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Malpractice Issues in Radiology |
1 Department of Radiology, Rush North Shore Medical Center, 9600 Gross Point Rd., Skokie, IL 60076, and Rush Medical College, Chicago, IL 60612.
Received November 27, 2002;
accepted after revision November 27, 2002.
Case summaries are based on actual events and lawsuits, although certain
facts have been omitted or modified by the author, who has supplied and
obtained authorization for the reproduction of the radiologic images. All
opinions expressed herein are those of the author and do not necessarily
reflect those of the American Journal of Roentgenology or the
American Roentgen Ray Society.
Introduction
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I'm really uncomfortable waiting two months to undergo screening mammography because I know that cancer can spread extremely fast, and the space of a couple of months can make a difference.
Concerned woman [1]
A new case of breast cancer will be diagnosed every 2 minutes and a woman will die every 13 minutes. [1]
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The woman's husband and daughter filed a medical malpractice lawsuit against the surgeon, charging him with negligence for failing to perform a biopsy at the time he first examined the patient. The plaintiffs alleged that the 6-week delay from the day on which the surgeon first saw the patient to the day on which the biopsy was performed and the diagnosis of carcinoma was established had deprived the woman of any chance of survival.
The case proceeded to trial, during which expert witnesses for the plaintiff testified that the 6-week delay in diagnosing the breast cancer adversely affected the woman's prognosis. Expert witnesses retained by the defense testified that the 6-week delay made no difference in the patient's outcome. When the trial concluded, the jury adjourned to consider the evidence. After deliberating for 7 hours over 2 days, the jury returned a verdict in favor of the plaintiff, awarding the deceased woman's family $2.8 million.
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A recent survey by an insurance company that provides professional liability coverage for nearly three quarters of all physicians in Massachusetts disclosed similar findings [4]. The survey found that 70% of lawsuits closed with an indemnity payment to the patient or her family, even though medical oncology experts testified in many cases that the patient's breast cancer was so aggressive that earlier diagnosis would not have made any difference in treatment or outcome. The survey also found that the financial awards were higher when the patients were young, nulliparous, or pregnant.
Whether a physician is found liable for injuries allegedly sustained by a patient because the diagnosis of her breast cancer was delayed is ultimately determined by a jury. Most medical malpractice lawsuits, however, are settled out of court through negotiation among attorneys and claims representatives of insurance companies. Even though no jury is physically present during these negotiations, settlements are usually based on what these individuals think a jury would likely do in the specific case at hand [5].
Because juries are selected from the public at large, resolution of medical malpractice litigation is inextricably linked to the public's perceptions of the subject about which the litigation revolves. With regard to malpractice lawsuits that deal specifically with delays in the diagnosis of breast cancer due either to misinterpretation of a mammogram or failure to communicate in timely fashion abnormalities that are seen on the mammogram, verdicts rendered by juries are often determined by jurors' perceptions of how efficacious screening mammography is in reducing mortality from breast cancer and the degree to which a delay in diagnosis of breast cancer increases mortality from the disease. We shall analyze each of these public perceptions in finer detail.
The Public's Perceptions Regarding the Efficacy of Mammography
The ongoing debate about the efficacy of mammography, spurred on by the
periodic publication of scientific studies that seem to alternately support,
then question, and then support once again the value of mammography in
relation to breast cancer, has been chronicled previously
[6,
7,
8]. I shall briefly review
reports that have appeared in the scientific literature during the past 2
years.
In May 2001, proponents of mammography were elated when Cady and Michaelson [9] reported that mortality reduction in mammographically screened patients could reach as high as 75%. Five months later, however, Richard Horton [10], the editor of The Lancet, adopted an opposing viewpoint in an editorial that concluded, "At present, there is no reliable evidence from large randomized trials to support screening mammography programs." Duffy et al. [11] immediately objected, referring to Horton's commentary as "at best ill considered."
A series of letters to the editor of The Lancet, some expressing support for mammographic efficacy, others denying the value of mammography, appeared. One letter writer criticized those who argue that screening mammography should be eliminated because its efficacy has not been scientifically validated [12]:
Our primary criticism is the notion that a screening program can be justified only if it reduces mortality..... However, outcomes such as quality of life are also important to patients and could justify screening programmes.
Still another letter writer, a surgeon from the United Kingdom [13], wondered why reports criticizing mammography raise a lot of angry rebuttal. Agreeing that studies questioning the value of mammography "shake the very basis of intuitive logic," the author then rhetorically asked, "But isn't the world frequently counterintuitive?" Returning to the opposite view-point on the issue, Danish researcher Peter Gotzche [14], in a letter, reaffirmed his findings that there is no evidence of benefit from screening mammography.
