In medicine, an incidentaloma is a tumor (-oma) found by coincidence (incidental) without clinical symptoms or suspicion. It is a common problem with the current rate of imaging and is the name given to a lesion found by accident when doing x-rays or other imaging procedures for something else. These lesions or masses are found on the adrenal gland which sits on top of the kidney.
Up to 7% of all patients over 60 may harbor a benign growth, often of the adrenal gland, which is detected when diagnostic imaging is used for the analysis of unrelated symptoms. With the increase of "whole-body CT scanning" as part of health screening programs, the chance of finding incidentalomas is expected to increase. 37% of patients receiving whole-body CT scan may have abnormal findings that need further evaluation.
When faced with an unexpected finding on diagnostic imaging, the clinician faces the challenge to prove that the lesion is indeed harmless. Other tests are required to determine the exact nature of an incidentaloma.
What are the facts about adrenal masses discovered during imaging for non-adrenal related causes?
• It is the commonest adrenal 'disorder'
• Found during 1-5% of abdominal CT scans
• 5-10% patients have non-functioning adrenal masses found at postmortem examination
• Male to female ratio is equal
• Most incidentalomas are benign and hormonally inactive
• Few patients require adrenalectomy
• Diagnostic assessment needs to evaluate:
o Is the lesion hormonally active
o Is the lesion malignant
Tom Cawood states that evaluation of adrenal incidentalomas is costly, has high false positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant and it’s time for a re-think of the whole matter. Cawood suggests that we-re-assess the performance of current clinical recommendations for the evaluation of an adrenal incidentaloma.
Cawood performed a literature review of electronic databases (Pubmed, Ovid and citation searches from key articles) from 1980 to 2008. Eligible studies were those deemed most applicable to the clinical scenario of a patient referred to an endocrinologist for assessment of an incidentally detected adrenal mass. Surgical series, histopathological series and oncological series were reviewed and most were excluded.
Results:
• The prevalence of functional and malignant lesions presenting as adrenal incidentaloma was similar to that quoted in most reviews, other than a lower incidence of adrenal carcinoma (1.9% vs 4.7%) and metastases (0.7% vs 2.3%).
• The development of functionality or malignancy during follow-up was rare (<1% style="font-weight: bold;">Bottom Line:
This argues for a review of current guidelines.
Current recommendations for evaluation of adrenal incidentaloma are likely to result in significant cost, both financial and emotional, due to high false-positive rates.
The dose of radiation involved in currently recommended CT scan follow-up confers a risk of fatal cancer that is similar to the risk of the adrenal becoming malignant.
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
Showing posts with label breast cancer. Show all posts
Showing posts with label breast cancer. Show all posts
Saturday, June 13, 2009
Thursday, May 14, 2009
Does Cancer Screening Really Help All?
No evidence so far that it helps with certain cancers reports Robert W. Rebar, MD [Journal Watch General Medicine, 2009].
As much one would like to believe that early detection for all automatically leads to better care, that is not always the case. Although it is true that finding and treating cancer at an early stage will help in some cases — such as colon cancer and Pap smears that reduce deaths from cervical cancer — the data are less conclusive for at least three other cancers.
Ovarian carcinoma
Ovarian carcinoma is the leading cause of death from gynecologic malignancies in the U.S., reports Robert W. Rebar, MD largely because diagnosis usually is not made until disease is advanced.
In a study funded by the National Cancer Institute, of more than 30,000 women in the study’s screening arm who underwent at least one annual screen, 11.1% had at least one positive test result. The positive predictive value of the tests ranged from 1.0% to 1.3% during different screening rounds, and 4.7 to 6.2 cancers per 10,000 women were identified with screening. The ratio of surgeries to detected invasive ovarian cancer cases was 19.5 to 1.
Unfortunately 72% of cancers were late stage. Because the prevalence of ovarian cancer is low, false positives are numerous and screening leads to surgery for many women who do not have cancer. The benefits of screening will outweigh the harms seems unlikely.
Prostate cancer
In an op-ed in USA Today (4/23/09), Kevin Pho, MD, a primary-care physician in New Hampshire, questions whether "early screening" is "always in the patient's best interest." Dr. Pho cited two studies appearing in the New England Journal of Medicine that examine "the effects of prostate cancer screening."
In one study, "sponsored by the National Institutes of Health," researchers "found that such screening did not decrease deaths." Meanwhile, "the second study showed that for every death prevented, 50 men would suffer from over-diagnosis." To put the problem in context: Only 3% of men die from prostate cancer; 97% will die from something else.
Almost one-third of those treated for prostate cancer suffer from significant side effects, including impotence and urinary incontinence. Taken together, the study found that the benefit was minimal, and far from definitive.
Breast Cancer[see Part II in my series of article on Mammagraphy http://drperryhookman.blogspot.com/2009/05/mammography-different-after-age-65-full.html]
Dr. K.Pho notes that "similar issues influence breast cancer screening decisions" and that physicians "cannot be sure of which cancers are dangerous." As a result, "for every life saved from breast cancer, 10 more lives will be affected by" biopsy or breast surgery. He concludes, There cannot be a one-size-fits-all approach" to preventive care.Because doctors cannot be sure of which cancers are dangerous, every woman with a suspicious finding is subjected to a biopsy or breast surgery. For every life saved from breast cancer, 10 more lives will be affected by the ensuing procedures.
