The ‘Decline’ of Medical Care in the Empire State

February 20th, 2014

New York City and vicinity has the best of everything and the worst of everything, a fact to which all great cities can attest. In New York, I’ve been able to have rarely diagnosed conditions identified through the perseverance of someone born to the theme of “I can do this!” Expertise is all around us today. If you can define the problem before you, an answer can be found. This permitted me to learn I’d been poisoned (see previous posts) and had suffered a fungal infection from the overuse of antibiotics. I’d obtained a diagnosis of gluten intolerance without undergoing surgery because my doctor happened to have studied advanced diagnostic techniques in Japan.

When I say ‘decline’, as in the title of this post, I mean your right to refuse any service of dubious purpose and/or quality. Yes, Virginia, you are allowed to decline any suggestion someone makes to you for any purpose and ask for clarification. For instance, what do you say to a radiologist who tells you that you must permit her to take 21 mammography films of your breasts due to the presence of a palpable lump? How about, ‘No. Is there something wrong with the equipment that you need so many films?”

So, in June of 2011, when a radiology technician looked at her orders and saw how many films had been ordered for me, she appeared disturbed by the information. I asked her what had been ordered. When she replied that a large number of films had been ordered (my memory indicates it was around 21 films), I refused. In this case, I’d just been ordered to take as many as a dozen more films than was needful. Hindsight informs me I ought to have walked out of that office but I was in distress. A woman newly informed she has breast cancer isn’t in the greatest shape for assessing the recommendations of professionals. Sad to say, you must be prepared to do just that.

The technician admitted she’d never performed that many films on a single patient before at one time. “I’m not allowed to change the orders but I can talk to the radiologist about your concerns.”

I felt grateful for her understanding. “Thanks, please do. This is simply too much exposure for even a hard-to-test woman. And I just don’t have that much to photograph!”

When the tech returned, I was escorted into the august presence of the radiologist who was frankly angered by my questions. However, hard experience had taught me to refuse rather than become refuse. It took me a minute to get used to her German accent but she basically ordered me to take the films. Five minutes later, following my calm but firm rejection of her prescription, she finally agreed to reduce the numbers of films and sixteen were taken, all told. I now realize even that was excessive after reading an article in the British Medical Journal (BMJ), about one of the largest studies ever done on the efficacy of mammography in reducing mortality rates in invasive breast cancer cases.

Performed in Canada, where national health insurance permits large numbers of women to be ‘followed’ for various health conditions, more than 18,000 exams were recorded. This led to approximately seven percent of the women to be identified as having invasive breast cancers. The statistical aspects of this study were problematic since another common form of cancer wasn’t included and assignments of the women between the ‘study’ and ‘control’ arms (with mammograpny or with manual examination alone) turned out to be a tainted process.

Nonetheless, the aims of the study were admirable and the responses of experts in this field were highly educational in evaluating the article, instead of merely rubberstamping the findings. The Canadian study concluded that manual examinations weren’t more or less effective than mammography in identifying cancers as measured by the survival rates of women under the age of sixty. One respondent, Dr. Kopans of Harvard University , had even evaluated the machinery of that period in 1990 and identified the machinery as producing films. of inferior quality. That, along with other factors, influenced the mortality statistics. Belated identification would certainly increase mortality.

Overall, the recommendations of the American Cancer Society remain aggressive for early detection of breast cancer. The Mayo Clinic advises women to work with their doctors to determine screening options based upon their personal risk factors but also believed the study noted above to minimize the importance of screenings in mortality reduction. What we can all learn from this controversy is that to question the opinions and research of professionals is not just permissible but essential if we are to reach our goals.

The response I sent into the journal wasn’t deemed suitable for publication by the BMJ. Perhaps it had something to do with my comparison of mammography equipment to elevators in the USA and Europe. Elevators are required to have posted their age and last date of assessment by repairmen. Perhaps X-ray machines ought to as well. Truthfully, the rapid responses they did post were far more erudite than my own.

Fortunately, my questions about the mammography process I experienced did bear fruit via my email exchanges with Dr. Kopans. He kindly replied to my letter about machine repair and appropriate levels of radiation exposure at various ages, also granting permission for me to post his reply for all to view. Please note in that letter, I recalled the wrong number of mammograms that were recommended and taken. Unsure, I called the radiology practice today and they looked up the exact numbers in question – 16 films taken (and at least five refused) in June of 2011. Here is that exchange:

Dear Dr. Kopans,

I was most impressed by your rapid response to the BMJ article on mammography and hope you have the time to respond to a question about radiology guidelines for optimal safety in breast cancer screenings. After a palpable mass was noted upon examination by a physician, I visited a surgeon who ordered mammography studies, to be followed by a sonogram. I was shocked when the radiologist ordered seventeen films and politely refused what I believed to be unnecessary radiation exposures. After some argument, the order was reduced to twelve films and I reluctantly complied, along with a rather skeptical tech whod also appeared perplexed by these orders.