In the midst of the myriad conflicting reports debating the value of mammography, a New York oncologist, David Golde, commented in a Wall Street Journal column [15]:
What if we can't prove conclusively that screening works? Well, there is more to medicine than data, statistics and the rigorous application of the scientific method. State-of-the-art care also requires the prudent application of common sense.... Simply because the proposition that routine screening saves lives has not been scientifically proven does not mean that mammography does not save thousands of lives each year.... It would be the height of folly to discontinue the practice of mammography if there is a good chance that doing so would increase morbidity and mortality in breast cancer patients.... The utility of mammographic screening cannot be measured by test-tube science. Unfortunately, the definitive answers we seek are simply not available at this time. Nevertheless, I firmly...believe that routine mammograms lead to improved outcomes in breast cancer patients.
In February 2002, the United States Preventive Services Task Force completed a 2-year review of research data measuring the efficacy of mammography and concluded that all women older than 40 years should have a mammogram every year [16]. The report was released by Tommy Thompson, Secretary of Health and Human Services, at a well-publicized press conference [17]. The task force deemed the evidence favoring mammographic efficacy to be "fair," a down-grade from "good," the rank the task force had conferred on the evidence 6 years earlier [18]. Also as part of its report, the task force expressed disagreement with a study denying the value of mammography that had been published several months earlier by researchers Olsen and Gotzsche [19] associated with the Nordic Cochrane Centre, a Danish research institute.
An article in the March 2002 issue of the Journal of the National Cancer Institute [18] explained the basis for the controversy regarding mammography that existed at the time. Both the United States Preventive Services Task Force and scientists Olsen and Gotzsche had reanalyzed the data derived from the eight most commonly recognized clinical trials on screening mammography conducted over the past 35 years. Although both groups agreed that nearly every trial had flaws, the two arrived at opposite conclusions. The Cochrane researchers maintained that the benefits of screening should be measured in terms of overall mortality, not disease-specific mortality—deaths specifically resulting from breast cancer—which it considered a biased end point. Under that reasoning, the Cochrane researchers had come to the conclusion that screening mammography had little effect in reducing mortality from breast cancer. The task force members, on the other hand, believed that the flaws were not significant and therefore concluded that no basis existed to question the original efficacy data. Simply stated, respected statisticians on both sides of the issue looked at the same data, rendered varying interpretations, and came up with opposite conclusions.
In March 2002, Nystrom et al. [20] updated five other long-running Swedish studies and concluded that mammography did save lives. Those researchers concluded that mammography reduced a woman's risk of dying from breast cancer by 21%, a statistically significant reduction, albeit modest and "relative" [21]. However, those researchers did acknowledge that when all-cause mortality was considered the end point, the reduction in breast cancer mortality was "barely measurable."
A Chicago Tribune reporter [22] analyzed the Nystrom data and the meaning of the term "relative reduction." Relative benefit, pointed out the reporter, which makes an absolute difference appear larger, is confusing even for physicians and even more confusing to patients. The reporter pointed out that the Swedish review showed a relative death benefit of 21% among women who had mammograms, a figure that was based on the determination that of 129,750 women who underwent mammography, 511 died of breast cancer during the next 15 years—a death rate of 0.4%. In the comparison group of 117,260 women who did not undergo mammography, 584 breast cancer deaths occurred during the same period—a death rate of 0.5%. Indeed, that did constitute a 21% relative benefit in favor of mammography, but the absolute difference between the two groups was seven deaths a year in a female population of 250,000.
The Tribune reporter then interviewed Donald Berry, chief of biostatistics at the M. D. Anderson Cancer Center in Houston, who calculated that the Swedish estimate of a 21% relative benefit received from screening mammography means that the average woman in her 40s would gain a little less than 3 extra days of life. Women in their 50s would gain a little more than 3 days, and women in their 60s, 8 extra days.
