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    Saturday, May 2, 2009

    MAMMOGRAPHY – FULL DISCLOSURE: PART I OF II

    Leonard Berlin, MD, FACR, is chairman, of the Department of Radiology, Rush North Shore Medical Center, Skokie, Ill, and professor of radiology, Rush Medical College, Chicago. He writes that misinformation of mammography is the cause of much confusion and medical malpractice suits. He has strongly held opinions- expressed in a pointed way. For instance-

    • “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 filed in the United States that allege a delay in the diagnosis of breast cancer, radiologists are the most frequently sued specialists.

    • 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?

    • Berlin suggests that it is because we have oversold mammography. We have marketed mammography without informing the American public all that we know about not only the benefits, but also more important the limitations and potential harms of mammography. True, admits Berlin, the high level of mammographic utilization that we have achieved through these marketing efforts has resulted in overall improvement in the health and welfare of American women, but at the same time, this marketing has resulted in something that can be considered detrimental: an exponential growth in malpractice litigation alleging misinterpretation of mammograms.

    We opines Berlin- that is, the radiology community know that there are divergent opinions in the scientific community. There are contradictory interpretations of available data that deal with the question of whether early diagnosis of breast cancer by means of mammography, and whether it does, or does not, lower the mortality rate from breast cancer. We know that while there has been a decrease in the number of deaths attributable to breast cancer, it is not clear whether it has resulted from earlier diagnosis or better treatment, or both. His strongly presented viewpoints are as follows:

    • In as many as 70% of patients in which a new mammogram discloses a cancer, a finding that probably represented the cancer is visible, in retrospect, on a preceding mammogram that had been interpreted as normal.

    • We know that some breast cancers are so virulent and possess such high-grade malignant potential that even if they are detected early by mammography, it will be too late to prevent a woman from dying of the disease.

    • We know that some breast cancers grow so slowly and possess such low-grade malignant potential that the value of early diagnosis is questionable and in such cases, delays in diagnosis will not adversely affect the patient's chance for cure.

    • We know that the percentage of ductal carcinoma in situ (DCIS) cases that will evolve into invasive carcinoma lies between 14% and 60%,

    • and that the death rate within 10 years among patients with DCIS is 1% to 2%.

    Finally Berlin points to the tenets of preventive medicine which promises a lot and especially to an article entitled "The Arrogance of Preventive Medicine in which a Canadian internist-researcher identified three elements of arrogance that he believes characterize the field of preventive medicine:

    • First, it is aggressively assertive, pursuing symptomless individuals and telling them what they must do to remain healthy.

    • Second, preventive medicine is presumptuous, confident that the interventions it espouses will, on average, do more good than harm to those who accept and adhere to them.

    • Finally, preventive medicine is overbearing, attacking those who question the value of its recommendations.
    Berlin opines based on this article that-

    • Many radiologists believe so strongly that every woman will benefit from mammography that they fear that merely discussing potential negatives regarding mammography will dissuade women from undergoing the examination.

    • During busy office visits, it is difficult to thoroughly discuss with women the benefits and harms of mammography...Nevertheless; we should strive to correct misperceptions whenever possible.

    • Many women overestimate the protective benefits of mammography and underestimate its possible risks, including the evaluation of false-positive mammograms and over diagnosis leading to unnecessary mastectomy, radiation, or chemotherapy.

    • Clinicians should describe potential benefits of mammography without candy coating its plausible harms.

    Internist-author H. Gilbert Welch has commented as follows:
    Ideally, the "right" reason [for women to undergo mammography] would be that each woman had made an informed choice, or in other words, had made her own decision after being fully informed of the likely benefits and harms of screening experienced by women just like her. While such ideal conditions for decision making may exist somewhere, I don't foresee them on our planet any time soon...Perhaps if we used less alarming language about cancer risk when we introduce patients to screening, they would have less need for reassurance...We [should talk about screening] in the context of choice instead of obligation.

    For that reason and for fully informed decision making by women I will be posting Article II in this duo of mammography research tomorrow.

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