Sunday, January 29, 2006

Have We Radiologists Oversold Mammography?

Here is one beautiful article by Leonard Berlin, MD, FACR, is chairman, Department of Radiology, Rush North Shore Medical Center, Skokie, Ill, and professor of radiology, Rush Medical College, Chicago.

From cigarettes to pharmaceuticals to financial services, all advertisements feature a disclaimer: Why not those for mammography?
"The allegation of a delay in the diagnosis of breast cancer is the leading cause of medical malpractice litigation in the United States today, and has been for the past decade. Of all medical malpractice lawsuits lodged against radiologists, the most frequent cause is the allegation of a missed breast cancer on mammography. Why has "missed breast cancer" risen to first place in the medical malpractice standings? Author suggests that it is because we have oversold mammography. We have marketed mammography without informing the public all that we know about not only the benefits, but more important the limitations and potential harms of mammography. "
Read The Full Article Here-

2 comments:

Greedy Trial Lawyer said...

The lack of fine print is not the reason for the breaches of the standard of care in the diagnosis of breast cancer.

Your profession can add all the fine print and disclaimers it wants to its advertising. It will not do one thing to improve the quality of the medical care provided.

I suggest you may actually have an impact on patient care (and reduce malpractice claims) if you put some bold lettering on your view boxes to remind yourselves that speed in the examination of a study is no virtue.

diora said...

Greedy trial lawyer - you really haven't read the referenced article nor have you understood the point. And by the way - I am not a doctor. But I am the person who first posted the link to this article. I believe that if women like me knew all the facts, there'll be less law suits. My perspective changed from learning more about both benefits and risks of screening; also from learning how much of interpreting tests (both mammograms and needle biopsies) is a judgement call and how ambiguous this judgement call can be.

Let me spell it out for you - I am sure the doctors here will correct me if I get something wrong:
1. different tumors grow at different speed and early detection doesn't necessarily improve the outcome (so when some "expert witness" tells "if it had been found earlier ..." - they are lying, they have no way of knowing that, there is just no test or science to say for sure):
- some cancers will never progress in your lifetime but if diagnosed you'll be treated and suffer side effects of the treatment (doesn't seem like a benefit to me - but others may disagree)
- some are so aggressive that they can spread microscopically before they ever get detected by any means so by the time they are ever visible on mammogram - it is too late. So, if you happen to have one of these tumors you'll get extra years being sick (doesn't seem like a benefit to me, but maybe you are different)
- some tumors grow sufficiently slow that they are perfectly treatable even if detected later
- some grow just fast enough to threaten your life and if you happen to catch them in just the right moment before they spread your life may be saved
2. The researchers are still arguing about how big the last group is (and even if it exists). There have been 7 trials of mammograms; all with some flaws. 5 found a small (in absolute numbers) survival benefit, 2 - no benefit at all. There are some researchers that argue that these 2 had flaws (most of which were answered, btw), others argue that these 2 studies were the best. You can read PDQ Summary of Evidence on NIH website or USPSTF take on the evidence and see for yourself; you can also search on CNBSS to see both the criticisms of the study and the authors' reply (example: critics say that their radiologist was bad; but in fact their detection rate was no worse than that in other studies, etc). Personally I find authors' reply more convincing (I am not a doctor but I have math background and this stuff is mostly math); I also find it interesting that these two are the only studies that allowed independent audit of their data. One of these 2 studies is the only study that specifically looked at women in their 40s.

Whatever; if you are an optimist you'll get maybe 1 in 1700 women in their 40s whose life will be saved by mammograms and 1 in 1200 women in their 50s. If you are a pessimist -you'll get 0.

3. Interpreting mammograms is not an exact science. It is not about finding black on white - it is more about lighter grey on darker grey - a judgement call. For women with dense breasts it is more like white on white. Just because if this year you know that there is cancer and can find traces of it on the previous mammogram (knowing where it supposed to be), doesn't mean it should've (or could've) been found last year. You can always find stuff if you know where to look - doesn't mean you can find it if you don't know where to look.

4. The US has higher false positives rate than any other country, but the same detection rate. People like you is the cause. Sure, if all radiologists send 100% of women for biopsies there'll be less lawsuits. Is that what you want?

Again I am not a doctor. I am just a 40-something woman who believes she has a right to have complete information before making a decision that is right for her. In fact, after I read the referenced article my first reaction was anger - because the doctors fail to disclose the information and because I believe I have a right to know the truth and to make my own decisions about my body.

I do believe that if we heard less "propaganda" and more facts in the media there'll be less lawsuits. But it is just me.

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