Questions about the efficacy of mammography continued to be raised. In the April 2002 issue of The New Republic [23], a senior fellow at the New America Foundation pointed out that even though approximately 60% of women in the United States older than 50 years are now screened regularly, up from 13% in 1980, the mortality rate from breast cancer has only recently begun to drop. Age-adjusted mortality rates from breast cancer held steady at about 27 deaths per 100,000 women from 1973 to 1992, when the numbers began to dip slightly, according to the author. By 1998, the last year for which statistics are available, the death rate from breast cancer was down to 22.7 per 100,000, a significant reduction, but, in the opinion of the author, still modest when one considers the vast increase in the number of women who are now being screened. The author added that some cancer experts argue that this drop is mostly the result of improved treatments, especially tamoxifen, which can cut a woman's risk of cancer recurrence by as much as 25%. At about the same time, however, Stephen Feig [24] interpreted the data quite differently. Fieg's conclusion was that despite a 24% increase in breast cancer incidence in the interval 1983-1997, the fact that a reduction of 15% in mortality rates from the disease occurred meant that mammography was quite effective.
In a New York Times article in April 2002, reporter Gina Kolata [25] discussed the issue of efficacy of mammography with two experts on opposite sides of the debate. The first, Barnett Kramer, director of the Office of Disease Prevention at the National Institutes of Health, voiced concern about overdiagnosis, suggesting that mammography is finding many cancers that either would go away if left alone or would be found and treated later without a change in outcome when they became larger. Kramer pointed to the fact that mammography finds very small tumors and lesions, such as carcinoma in situ, that often do not progress to invasive carcinoma. According to this researcher, the in situ prevalence rose from 6.1 per 100,000 in 1983 to 31 per 100,000 in 1998. During the same period, the incidence of small cancers rose from 22 to 60 per 100,000, whereas the number of women with cancers larger than 2 cm in diameter decreased only slightly. If screening worked perfectly, hypothesized Kramer, every cancer found early would correspond to one fewer cancer found at a later stage. But, he concluded, this has not happened.
Reporter Kolata then talked with Larry Norton, a breast cancer expert at Memorial Sloan-Kettering Cancer Center. Acknowledging that screening does find some tiny cancers that may not become deadly, Norton nonetheless countered that screening finds tiny tumors that would later become untreatable or would require drastic surgery and large doses of chemotherapy if not detected early. Although admitting that the data are not entirely clear, Norton nevertheless expressed a strong belief that mammography screening is beneficial to the public. Yale University's Carol Lee expressed a similar viewpoint [26]:
Despite these continuing controversies, mortality from breast cancer in the United States has been decreasing steadily for the past 25 years.... Although some of this decrease may be attributable to improvement in the treatment in breast cancer, early detection through screening mammography has undoubtedly played a role in this mortality reduction. The controversies that surround the issue of screening should not detract from the fact that screening mammography has proved to save lives.
Feig went a step further than Lee: "It is likely that screening rather than advances in treatment was responsible for nearly all of the [reduction in breast cancer mortality]" [27].
In August 2002, Duffy and 22 other researchers [28] published the results of their review of data derived from mammography screening studies conducted in seven Swedish counties and covering approximately one third of the population of Sweden. Those researchers determined that mammography resulted in a 40-45% reduction in breast cancer mortality among women who were screened.
The mammography controversy flared up once again in September 2002, when two contradictory articles on the subject appeared in the same issue of Annals of Internal Medicine. One, authored by Canadian researchers, concluded that mammography screening did not reduce breast cancer mortality [29]. The other, by researchers at the United States Preventive Services Task Force, concluded that in randomized controlled studies mammography had been shown to reduce breast cancer mortality among women 40-74 years old [30].
Commenting in a New York Times article by Kolata about these conflicting conclusions, Stephen Goodman, a biostatistician at the Johns Hopkins Cancer Center, observed [31]:
There is a level of scientific uncertainty that is not reflected in the numbers but exists in the minds of all the analysts.... In the end, the mammogram debate reflects a conundrum of modern medicine. The answers that are needed—what are the benefits and what are the risks—are right at the fuzzy boundary of what science can deliver. It's like looking through a microscope at something just at the limits of resolution. Reasonable people can differ on what the evidence is.
The question of whether early diagnosis of breast cancer accomplished by any means reduces death rates reached the front-page head-lines again in October 2002, when a Chinese study showed that breast self-examination by women did not reduce mortality rates from breast cancer [32]. At the same time, Ernster et al. [33] reported that approximately 20% of all mammography-detected breast cancers were ductal carcinoma in situ and that only about 2% of women who have been diagnosed with or treated for this disease have died of breast cancer. Those researchers raised the question of whether the high detection rate by mammography of the often-benign ductal carcinoma in situ has contributed to an overstating of the reduction in breast cancer mortality rates associated with screening mammography. They concluded that there is as yet no definitive answer to the question.
