According to a recent study, in almost 16% of the cases, radiologists will report false-positive cancer readings in mammogram x-rays. Many of these radiologists are younger and newly trained doctors who may be likely to make more errors in interpretation than their more experienced counterparts.
The Journal of the National Cancer Institute found that only if the radiologists could compare films from their earlier mammogram screenings, the rate of these “false-positives” could be lowered significantly.
Dr. Joann Elmore, professor of epidemiology at the University of Washington (School of Medicine), says that it is alarming how common false-positives have become in the US. She also said that false-positives are most likely to occur in the case of breast cancer mammogram screenings but it shouldn’t discourage women from having annual check-ups.
According to Dr. Elmore, even though mammography is not the perfect test, it is still the best technology we have for detecting breast cancer at this point in time, and women only have a 10% of a chance of being called back for additional screenings.
She suggests that women should continue to have mammograms at the same testing facility so that the radiologists can compare past screening results.
In an interview with CBS Radio, Elmore said that if a woman has been going to the same facility for 5 or 8 years, the radiologists can just pull up the old films and get some assurance that a slight abnormality has been stable for over 5 or 6 years.
When radiologists compare current films with past screening images, the chances of false positives reduce by 70%.
Getting called back for a second test may not mean anything
The study involved 24 radiologists who evaluated mammogram readings from 2,169 women from the years 1985-1993, and this gave them time to follow-up with the patients.
The study also analyzed the rate of false positives diagnosis given by the doctors and then associated it with the training and experience of the radiologists and to the factors pertaining to the patients (for example, patient’s age).
Dr. Elmore said, out of 100 women to go to get a mammogram screening, 10 may be called back for more testing, and a majority of these women (who get called back) don’t have breast cancer.
According to the study, the rate of false-positives ranged from 2.6% to 15.9% but when it was adjusted for the effect of factors like patients’ age, the rate dropped to 3.5% to 7.9%.
The reason why age affects the false positive rate so much is that younger women’s breast tissue is much denser, making it far more difficult to interpret their mammograms.
The study also found that physicians who graduated from medical school within the last 15 years had 2-4 times higher rate of false-positives than their more experienced colleagues.
Dr. Elmore suggests that young doctors may have gone through training that focuses on finding cancer but doesn’t emphasize on the fact that false positive results can cause them to call back healthy women for additional tests. She said that experience matters a lot in these cases.
She also admitted that it is also possible that these younger doctors are just catching more cases of cancer, but it’s not certain at this point.
The truth is that the threat of malpractice lawsuits may cause doctors to err on the side of caution when it comes to mammogram interpretations. After all, mammography is one of the topmost causes of medical malpractice lawsuits in America.
Even though the study succeeded in deducing which doctors interpreted the most false-positives, it failed to discern which doctors were most accurate in catching cancer. It should be noted that 45 cases of breast cancer were verified out of the 2,169 mammogram readings that were performed for the study.
A false positive leads the woman to be called back for additional tests which can be limited to added x-ray exams or some other form of examination by a specialist.
In some cases, the callback can lead to a biopsy, which means removal of a small part of breast tissue for a more thorough examination. This microscopic examination is considered the “gold standard” for detecting out-of-place lesions.
Whatever the case may be, false positives result in a heavy financial and psychological burden for many women.
Case Studies: Misread Mammogram and Ultrasound Interpretations
Harris v. Hanson, 2009 MT 13, 349 Mont. 29, 201 P. 3d 151
Sandra K. Harris v. John Hanson 349 Mont. 29
Medical malpractice action was brought by the patient against doctors, alleging that they were careless and failed to diagnose her breast cancer from an ultrasound and a mammogram.
Sandra K. Harris brought a medical malpractice lawsuit against Joe Dillard, M.D. (Dillard), Anne W. Giuliano, M.D. (Giuliano), and John V. Hanson, M.D. (Hanson).
Sandra claimed that these doctors were professionally neglectful and failed to detect her breast cancer from a mammogram test which was carried out in February 2002, then again in January 2004, and an ultrasound test in March 2004. Harris had a total of 4 mammograms performed during February 2000 and January 2004.
Dr. Hanson and Dr. Giuliano both read the mammogram that was performed in February 2002. In order to increase the accuracy of a mammogram, two radiologists read it and this standard practice is often referred to as “double reading.”
Both radiologists, Dr. Hanson and Dr. Giuliano, did not communicate with each other before reading the mammogram results in February 2002. Both of them read the interpretation as negative and declared there were no new findings since a previous mammogram that was performed in November 2000.
Then in June 2004, Harris felt an abnormality in her left breast and consulted with Dr. Fishburn, her internist.
Dr. Fishburn ordered another mammogram which was read by Dr. Hanson in July 2004. According to his reading, the mammogram showed an abnormality which wasn’t discovered in the exam performed six months ago in January 2004.
