and missed by film in that category of women were invasive and high-grade in situ cancers, according to Pisano et al. The investigators in fact recommended the use of digital technology in these subsets of women. And since most gynecologists recommend that women begin mammography at 40, or 35 for those with a family history of breast cancer, a significant number of women are impacted.

But the obstacles to adoption are formidable. In acknowledging the cost differential, the researchers noted that a cost-effectiveness analysis is under way (see STAT Read). The results are not likely to help in the short term. Compounding the cost differential of the technology is the associated—and not insignificant—cost of building a network in a hospital that is robust enough to handle a busy digital mammography service. Add to that the fact that when Congress provided for increased reimbursement for digital mammography, it was the technical, not the professional fee, that was boosted. This could present adoption problems because the extra time it takes to read a digital mammogram is unreimbursed. If the DMIST cost-effectiveness analysis shows the potential for savings to the health care system, perhaps CMS can be convinced to take another look at how mammography is reimbursed and to consider the associated professional and technical costs of implementing the technology.

Because every major newspaper in the country trumpeted the benefits of the digital modality for younger women, it could be argued that there are tangible marketing benefits to equipping a hospital or imaging center with digital mammography technology if the capital can be accessed. At any rate, providers should be ready to answer the question, "Do you offer digital mammography?"

Cheryl Proval