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December 17, 2004

BehindTheMedspeak: Mammography and the limits of looking

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Ten board-certified radiologists looked at 150 mammograms, of which 27 had come from women who developed breast cancer, and 123 from women known to have been healthy.

One radiologist caught 85% of the cancers.

Another caught only 37%.

A third saw suspicious masses in 78% of the 150.

A fourth saw "focal asymmetric density" in half the cancer cases; a fifth saw no "focal asymmetric density" at all.

One particular mammogram caused perplexity: three of the radiologists thought it was normal, two thought it was abnormal but probably benign, four couldn't make up their minds about it, and one was convinced it was cancer.

The woman was fine.

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Malcolm Gladwell noted these results in his superb article, "The Picture Problem: Mammography, Air Power, and The Limits of Looking," which appeared in the December 13 New Yorker.

He wrote, "So much of what can be seen on an X-ray falls into a gray area that interpreting a mammogram is also, in part, a matter of temperament. Some radiologists see something ambiguous and are comfortable calling it normal. Others see something ambiguous and get suspicious."

He went on to note that caution simply creates another kind of problem, namely, excessive work-ups and testing that needlessly subject healthy patients to the time, expense, anxiety, and discomfort of biopsies and further testing.

Not to mention the false-positives that sometimes lead to major surgery and associated complications.

Eyes

More:

    If screening doesn't screen, it ceases to be useful.

    The reason a radiologist is required to assume that the overwhelming majority of ambiguous findings are normal, in other words, is that the overwhelming majority of ambiguous things really are normal.

    The screen seldom gives you quite enough information.

    Under the circumstances, it is not hard to understand why mammography draws so much controversy.

    The picture promises certainty, and it cannot deliver on that promise.

Forget the meaningless "Medicine is an art, not a science."

Even if it's a science, it's still an art, because the science, in the end, depends on human judgment and temperament.

As physician-playwright Dr. Barry S. Levy said, "You take enough screening tests, you'll find something abnormal."

I concur.

It's my position that, apart from Pap smears in women who're sexually active (nuns don't need them - it's a little-known fact that the incidence of cervical cancer in nuns is zero) and haven't had a hysterectomy (don't laugh - many women continue to get annual Pap smears after their hysterectomies even though they have no cervix; I consider this malpractice and fraud, but we'll save that for another time), no one under the age of forty should ever go to a doctor unless they're sick.

Atlas04

You heard me right: no annual physical, no check-ups, nothing, nada, zilch.

December 17, 2004 at 04:01 PM | Permalink


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Comments

Well, amend that to kids after a certain point--there are developmental weirdnesses that can be caught early and remediated--I'm with you.

The decline of the skill of practical nursing--knowning what to do and when do it--for most minor self-limited illnesses is a sad fact. I'm not sure, though, of the cause.

Posted by: Liz Ditz | Dec 18, 2004 10:41:28 PM

Having had a mammogram this month, this post doesn't make me feel very good. My doctor said it was "negative" but now I wonder. If you have enough people look at your report, they will likely find something. Last month I was healthy, feeling fine...this month I have high blood pressure, high cholesterol, GERD, hiatal hernia, and a stricture of my esophagus...and that was after only one visit to a nurse practitioner. If they keep looking there's no telling what else they might find.

Posted by: Lisa | Dec 18, 2004 1:57:58 PM

Malcolm Gladwell's The Tipping Point is also an excellent read - highly recommended.

Posted by: Russ | Dec 18, 2004 11:27:27 AM

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