Is there any agreement within your profession about the quality of a machine that would require so many views in order to guarantee satisfaction? Might a better maintained machine require far fewer films, requiring women like myself to question any orders for more than three views per breast (oblique, side and frontal?). It appears that patients must be more knowledgeable about our care in order to optimize our access to care and if more of us asked the proper questions, providers would have a great argument for modernizing and maintaining their equipment. They might otherwise have fewer patients selecting their facilities. Sonograms should provide adequate additional information for our over-exposed population of women over the age of 25.

An additional question I have is the use of MRI films as follow-up to diagnosed cancers. I was informed that gadolinium was needful although in previous brain MRIs (to view damage inflicted by pesticide exposures), it proved unnecessary. When I requested those studies be performed without contrast, the radiologists agreed and found the results to be of equal value. Current opinion informs me that contrast is a requirement for viewing masses in the breast. I have already had a lot of material removed from both breasts and dislike the idea of absorbing dyes with radioactive content into the fat cells with existing cancer risks. Are there other options? My physician would prescribe this exemption if I can obtain professional opinions indicating suitable alternatives.

Thank you for your attention. If you wish, I can post your reply to a blog that will be seen by others but will only do so with your permission.

Barbara Rubin
Dear Ms. Rubin:

Feel free to share my response.

You have asked several important questions. As you can imagine I cannot address your particular situation because I have not seen the images in question. I would certainly hope that the number of images obtained was not due to poor quality imaging. It is sometimes necessary to obtain several pictures from different directions to see around normal breast structures. For example, if there is a birch tree in a pine forest, even though the birch has white bark, it can be hidden by the pine trees unless you find a viewing angle where the birch becomes visible. I agree, even 12 films seems excessive to me, but sometimes it is difficult to get the angles that are needed.

The oblique and top to bottom (there is really no “frontal view”) are standard for screening. The side view or straight lateral is a variation of the oblique view that may be sufficient to give the radiologist the answer needed to solve the question, but often other images are needed including spot compression to try to spread the structures apart to see between them, and magnification views to provide higher detail over a small area.

The good news is that radiation risk to the breast is very low once the tissues have matured. All of the data show that radiation risk to the breast (mammography causes very little scatter beyond the breast) is in teenagers and women in their early twenties. There is little if any risk to the breast after the age of 30, and any risk after the age of 40 is so small it cannot be measured and may well be zero. No one has ever been shown to develop a breast cancer from mammograms. Hundreds of millions of mammograms were performed in the late 1980’s and early 1990’s. If mammography was causing cancers there should have been a major jump in incidence in the late 1990’s and around the turn of the century (radiation induced cancers do not appear for 8-10 years). Instead, the incidence of breast cancer dropped around that time. If you are over the age of 40 there is probably no risk from mammography.

Sonograms often help to determine the importance of a finding on mammography once it has been shown to be real on the mammogram and not simply normal tissues that superimpose on the screening images. Superimposed normal tissue can make shadows that look like a possible cancer, but turn out to be normal tissues projected on top of one another. If someone holds one hand up in front of a bright light it is easy to tell that the shadow on the wall is a hand, but if you start adding other shadows on top it becomes difficult to be certain what is causing the shadows. This is true for all mammograms, even on the best machines. We developed a technique called Digital Breast Tomosynthesis (some call it 3D mammography) that eliminates some of the problems with standard mammography, and these devices are gradually replacing standard machines. This will eliminate some, but not all of the problems.

Unfortunately, ultrasound is not the solution since there are even more confusing findings on ultrasound images if you use it to scan the entire breast. However, it is very helpful if you know where a questionable lesion is, to help determine if the lesion is something to worry about or not.

Unfortunately, Magnetic Resonance Imaging (MRI) of the breast, with the exception of imaging breast implants, requires the intravenous injection of gadolinium. Unlike some MRI of other organs, breast MRI relies on imaging the tiny blood vessels associated with cancers to be able to identify and analyze them. We are trying to find ways to eliminate the need for intravenous contrast material, but none have been successful. The good news is that these are not radioactive particles. They are excreted fairly efficiently from the body as long as kidney function is good

I hope that I have answered your questions.

Sincerely yours

Daniel B. Kopans, M.D.

Daniel B. Kopans, M.D.
Professor of Radiology, Harvard Medical School
Senior Radiologist, Breast Imaging Division
Department of Radiology, Massachusetts General Hospital
Avon Comprehensive Breast Evaluation Center
ACC Suite 240
15 Parkman Street
Boston, MA 02114

Office: 617-726-3093
Fax: 617-726-1074

Categories: Articles, British Med. Journal, Letters, Life Observations

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