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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Michael Hewitt
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Michael Hewitt

Brilliant piece!

Saurabh Jha
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Saurabh Jha

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?

legacyflyer
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legacyflyer

Perry,

Thanks for the support. I was expecting to be blasted.

Perry
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Perry

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… Read more »

Perry
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Perry

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

legacyflyer
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legacyflyer

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… Read more »