Health News Review

I’ve spoken and written about the imbalance in the news coverage about the U.S. Preventive Service Task Force’s new guidelines on mammography last November.

If stories and communications are going to use anecdotes, then for every anecdote about a woman who claims her life was saved by a mammogram in her 40s (something that can’t be proven), there should be a countering anecdote with a woman who had a mammogram in her 40s and got a diagnosis of DCIS or ductal carcinoma in situ.

Well the New York Times nailed that story this week, under the headline, “Prone to Error: Earliest Steps to Find Cancer.

I’ll only offer the link and will post only this one excerpt:

“Diagnosing D.C.I.S. “is a 30-year history of confusion, differences of opinion and under- and overtreatment.”

Everyone should read this story in its entirety.

It covers what was missing too often in the discussion about mammography screening last November. There are tradeoffs of harms and benefits. There is a need for fully informed shared decision-making in the face of this diagnosis. This story makes that clear. Much of our public discussion has not.

Comments

Dennis (Investigator/Negotiator) at Medical BillDog posted on July 21, 2010 at 10:18 am

Thanks, Doc, for drawing attention to this important article. It’s good to see the popular press get one right, now and again. For me Stephanie Saul’s key points were
(1) 1 in 6 needle biopsy positives for DCIS are wrong
(2) run, do not walk, from an oncologist who claims to be infallible or even implies infallibility.
Sound about right?

Maryann Napoli posted on July 21, 2010 at 3:15 pm

I agree this is a terrific article, largely because it includes the voices of women who were misdiagnosed. One criticism, however: Unskilled pathologists come across as the problem. To me, mammography screening w/o prior informed consent is the problem. How many women would subject themselves to this screening test if they understood—-well in advance—-that the test is far more likely to ruin your life than save your life? See this Cochrane review of all randomized controlled mammography screening trials. http://www2.cochrane.org/reviews/en/ab001877.html

Gregory D. Pawelski posted on July 21, 2010 at 11:41 pm

Maryann’s comment about unskilled pathologists coming across as the problem, is well noted. Cancer Medicine: Priinciple of Multidisciplinary Management (6th Edition) tells us that pathologic uncertainty is a shaky foundation on which to build therapeutic strategy. When doubt exists concerning the nature of a neoplasm, additional opinions are always appropriate.
Pathology is a very visual science. It appeals to people who have a talent for recognizing patterns. This pattern recognition comes after years of practice. Cancers grow in recognizable patterns that allow for their identification. A breast cancer has a certain growth pattern that differs from a carcinoma of the lung. Benign conditions also have patterns.
It is said that a pathologist will never make a diagnosis unless they are 200% sure of the diagnosis. Having said that, there are situations where a definitive diagnosis cannot be rendered. Sometimes it is because the biopsy sample that was taken by the surgeon is too small, or perhaps taken from an area that is not representative of the patient’s lesion.
Physicians tend to settle on the smallest amount of tumor tissue possible, often with a fine needle aspirate that collects just a few cells, for biopsy analysis. Larger bore needles (tru-cut) are needed to perform core biopsies or even remove entire lymph nodes, so that they can collect enough “live” tissue to more reliably determine the histologic and molecular features of a cancer.
Then there comes a time when a pathologist must admit that they do not know. Considering that the rarest of diseases pass under the pathologists’ microscope, this is not surprising. There are several diagnostic tests or special stains (immunohistochemistry) which the pathologist can turn to which may aid in the diagnosis.
In a statistical analysis, the tentative diagnosis, the interpretation of stains and conclusions drawn from immunohistochemistry are independent factors in reaching a diagnosis. The immunohistochemical (IHC) staining test is performed on microscope slides, with intact cells and looks for proteins themselves.
The cell-block technique is useful for IHC and can give morphological (structural) details by preserving (iin paraffin wax) the architectural patterns. However, according to cell function analysis, investigators can only measure those analytes (subtance or chemical constituent) in paraffin wax that they know to measure. If you are not aware of and capable of measuring a biologically relevant event, you cannot seek to detect it.
Cell-blocks are paraffin-embedded and paraffin-embedded tissue can change over time. These proliferating populations of cells are biologically distinct in their behavior from “fresh” live cells that comprise human tumors.
Because the results of the IHC test can sometimes be ambiguous, many doctors suggest the FISH (fluorescent in situ hybridization) test for a second opinion. However, there has been poor concordance in terms of FISH testing in a central laboratory compared to local laboratories, which the prevalent notion regarding FISH is that it is 100% accurate.
They have yet to explore all the quality control issues of FISH. Several things can be done to improve performance and reduce variability. One thing is to train the interpreter. Another is to have the laboratory be certified. According to clinicians at the Mayo Clinic, oncologists need to be more aware of which laboratory performs the tests and who interprets the results, because it can make a huge difference.

Kathi posted on May 6, 2011 at 7:20 pm

Our mutual friend Jody just pointed me to this post. We just attended the NBCC Conference this past weekend. I had a partial mast, radiation & tamoxifen after rather extensive DCIS was found in one breast. The pathologist that evaluated my stereotacic biopsy was 200% sure of what it was. I double-checked the analysis that was done myself. It’s frustrating that we can’t yet tell which in-situ ductal and lobular carcinomas are slow-growing and/or which are likely to turn invasive. Some of the research available on the likelihood of DCIS becoming invasive is confusing or flawed or was done before screening mammography was commonly done.
Yes, it was a traumatic experience, and yes, the fact that I call my blog “The Accidental Amazon” may be even more ironic than I initially intended it to be. But, according to my own final path report, the cells were found to be between Grade 2 and 3, meaning that they were growing moderately quickly. There was even an apparent increase in the spread of them from what was seen on the first diagnostic images to what was seen on the pre-surgery mamm I had for wire localization. That tells me I did the right thing. I think it was a lot less stressful to have had half my breast lopped off when I did than to sit around waiting and wondering.
We heard some interesting things at the NBCC Conference about how researchers are learning more about how cancer cells get switched on to start growing into tumors in the first place. Hopefully, not too far down the road, this may mean that ‘early detection’ will truly be a meaningful phrase, and that we will know how to do just enough but not too much in order to halt them in their tracks.