Physicians

Radiologist: Thou Shalt Disclaim by Law

There is an old joke. What’s a radiologist’s favorite plant? The hedge.

Radiologists are famous for equivocating, or hedging.

“Pneumonia can’t be excluded, clinically correlate”. Or “probably a nutrient canal but a fracture can’t be excluded with absolute certainty, correlate with point tenderness”.

Disclaiming is satisfying neither for the radiologist nor the referring physician. It confuses rather than clarifies. So one wonders why legislators have decided to codify this singularly unclinical practice in the Breast Density Law.

The law requires radiologists to inform women that they have dense breasts on mammograms. So far so good.

The law then mandates that radiologists tell women with dense breast that they may still harbor a cancer and that further tests may be necessary.

You may quibble whether this disclaimer is an invitation or commandment for more tests, or just shared decision-making, the healthcare equivalent of consumer choice.

But it’s hard to see why any woman would forego supplementary tests such as breast ultrasound, magnetic resonance imaging and 3 D mammogram, or all three, when their anxiety level is driven off the scale.

What piece of incontrovertible evidence inspired this law, you ask?

Perhaps a multi-center trial run over 10-15 years that randomized women with dense breasts to (a) mammograms plus additional screening and (b) screening mammograms alone, show that additional screening saves lives, not just find lots of small inconsequential cancers.

No. The law was instigated by a heart-rending anecdote, which avalanched into the “breast density awareness” movement, cloaked by an element of scientific plausibility: women with dense breasts may have a higher incidence of cancer; a conjecture of considerable controversy.

Wasn’t  the Affordable Care Act (ACA) supposed to usher an era of rational policy-making, guided by p values, statistics not anecdotes?

Many physicians believe that the government does little good when it juxtaposes itself between physician and the patient. However, the government can be the most disinterested agent if it wished.

Yet it seems unwilling not only of disavowing policy of ideology, as the mandate to show the fetus on ultrasound to women undergoing termination of pregnancy in certain states indicates, but of any inclination of understanding medical evidence.

The law has passed in both red and blue states displaying that rare bipartisanship seen only when the nation is under imminent threat of war. You don’t have to be a psephologist to figure out that embracing pink doesn’t lose votes.

And there lies the problem. The ACA attempts to realign the incentives of physicians and patients. It explicitly emphasizes evidence in the practice of medicine. However, it hasn’t shut the direct line between the legislator and the citizenry through which rational healthcare policy-making can be undone. The identifiable victim still reigns supreme.

Screening is good. But up to what point?

Untrammelled by costs for fear of the label death panels, indeed unmoored by any number, the ACA makes it unclear when the pursuit of early cancer should cease.

How many women with dense breasts should have annual MRIs to save one life from cancer? A thousand? Ten thousand? A million? Ten million? Is there a limit?

Saurabh Jha, MD is an Assistant Professor of Radiology at the University of Pennsylvania. His scholarly interests include the value of imaging and dealing with uncertainty in clinical decision making. Jha views most problems in medicine as problems of imperfect information. He trained in the UK and migrated to USA for more predictable weather and a larger yard.

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12 replies »

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  3. Legacy, mostly agree with you, except for the bit about the “industrial complex”. The American College of Radiology does not support the law (they do support mammography).

    The law speaks of the power of advocacy.

    Science versus democracy. What chance does science stand?

  4. By the way, since the ACA has not addressed tort reform, following Evidence Based Medicine recommendations will not likely hold up in court.

  5. Legacy, I understand perfectly. My wife is a radiologist and HATES mammography. As a woman, she also feels that while there is some benefit, the emotional and political complexes have overblown the extent of the disease. Hence women are terrified of breast cancer and will do anything to keep the demon at bay. She was in the mammo center last week and did one on a 75 year old woman who has been treated for 3 other cancers.
    Not to mention the huge medical legal ramifications for a so-called “missed lesion”. The test in this country has greatly limited usefulness because radiologists don’t want to overlook anything that might be construed as an early cancer.
    Yes, when the government pokes it’s nose into health care and medical issues, the politics will outweigh the valid science.

  6. I read mammograms, breast US, did breast biopsies and needle localizations for 25 years. Luckily for the last 5 years I have not had do mammography/breast imaging.

    Mammograhy is not a very good test; it has a high false positive rate and a moderate false negative rate – even in the best hands. Unfortunately, it is the best we have for screening – at this point. There is also MRI, which is probably too expensive to be a screening test and tomo-synthesis, which is just getting started and expensive too.

    Because of unrealistic expectations, the medical-legal risks of doing breast imaging are out of control. In virtually every case of an interval detection of a tumor (means a woman has been getting screened and cancer is detected on subsequent exams) an “expert” can go back and see it on the prior image. You can imagine what that means.

    The whole field has been out of control for many years. There now exists a
    “Mammography/Industrial Complex” that is the most sacred of sacred cows. Research spending on Breast Cancer is many multiples of spending on prostate cancer despite similar incidence and mortality. Speak against this sacred cow and you will be labeled as a horrible sexist, chauvinist, etc. (Watch the comments to this posting)

    And of course some members of my own field (Radiology) have drunk the KoolAid too. And the fact that there is money to be made isn’t irrelevant to their concerns.

    We would be a whole lot better if we just turned down the volume on Breast Cancer from 11 (reference to “Spinal Tap”) to a more reasonable number. Don’t hold your breath waiting for this to happen.

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