Joann Elmore, MD, MPH; John Choe, MD, MPH
Acknowledgments: The authors thank Raymond Harris, PhD, and Suzanne Fletcher, MD, for their helpful editorial suggestions.
Grant Support: Dr. Elmore is supported by grant K05-CA104699 from the National Cancer Institute.
Potential Financial Conflicts of Interest: Dr. Elmore has served as an expert witness on the topic of risk communication.
Requests for Single Reprints: Joann G. Elmore, MD, MPH, University of Washington School of Medicine, Harborview Medical Center, 325 Ninth Avenue, Box 359780, Seattle, WA 98104-2499; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Elmore: University of Washington School of Medicine, Harborview Medical Center, 325 Ninth Avenue, Box 359780, Seattle, WA 98104-2499.
Dr. Choe: University of Washington, 325 Ninth Avenue, Box 359780, Seattle, WA 98104.
Elmore J., Choe J.; Breast Cancer Screening for Women in Their 40s: Moving from Controversy about Data to Helping Individual Women. Ann Intern Med. 2007;146:529-531. doi: 10.7326/0003-4819-146-7-200704030-00010
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Published: Ann Intern Med. 2007;146(7):529-531.
We should move beyond a discussion of the quality of the evidence for breast cancer screening for women in their 40s. Instead, we should learn to live with smaller absolute benefits and higher risks than those we had originally hoped for. In the face of continuing controversy about the evidence, our priority now should be to help women make informed decisions.
Three articles in this issue (1–3) can help us make the transition from controversy to action. The first is a succinct clinical practice guideline from the American College of Physicians (ACP) that advises clinicians on how to approach breast cancer screening decisions when seeing individual patients in their 40s (1). The practice guideline was guided by a systematic literature review in this issue of the benefits and potential harms of screening (2). Unlike previous reviews that generally emphasize data on benefits of screening from only randomized trials, the review, by Armstrong and colleagues (2), also examined data from 117 observational studies and summarizes extensive data on the potential harms of screening, such as overdiagnosis and radiation exposure. Their review also discusses how to assess benefit and risk on an individual basis, which will be particularly relevant to women younger than the age of 50 years. To our knowledge, a second systematic review article in the issue, by Brewer and colleagues (3), is the first to specifically examine the long-term consequences of false-positive mammograms in such detail.
Edward J. Volpintesta
April 19, 2007
Mammograms and Defensive Radiology
The authors were correct to point out how radiologists, because of fears of future litigation often order additional testing and even breast biopsies when reporting mammograms.
Unfortunately, radiologists' fears of litigation extend far beyond the reading of mammograms. With increasing frequency, CAT scans of the abdomen or chest report sub-centimteter nodules that, in the majority of instances prove on follow-up scans to be benign.
Not only is the follow-up and waiting period a source of anguish for patients who expect to be told that they have cancer or some unusual disease, but the explanations to patients, the ordering of additional tests, and, in some instances referrals to specialist is a time-consuming and frustrating effort.
This is a pervasive problem that is shared by all doctors, but it affects general internists and family physicians the most. It amounts to a distraction that diminishes the value of physicians'clinical skills and judgment, making some feel more like technicians than doctors.
I don't know much "defensive radiology" raises the cost of health care,or even if any such studies exist; but, the cost has got to be a lot.
The point is that, unless, medical liability methods are improved, doctors have no choice but to practice defensively.
Taking medical disputes out of the courtroom and handling them in "health courts" presided over by judges with special training in medical liability is often discussed as a better way of handling malpractice issues. By eliminating the adversarial nature of the legal process that now exists, it would give doctors the security they need to use their judgment and not fear ruining their reputations or their livelihoolds because of a frivolous malpractice suit.
Unless better ways treating medical liability are found,such as medical courts, the advances of medicine will be too costly to use, financially for society and emotionally for doctors.
Eventually, the legal risks of new technology will outweigh their medical benefits. Medical research will bde stunted the health system will have taken another step backwards.
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Hematology/Oncology, Breast Cancer, Cancer Screening/Prevention, Prevention/Screening.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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