When Dr. Hanson found this abnormality, he conducted an ultrasound test of Harris’s left breast and concluded the affected area was suspicious for cancer cells. The test results confirmed that Harris had cancer in her left breast and she went through aggressive radiation therapy post-surgery.
A pathologist from the University of Maryland, William H. Rodgers, M.D. testified as an expert for the defendants. His background includes both an M.D. and a Ph.D. in embryology and cell biology.
He has been involved in extensive research programs in the field of breast cancer and used to teach at Vanderbilt University. Dr. Rodgers was also the Director of Anatomic Pathology at both University of Maryland and Oregon Health & Sciences University.
He studied stromal-epithelial interactions for 20 years, which is the basic biological study of several cancers including breast cancer. Analyzing the stromal-epithelial interactions shows how the malignant cells interact with normal breast tissue to form the tumors.
Rodgers was also part of the clinical research in cytopathology which is a diagnostic technique that interprets breast biopsies.
It also studies the interaction between pathology and radiology in a mammography screening. Even though Rodgers was not board-certified in radiology, he frequently interpreted mammograms with doctors as part of his practice.
When Harris objected that Rodgers was not a radiologist, the expert testified that he was sure that cancer like Harris’s would be impossible to detect on an x-ray and it had been present for at least 10 years.
The plaintiff argued that since Rodgers only studied a small sample of Harris’s malignant breast tissue at a specific point in time, he did not utilize the size of the entire mass measured by the mammogram which was later declared to be a lymph node, nor did he use the ultrasound measurements conducted between the months of March 2004 and August 2004.
Harris’s cancer was invading ductal cancer which is far more likely to be detected on a mammogram than lobular cancer.
Also, Rodger’s opinions were prepared to be used in litigation. In the light of both of these factors, his conclusions about the growth rate and visibility of Harris’s cancer revealed that modern scientific theories were, in reality, junk science.
Under Rule 702 in the state of Montana, the reliability of an expert is tested in 3 ways:
- Whether the expert is certified and competent
- Whether the field of the said expert is trustworthy
- Whether the competent expert steadfastly applied the reliable field to the facts
Rodgers is a pathologist and he is well-qualified in his field. The record shows that he has a substantial amount of experience and knowledge in the field of breast cancer, including how its detection, development, and treatment.
Since Rodgers is also highly experienced in using mammography, the District Court acted within its legal discretion when it allowed Rodgers to testify over plaintiff’s objection.
Rodgers expressed his opinion by explaining that a tumor has several regions that have a particular arrangement of stroma and cells which is usual in case of lobular carcinomas. He said these patterns are often times invisible in a mammogram.
The reason it’s hard to detect is in this particular cancer, the density of tissue is similar to the density of regular fibrotic tissue in healthy women. He further explained that doctors don’t see images radiologically that are standard of common breast cancer, which is essentially what they’re looking for in a screening test.
He said that it is not a test designed to determine medullary cancers or tubular cancers or any special kinds of cancers; it’s designed to catch the most commonly occurring cancer – ductal carcinoma.
Rodgers went to say that in his opinion, Harris already had a tumor in her breast for at least past 10 years because of the low growth rate and low-grade features of the tumor.
In the end, the court concluded that Rodgers’ testimony met the requirements of Rule 702 and his opinions were not merely new scientific theories. His expert field – Pathology – was established as trustworthy and Rodgers was established as a competent expert in that field.
That’s why it was left for the jury to decide whether Rodgers gathered and studied sufficient facts and appropriately applied those facts to reach his conclusion.
The jury decided – based on the expert’s testimony – that Harris’s breast cancer would have been impossible to detect on an x-ray and it could have been there for at least 10 years before her mammogram screening.
Misinterpreting a Mammogram is a Major Oversight
Contrary to what many people seem to think, misdiagnosis claims are not rare. According to a study published by BMJ Quality and Safety in 2014, 1 in 20 adults in America who seek medical care in community health clinics or emergency rooms face errors in their diagnosis.
When women go for their annual gynecological visit or after they feel a suspicious lump in their breast, they expect their doctor to interpret their mammogram to identify any abnormalities – abnormalities that could indicate the presence of a tumor.
After all, early detection is the best protection against breast cancer.
Unfortunately, more mammograms are misread than you may imagine. A radiologist will look at the test results after your screening and communicate the findings to your physician. If the radiologist fails to notice the signs of cancer, it is very likely that the diagnosis you received is incorrect.
This misread mammogram result will lead to a delay in the correct diagnosis of breast cancer which may prove to be disastrous.
If you or a loved one has received a misread mammogram which caused a delay in right diagnosis and necessary treatment, you need to hold the neglectful professional(s) accountable for their actions.
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