The Public's Perceptions Regarding Delays in Diagnosis of Breast
Cancer
That it is the public's perception that even a short delay in diagnosis of
breast cancer causes harm is quite clear. Examples of such perceptions can be
found at the beginning of this article and in the following comments made in a
recent Texas State Medical Society publication
[34]:
Women now expect to survive breast cancer if they follow medical advice.... We have pretty much been told that if we catch breast cancer early, we stand a good chance of living.
I shouldn't die from breast cancer...[Isn't it true] that if you catch the cancer soon enough I'll live?
It's very hard for a doctor to argue that any delay was either in the patient's interest or didn't harm the patient.
In September 2002, United States Secretary of Agriculture Ann M. Veneman announced that she had developed ductal carcinoma in situ [35]. Commenting on the fact that Veneman's cancer "could not have been detected without a mammogram," President George W. Bush said [36]:
I knew I picked an extraordinary person when I named her to run the Department of Agriculture. I didn't realize I was going to pick a heroic figure as well, an example for many people to understand the need to get a mammogram, the need to take care of yourself, the need to screen early, the need to understand that we can stop cancer in its tracks if we all take wise moves.
Some hospitals and radiologists continue to exaggerate the capability of mammography to detect very tiny lesions. One hospitalsponsored newspaper advertisement states, "Unlike a breast self-exam or a physical examination performed in a doctor's office, mammograms can often detect tumors as small as the head of a pin" (Fig. 1). An advertising supplement entitled "Early Detection Pays Off" published in The New York Times Magazine [37] states that "Mammograms can detect breast cancers as small as1/5 of an inch [5 mm]."
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That even short delays in the diagnosis of breast cancer can substantially adversely affect the patient's prognosis continues to be reinforced. A front page article in a Toronto newspaper [38] that focused on some women's experiencing 1- to 2-month delays in obtaining mammography stated that "Previous research has shown that delaying treatment by 3-6 months among women with symptomatic breast cancer is associated with poor survival."
Although published reports indicate that delays of up to 3 months do adversely affect the patient's survival [39], other reports have found contradictory results [40]. Tartter et al. [41] reviewed 606 patients with breast cancer, 8% of whom had a delay in diagnosis ranging from 6 months to 6 years and averaging 11 months. The average size of the diagnostically delayed cancers was 2.3 cm compared with 1.8 cm for cancers that had been diagnosed without delay. However, nodal involvement was no more frequent in the delayed cases, and the incidence of local recurrences and distant metastases was similar in both groups. Outcomes were not statistically different, findings that the authors acknowledged are counterintuitive but that were in agreement with findings from other studies. In another study of patients in whom diagnoses of breast cancers were delayed, Goodson and Moore [42] also found that delays were not associated with a higher incidence of lymph node involvement, a greater likelihood of needing a mastectomy, or the eventual outcome. Those researchers also found, however, that 25% of the women in this group filed medical malpractice lawsuits.
Finally, Daniel Kopans, a staunch supporter of mammography, has acknowledged, "It is well established that merely finding cancer earlier does not mean that the test actually saves lives or even alters the course of the disease" [43].
Influence of the News Media on the Public's Perceptions About
Mammography
The printed and spoken news media play an enormous role in shaping the
public's attitude regarding the relationship of mammography to early diagnosis
of breast cancer. In an editorial published recently, Valerie Jackson
expressed the belief that newspaper editors are biased against mammography, as
manifested by their disproportionate coverage of articles that are critical
rather than supportive of mammography
[44]:
The American College of Radiology and the Society of Breast Imaging issued press statements noting the value of mammographic screening. These statements, as well as many letters to editors by those in favor of screening mammography, fell on deaf ears. In many cases, newspaper editors merely refused to publish letters that pointed out the value of screening mammography.
Several published reports seem to refute Jackson's belief. A survey of articles published in six top-circulation United States newspapers focusing on the subject of mammography revealed that quotes and recommendations in the articles were twice as likely to support rather than express reservations about mammography, and in fact, tended to overrepresent the value of screening mammography [45]. A later report that surveyed not only print news stories in the 10 highest-circulation United States newspapers but also transcripts from three major television networks relating to mammography disclosed that 60% of these stories recommend that women should either "probably" or "definitely" be screened by mammography [46]. This report also pointed out that articles and television stories focusing on whether women should take tamoxifen to prevent recurrence of breast cancer highlighted greater uncertainty about the drug than about the diagnostic procedure of mammography. Most news stories favored the routine use of screening mammography but urged caution about using tamoxifen. In other words, whereas taking tamoxifen was presented as a difficult decision, having a mammogram was presented as something women simply ought to do.
