“Missed” Cancers

If every radiologist who had missed a mammographically-detected cancer were to quit reading mammograms tomorrow, there would be no more mammography. The truth is that the breast is a very complex organ to image, and there are a number of benign conditions that mimic the appearance of cancers. Unfortunately, the public’s perception is that a “normal” mammogram means that there is no cancer, and this misconception, coupled with the prevalent idea that, somehow, the physician is responsible for bad health outcomes, leads to many lawsuits being filed over cancers in which the interpreting physician had very little likelihood of affecting the ultimate result.

What can be done about this unfortunate situation? My next few blogs will address a few different approaches to the missed cancer—from prevention to attitude—in an attempt to make these occasions less frequent, more understandable, and less emotionally traumatic when they occur. I will attempt to address the subject from both the patient and physician perspectives in an attempt to develop better understanding among all those who are concerned.

Mammography is an excellent technology, but it’s limited in its ability to present information to the radiologist. The limitations of mammography are largely the result of the variability of the tissue that comprises the breasts of individual patients, and how that tissue presents on an X-ray image. Basically, X-rays go through fat cells easily, allowing cancers to appear in stark contrast to the surrounding tissue. Glandular tissue, on the other hand, appears white and can hide—or obscure altogether—cancers that may be in the breast. This is particularly true for small, early stage cancers.

As a cancer grows it will become more evident, even in dense glandular tissue, and it may even reach the size where it can be felt. In these cases, when the radiologist—knowing where the cancer is in the breast—looks back to prior mammograms, he or she can see the cancer in the maze of glandular densities. This is not a miss, for the cancer is only identifiable in hindsight. This case may be very “defensible” from a legal perspective, but it does not alter the fact that the patient has a cancer, or that she had that cancer at a time when she thought she was “normal."

Cancer news is always bad news for the patient. Emotions run high and it is very easy for the patient to transfer her anger about the disease to her physician. This is especially true when he fails to communicate with the patient either because the subject is unpleasant or he is afraid to discuss a subject that could end in litigation. In most cases the patient is looking for understanding, but failure to communicate and to share the patient’s pain sends the message that something went wrong. This is never a good outcome.