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marcia.javitt{at}na.amedd.army.mil
Publication of the January 2006 issue of the American Journal of Roentgenology marks the inauguration of the new Women's Imaging section dedicated to the diagnosis and treatment of conditions and diseases uniquely affecting women. This new section in AJR covers a broad spectrum of topics, including clinical imaging, screening and wellness, technology assessment, comprehensive and cost-effective health care, risk modeling, training, continuing medical education, health care policy, staffing shortages, and reimbursement. The content encompasses all technologies related to women's imaging (breast imaging and mammography, obstetric and gynecologic imaging and sonography, sonohysterography, hysterosalpingography, CT, MRI, imaging-guided minimally invasive therapy, angioembolization, and bone density evaluation, to name just a few).
What are the incentives for this initiative, and what is the potential impact of women's imaging in health care today? Although it is difficult to take the full measure of this question, there are some parameters that we can consider. Here are a few examples that demonstrate the mandate for this subspecialty:
First, according to the American Cancer Society estimates for 2005 [1], there will have been 662,870 new cases of cancer in women in the United States, of which 32 % will have been breast cancer and 12 %, gynecologic malignancies. There will have been about 275,000 cancer deaths in women in 2005, 15% of those from breast cancer and 11% from gynecologic cancers. Although lung cancer represents 12% of new cancers expected in 2005, it will have been the leading cause of cancer deaths in the United States (27%). About one in five women smoke in the United States today even though cigarette smoking is the most important source of preventable mortality and morbidity worldwide and is the cause of an estimated 178,311 female deaths annually [2]. The National Institutes of Health estimated the overall costs for cancer in 2004 for both men and women to be about $190 billion, which includes about $104 billion for indirect costs related to lost productivity from premature deaths as well as direct medical costs [1].
Second, according to the Centers for Disease Control and Prevention [3], more than half of people who die each year from heart disease are women. Heart disease is the leading cause of death in both men and women in the United States. In 2003, 23.5 million noninstitutionalized adults were diagnosed with heart disease. Although men suffer more heart attacks and strokes than women, the death rate for women is higher than for men. Women may have more subtle symptoms than men, such as back pain, a burning sensation in the thorax, or fatigue. They are less likely to seek medical attention and often present late in the course of the disease. Women are less likely than men to undergo testing such as coronary angiography, resulting in a delay in definitive treatment [4].
Third, diabetes affects more women than men in the United States, according to the Centers for Disease Control and Prevention [3]. Of the 16 million people in the United States who have diabetes, more than half are women, making it a leading cause of death today. Diabetes can affect not only women of childbearing age but also their unborn children. Women have a higher risk of heart disease, the most common complication of diabetes, than men—that is, of patients with diabetes who have had a heart attack, the survival rate for women is lower than that for men [5]. Compared with men, women with diabetes are at greater risk of developing blindness. Women with diabetes have a shorter life expectancy than women without it [5]. Socioeconomic barriers exist that prevent access to health care for women with diabetes [5].
Fourth, women are at five times greater risk than men for the development of osteoporosis. Of the 10 million people in the United States with osteoporosis and 34 million more with decreased bone mass, 80% are women. According to the U.S. Surgeon General, Richard H. Carmona, by 2020, half of Americans older than 50 years will be at risk for osteoporosis if no immediate action is taken [6]. About 1.5 million people suffer osteoporosis-related bone fractures each year. Within 1 year of suffering a hip fracture, one in five senior Americans die and an equal number enter a nursing home [7]. The direct costs of health care for osteoporotic fractures have been estimated at $18 billion dollars per year [6, 8].
Fifth, more than 60% of American adults and 15% of children and young adults up to the age of 19 years are overweight [9]. Obesity is the cause of more than 400,000 premature deaths per year and results in increased risk for heart disease, stroke, hypertension, and diabetes. Almost one third of adult Americans are obese (body mass index 25), including about 35 million women and 27 million men [10]. The prevalence of obesity has been increasing and has been linked to an increased risk of diabetes, hypertension, hypercholesterolemia, and an increased mortality rate. Obesity may be linked to higher death rates from cancer [10]. The total cost of overweight and obesity in 1995 updated to 2001 dollars has been estimated to be $117 billion, with direct costs of $61 billion and indirect costs of $56 billion [10].
What are the implications of this analysis? These and similar compelling observations represent a mandate for the development of women's imaging as a discrete subspecialty, distinguishing women's health care from non-gender-based health care in the population. Moreover, these statistics underlie the staggering costs associated with illnesses in women today. There is not only a huge financial incentive for us to intervene as health care providers, but also a moral, ethical, and professional imperative to do so.
The profound diversity, expertise, and finesse required to engage in the comprehensive practice of women's imaging has created a new breed of radiologist, one whose role goes well beyond mere film interpretation. Familiarity with oncology, internal medicine, surgery and its subspecialties, gynecology, infertility, pregnancy, cardiopulmonary diseases, and osteoporosis is required.
Our mission is ambitious and by its very nature will have us reach out to all providers who are part of the health care team taking care of women, not just to radiologists. Although women's imaging as a subspecialty is still in its infancy, the inception of this section in the AJR is vitally important and is a landmark in the growth and development of this field.
The interactions of women's imagers with the referring providers, and especially with the patients, have a much greater significance than merely creating accurate radiology reports. Clearly, a commitment to the best outcome and quality of life for the patients is paramount. We invite our authors and readers to support and participate in this work. Together we are engaged in the art and successful practice of women's imaging. This is the key to realization of the true power and potential of this vitally important field.
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