A survey of a random sample of American women [47] revealed not only that most women harbor a strong belief that the benefit of mammography has been scientifically proven, but also that 50% believe as well that proof of benefit exists for women 18-39 years old, a position not supported by any scientific data. The survey concluded that women's belief in the efficacy of screening is so strong that it leads them to an uncritical acceptance of screening at any age.
Should Controversies Surrounding Mammography Be Discussed
Publicly?
In her 2002 editorial, Jackson expressed great concern that the news
media's highlighting of the controversies surrounding the value of mammography
would have adverse effects on the public
[44]:
Some may argue that reexamination and discussion of the value of screening mammography is healthy: however, considerable damage has been done, since women and their health care providers are confused with regard to the need for mammographic screening.
Harvey Neiman, then chairman of the American College of Radiology's Board of Chancellors, expressed similar sentiments [48]:
The ACR is deeply concerned about contradictory reports [regarding the usefulness of screening mammography in savings women's lives] and the result they will have on women's health.... Everyone is now all too aware of the recent controversies raised about mammograms. However, the further public dissension and the ensuing media coverage only heighten the apprehension of women caught in the middle of an unnecessary tug of war. The only victims in this needless controversy are the women who may choose to ignore this life-saving procedure because of a conflicting message from the health care profession.
The concern of some in the health care community that public discussion regarding the value of mammography adversely affects women's health was so great that 10 medical organizations, including the American Cancer Society, the American College of Obstetricians and Gynecologists, and the American Medical Association, published an open letter to women and their physicians in the January 31, 2002, edition of The New York Times. The letter stated [49]:
We...are responding to coverage in the media and the resulting publication questioning the value of mammography. This discussion...concluded there was no scientific support for breast cancer screening with mammography.... While the existing studies of mammography screening have known limitations and even some flaws, the evidence as a whole probably supports reduced breast cancer mortality rates due to mammographic screening....
We have grave concern that the public debates have already begun to erode the confidence in mammography that has been built up over the past two decades.... There will be many thousands fewer breast cancer deaths among U.S. women this year due to the combined progress we've made in early detection.
Concern that fewer women are undergoing mammography as a result of these controversies does not seem to be borne out. A recent article in The New York Times [50] pointed out that nationwide the number of women who have screening mammograms continues to rise, and in fact, today almost 75% of eligible women are screened. The article added that under some insurance plans, extremely high rates of compliance with mammography—up to 97%—occur. One internist was quoted as saying, "Some of my patients refuse colonoscopy when I recommend it, but no one protests a mammogram." The director of a breast cancer resource committee added, "Mammography is an adequate screening tool, and women have bought into it."
A 2002 report on mammography capacity in the nation issued by the United States General Accounting Office [51] also found that the mammography screening rate has substantially increased each year and estimated that more than 40 million women underwent screening mammography in 2000.
Various experts have urged more, rather than less, disclosure and discussion about the controversies swirling around the efficacy of mammography. The editor of an internal medicine journal wrote recently [52]:
The debate about the effects of screening young women goes on, and nothing...will dampen it. The debate is worth following closely because women are deciding about breast cancer screening, and it's our role to keep them informed as best we can.
An editorial published in the Chicago Tribune in August 2002 echoed this opinion [53]:
The debate over mammography will go on. [Recent] developments are further evidence that women who want to make informed choices about their health need to know more about how studies are conducted, and what they really say.
The United States Preventive Services Task Force has also called for fuller disclosure [16]:
Clinicians should inform women about the potential benefits (reduced chance of dying from breast cancer), potential harms (e.g., false-positive results, unnecessary biopsies), and limitations of the test that apply to women their age.
A similar position was taken by the American Medical News in its section titled "Ethics Forum" [54]:
The recent debate concerning mammography and, specifically, whether early detection of breast cancer saves lives...is healthy...and injects a new dimension...in making evidence-based medicine a part of our regular routines and in deciding how much uncertainty to share with our patients.... We must encourage our patients to examine sources of information critically. More specifically, we must help them under-stand that news reports pick up the most attention-grabbing component of a study or journal article.... As physicians advising the community at large, we...need to talk about additional strategies to deal with the uncertainties those studies sometimes produce. Such discussions will help facilitate shared decision-making in real time.
In a previous article, I commented that [55]:
The two sides of the mammography story—one supporting without reservation, the other claiming mammography is of no value, will continue to attract public attention.... I believe that we should not be afraid of presenting the other side of the mammography story to the women of the United States and then intelligently discussing it with them.
