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Harvard Medical School Massachusetts General Hospital Avon Foundation Comprehensive Breast Evaluation Center Wang Ambulatory Care Center Boston, MA 02114
Dr. Berlin's thumbnail summary of the recent controversy over screening mammography [1] shows the conflicting conclusions in published articles, statements, advertisements, and the media that have caused a great deal of confusion. Given the hyperbole that has been used to convince women to be screened, I am not too surprised that they have unrealistic expectations. As a consequence, when breast cancer is not discovered early enough to be cured, some patients believe a mistake was made; they are angry, and this is the reason for the increasing number of lawsuits.
As a strong proponent of screening, I too am confused. For at least the past 20 years, experts in breast imaging have never, to my knowledge, ever suggested that screening will save all patients who develop breast cancer. The most optimistic projection has been a 50% decrease in deaths. We have explained for years that mammography is far from perfect and that a negative mammographic result does not guarantee that a woman does not have breast cancer. The exaggeration has come from cancer organizations and the media.
What has been absent from the discussion is the lack of responsibility among some of the journals and uninformed peer reviewers who have allowed the publication of gross misinformation [2] along with the misuse of science that has corrupted the analysis of the breast cancer screening data [3]. The aphoristic explanation that experts can look at the same data and come to opposite conclusions is nonsense. Opponents of mammographic screening have repeatedly misunderstood the data or manipulated it. The most recent example of this was mentioned by Berlin [1]. The manipulation of data can be seen in the repeated emphasis on the age of 50. There are absolutely no data that show an abrupt change in the parameters of screening occurring at the age of 50, yet peer review continues to let authors use this age as a point of analysis. Analysts separated women ages 40–49 despite the fact that the trials lacked the statistical power to permit such a division [4, 5], and articles were written to make the age of 50 falsely appear to be important [6].
The public clearly needs a more realistic understanding of screening, but women need to know that there is a significant benefit. A review of the arguments that have taken place over the years shows that opposing arguments have changed with time because they were based on misunderstanding the data. The arguments in support of screening have not changed at all because they have been based on the science.
Berlin [1] did not address the major problems with the legal system. His example of a woman who clearly had metastatic cancer before the delay in her diagnosis yet received $2.5 million is not the fault of confusion over mammography. It is a problem with the jury system, malpractice, and the courts' inability to deal with science. Physicians are being asked to adhere to an ethereal standard of care that is decided retrospectively by the whim of a jury. Anyone is permitted to be an expert, and jury decisions are influenced by how they feel toward the plaintiff and her experts versus the defendant and his or her experts. Experts who freely admit that they too have missed cancer that is visible in retrospect eagerly testify that others should not have overlooked a lesion. The fear of a lawsuit has greatly diminished the number of radiologists who are going into breast imaging. Educating women may help reduce the number of lawsuits, but the problem is deeper. A huge psychologic toll comes with the accusation of negligence because it strikes at the heart of being a physician.
I am proposing (unpublished manuscript) that we petition the courts to have an independent review of the vagaries of human perception. I believe that this change will show that humans cannot avoid failing to see cancers periodically and that missing occasional cancers should not be considered negligence. There is a precedent. Judge Pointer did this for silicone implants [7], which curbed the number of implant lawsuits.
If something is not done quickly we will have a lifesaving test with no one to interpret it.
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