Other cancers
The uncertainty surrounding tests is true of other cancers, including lung, skin (malignant melanoma), testicular and pancreatic (pancreatic adenocarcinoma), where little compelling evidence has shown that early screening is beneficial.
My opinion
The problem associated with these studies showing questionable or no benefit to a longer life for cancer victims is the statistics themselves. Statistics are still statistics and you are you. Some lives have been saved from early screening. But for every inspiring story of a person cured from cancer made possible by early detection, there are untold stories of many more who suffer from the side effects of unnecessary invasive procedures stemming from false positive test results.
But when only 1% of a certain population of 100 benefits that 1% may be you-and as far as you’re concerned you are 100% of the study.
Another example is that mammograms detect a number of slow-growing tumors that will never be harmful. But because doctors cannot be sure of which cancers are dangerous, every woman with a suspicious finding is subjected to a biopsy or breast surgery. Although it’s true that for every life saved from breast cancer, 10 more lives will be affected by the ensuing procedures, yours may be the life that’s saved.
Unless you believe with Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, who says, "I place considerable value on not suffering the side effects of treatment" and "death is not the only outcome that matters," you may choose not to undergo these uncertain screening procedures.
But at least you will be making an informed decision. As Dr. Pho states “patients must be better informed of the potential consequences either choice can bring.”
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
As much one would like to believe that early detection for all automatically leads to better care, that is not always the case. Although it is true that finding and treating cancer at an early stage will help in some cases — such as colon cancer and Pap smears that reduce deaths from cervical cancer — the data are less conclusive for at least three other cancers.
Ovarian carcinoma
Ovarian carcinoma is the leading cause of death from gynecologic malignancies in the U.S., reports Robert W. Rebar, MD largely because diagnosis usually is not made until disease is advanced.
In a study funded by the National Cancer Institute, of more than 30,000 women in the study’s screening arm who underwent at least one annual screen, 11.1% had at least one positive test result. The positive predictive value of the tests ranged from 1.0% to 1.3% during different screening rounds, and 4.7 to 6.2 cancers per 10,000 women were identified with screening. The ratio of surgeries to detected invasive ovarian cancer cases was 19.5 to 1.
Unfortunately 72% of cancers were late stage. Because the prevalence of ovarian cancer is low, false positives are numerous and screening leads to surgery for many women who do not have cancer. The benefits of screening will outweigh the harms seems unlikely.
Prostate cancer
In an op-ed in USA Today (4/23/09), Kevin Pho, MD, a primary-care physician in New Hampshire, questions whether "early screening" is "always in the patient's best interest." Dr. Pho cited two studies appearing in the New England Journal of Medicine that examine "the effects of prostate cancer screening."
In one study, "sponsored by the National Institutes of Health," researchers "found that such screening did not decrease deaths." Meanwhile, "the second study showed that for every death prevented, 50 men would suffer from over-diagnosis." To put the problem in context: Only 3% of men die from prostate cancer; 97% will die from something else.
Almost one-third of those treated for prostate cancer suffer from significant side effects, including impotence and urinary incontinence. Taken together, the study found that the benefit was minimal, and far from definitive.
Breast Cancer[see Part II in my series of article on Mammagraphy http://drperryhookman.blogspot.com/2009/05/mammography-different-after-age-65-full.html]
Dr. K.Pho notes that "similar issues influence breast cancer screening decisions" and that physicians "cannot be sure of which cancers are dangerous." As a result, "for every life saved from breast cancer, 10 more lives will be affected by" biopsy or breast surgery. He concludes, There cannot be a one-size-fits-all approach" to preventive care.Because doctors cannot be sure of which cancers are dangerous, every woman with a suspicious finding is subjected to a biopsy or breast surgery. For every life saved from breast cancer, 10 more lives will be affected by the ensuing procedures.
Other cancers
The uncertainty surrounding tests is true of other cancers, including lung, skin (malignant melanoma), testicular and pancreatic (pancreatic adenocarcinoma), where little compelling evidence has shown that early screening is beneficial.
My opinion
The problem associated with these studies showing questionable or no benefit to a longer life for cancer victims is the statistics themselves. Statistics are still statistics and you are you. Some lives have been saved from early screening. But for every inspiring story of a person cured from cancer made possible by early detection, there are untold stories of many more who suffer from the side effects of unnecessary invasive procedures stemming from false positive test results.
But when only 1% of a certain population of 100 benefits that 1% may be you-and as far as you’re concerned you are 100% of the study.
Another example is that mammograms detect a number of slow-growing tumors that will never be harmful. But because doctors cannot be sure of which cancers are dangerous, every woman with a suspicious finding is subjected to a biopsy or breast surgery. Although it’s true that for every life saved from breast cancer, 10 more lives will be affected by the ensuing procedures, yours may be the life that’s saved.
Unless you believe with Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, who says, "I place considerable value on not suffering the side effects of treatment" and "death is not the only outcome that matters," you may choose not to undergo these uncertain screening procedures.
But at least you will be making an informed decision. As Dr. Pho states “patients must be better informed of the potential consequences either choice can bring.”
Please remember, as with all our articles we provide information, not medical advice.
For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.
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.
• “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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