Some commentators have gone beyond simply urging more open discussion about the controversies regarding mammography and, in fact, have been critical of those who would like to curtail disclosure. In an article in Health, an Ohio oncologist, Leslie Laufman, stated [56]:
We doctors need to do a better job of reminding ourselves and informing women about the limitations of [mammography].... I am insulted by the medical community's attempt to distill the issue to a single message; don't worry about the controversy, just get a mammogram. As a woman it frustrates me. The attitude is that women are too stupid to sort it out, so they need a simple straightforward answer. I have a lot more faith in women than that.
Another observer has written [57]:
For their part, clinicians who favor routine screening tests like mammography...are all too ready to dismiss or revile recent studies that call utility of the test into question. They're doctors by gum and they know what's good for their patients!
Canadian researcher David Sackett [58] has written about what he calls the "arrogance of preventive medicine." Some proponents of preventive medicine, according to Sackett, are aggressively assertive, pursuing symptomless individuals and telling them what they must do to remain healthy. Some are presumptuous, confident that the interventions they espouse will do more good than harm to those who accept and adhere to them, and some are over-bearing, attacking those who question the value of their recommendations. Perhaps it is this kind of perceived arrogance on the part of proponents of screening mammography that led the creator of the nationally and internationally syndicated cartoon Sylvia to express anger at those "experts" who had "agreed that while it was possible that mammograms were beneficial... It was also possible they weren't" (Fig. 2).
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Responding to the desire of many of its members for more open discussion of the controversies involving mammography and breast cancer, the councillors of the American College of Radiology, at their 2002 annual meeting, passed a resolution calling for the undertaking of "an educational program that discusses and reviews with ACR membership and the American public the indications, efficacy, benefits and limitations of mammography" (American College of Radiology resolution 41, Benefits and Limitations of Mammography, in Minutes of the Annual Meeting, September 2002).
Summary and Conclusions: Can Malpractice Litigation Concerning Mammography and Delays in Diagnosis of Breast Cancer Be Reduced?
Allegations of a missed or delayed diagnosis of breast cancer remain the leading cause of medical malpractice lawsuits filed against radiologists and nonradiologist physicians. Indemnification payments resulting from jury verdicts and out-of-court settlements of breast cancer-related lawsuits continue to rise every year.
For payment to be awarded, the plaintiff must prove that the defendant physician was negligent and that the negligence caused injury to the plaintiff. The degree to which a patient has been injured by a delay in diagnosis of breast cancer is determined by a jury and is very much influenced by the public's perception of how effective screening mammography is in reducing the mortality rate of breast cancer.
In an effort to reduce the mortality and morbidity rates associated with breast cancer, the American College of Radiology, the American Cancer Society, and other professional organizations dedicated to furthering the welfare of the public have undertaken successful campaigns to encourage women to undergo screening mammography by emphasizing its benefits. Through such efforts, these organizations have achieved a high level of mammography utilization. At the same time, however, in their zeal to promote mammography, these same organizations may have tended to overlook recurrent published reports that raised questions about the value of mammographic screening. Most if not all advertisements and marketing campaigns sponsored by these organizations have extolled the benefits only, excluding any mention of potential limitations, of mammography. As a result, it is likely the public has developed perceptions that overrate the efficacy of mammography and the damage that may befall patients whose breast cancer diagnoses have been delayed. It may well be that this overselling of mammography and the raising of the public's expectations of what mammography can achieve in reducing breast cancer mortality rates have contributed to the rather spectacular rise in breast cancer medical malpractice litigation. If this is true and the pendulum representing the public's expectation of mammography has swung too far to the benefit side, then perhaps the medical establishment and its allied professional organizations should take a more evenhanded approach and make a concerted effort to shift the pendulum of public expectation back toward the center.
Acknowledging rather than denying the existence of controversies regarding the efficacy of mammography, disclosing rather than disregarding scientific studies that question the premise that screening mammography reduces mortality rates from breast cancer, and expanding rather than limiting public discussion and debate of viewpoints and opinions critical of screening mammography expressed by various researchers in the scientific community, will serve to assist the public at large in developing a realistic appraisal of mammography's role with regard to breast cancer.
The controversies swirling around mammography will continue, as will malpractice litigation alleging delays in the diagnosis of breast cancer. We can only hope that through better education the increasing incidence and severity of malpractice lawsuits arising from the performance of mammography will abate.
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