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Letter from the editor: “Primum, non nocere”
Seminars in Roentgenology VOL XXVIII, N O 4
OCTOBER 1993
Letter From the Editor: " P r i m u m , Non Nocere" HIS ISSUE is the first of two issues that will
T be devoted to the recognition of radiation damage to various organs. Skip Libshitz has put
together an impressive list of contributors who have provided us with some excellent papers on this subject. I hope that you find them as interesting as I have. Most of the readers of this journal are diagnostic radiologists. These radiologists are interested in the radiographic evaluation of the effects of radiation but are never the physicians who actually cause these effects. A few of us older diagnostic radiologists are fossils from a day when certification in radiology included certification in therapeutic radiology. Some of us have even performed a fair amount of radiation therapy. In my 2 years in the US Navy, I shared with one other individual the responsibility for all the radiation therapy performed in a 1,500-bed general hospital. I was always concerned about radiation damage to normal structures, which was inevitable in high-dose therapy to various tumors. I am sure that the radiotherapist today is concerned about the same problem. As a diagnostic radiologist in later years, I have occasionally encountered a tragic case where a patient developed a crippling problem secondary to the radiation therapy that had obliterated that patient's original tumor to provide longterm survival. A number of these cases were patients with severe small-bowel problems due to radiation enteritis. One case that I remember well was a hard-working woman executive who was forced to live with a chronic draining fistula from skin and soft tissue necrosis and subsequent scapular osteomyelitis that was secondary to radiotherapy for breast cancer. A major tenet that all of us learn in medical school and that all of us try to observe in clinical practice is "primum, non nocere": first, do no harm. This is often difficult for the surgeon or the radiotherapist whose patients may develop complications from an intelligent and carefully
planned therapeutic procedure. As diagnostic radiologists, it seems unlikely that we should perform any action that may harm our patients. However, the side effect inherent in some of the new and wonderful techniques that are available to us (computed tomography, magnetic resonance imaging, and ultrasonography, to name a few) is the recognition that we may unintentionally be harming our patient population. This problem is nicely outlined in a New England Journal of Medicine article by Black and Welch entitled "Advances in Diagnostic Imaging and Overestimations of Disease Prevalence and the Benefits of Therapy. ''1 I advise you to dig this article out and review it for yourself. It is not possible for me to adequately summarize it in a brief fashion, but it points out significant problems that arise from the diagnosis of small loci of such diseases as cancer of the prostate, thyroid carcinoma, and even breast carcinoma. It deals with the problems of lead-time bias and length bias and focuses on some of the problems of "early diagnosis" of various diseases. We may be, indeed we are, identifying many patients with small malignancies that are of low grade and unlikely to influence in any way the life of the patient. Identification of these lesions often leads to surgical procedures, sometimes radical, "in a newly detectable strata of disease for which the effectiveness of intervention is unknown. ''~ Removal of small lesions detected at an early stage may be curative, but it may also confuse our understanding of the course of any disease process because we may be removing lesions that never subsequently become clinically apparent. "The temptation to act aggressively must be tempered by the knowledge that the natural history of a newly detectable disease is unknown. ''1 Of course, the actual therapy initiated for diseases that we detect is the province of our clinical colleagues. But we need to give them guidance. It behooves all of us, the clini-
Seminars in Roentgenology, Vol XXVIII, No 4 (October), 1993: pp 291-292
291
292
cian and the radiologist, to learn more about the natural history of the early lesions that we are now able to detect. Alternative strategies, such as careful observation, may be warranted in many of these lesions. Early detection of some diseases can be lifesaving, but we must detect real disease. We may be creating needless "churning" without significantly influencing the real outcome of a disease process. This, in
WALLACE T. MILLER
essence, can be real "harm" growing out of our innocent use of these new imaging techniques.
Wallace 7". Miller, M D Editor REFERENCE
1. BlackWL, Well HHG: Advancesin diagnosticimaging and overestimations of disease prevalence and the benefits of therapy New Engl J Med 328:1137-1243,1993
OCTOBER 1993
Letter From the Editor: " P r i m u m , Non Nocere" HIS ISSUE is the first of two issues that will
T be devoted to the recognition of radiation damage to various organs. Skip Libshitz has put
together an impressive list of contributors who have provided us with some excellent papers on this subject. I hope that you find them as interesting as I have. Most of the readers of this journal are diagnostic radiologists. These radiologists are interested in the radiographic evaluation of the effects of radiation but are never the physicians who actually cause these effects. A few of us older diagnostic radiologists are fossils from a day when certification in radiology included certification in therapeutic radiology. Some of us have even performed a fair amount of radiation therapy. In my 2 years in the US Navy, I shared with one other individual the responsibility for all the radiation therapy performed in a 1,500-bed general hospital. I was always concerned about radiation damage to normal structures, which was inevitable in high-dose therapy to various tumors. I am sure that the radiotherapist today is concerned about the same problem. As a diagnostic radiologist in later years, I have occasionally encountered a tragic case where a patient developed a crippling problem secondary to the radiation therapy that had obliterated that patient's original tumor to provide longterm survival. A number of these cases were patients with severe small-bowel problems due to radiation enteritis. One case that I remember well was a hard-working woman executive who was forced to live with a chronic draining fistula from skin and soft tissue necrosis and subsequent scapular osteomyelitis that was secondary to radiotherapy for breast cancer. A major tenet that all of us learn in medical school and that all of us try to observe in clinical practice is "primum, non nocere": first, do no harm. This is often difficult for the surgeon or the radiotherapist whose patients may develop complications from an intelligent and carefully
planned therapeutic procedure. As diagnostic radiologists, it seems unlikely that we should perform any action that may harm our patients. However, the side effect inherent in some of the new and wonderful techniques that are available to us (computed tomography, magnetic resonance imaging, and ultrasonography, to name a few) is the recognition that we may unintentionally be harming our patient population. This problem is nicely outlined in a New England Journal of Medicine article by Black and Welch entitled "Advances in Diagnostic Imaging and Overestimations of Disease Prevalence and the Benefits of Therapy. ''1 I advise you to dig this article out and review it for yourself. It is not possible for me to adequately summarize it in a brief fashion, but it points out significant problems that arise from the diagnosis of small loci of such diseases as cancer of the prostate, thyroid carcinoma, and even breast carcinoma. It deals with the problems of lead-time bias and length bias and focuses on some of the problems of "early diagnosis" of various diseases. We may be, indeed we are, identifying many patients with small malignancies that are of low grade and unlikely to influence in any way the life of the patient. Identification of these lesions often leads to surgical procedures, sometimes radical, "in a newly detectable strata of disease for which the effectiveness of intervention is unknown. ''~ Removal of small lesions detected at an early stage may be curative, but it may also confuse our understanding of the course of any disease process because we may be removing lesions that never subsequently become clinically apparent. "The temptation to act aggressively must be tempered by the knowledge that the natural history of a newly detectable disease is unknown. ''1 Of course, the actual therapy initiated for diseases that we detect is the province of our clinical colleagues. But we need to give them guidance. It behooves all of us, the clini-
Seminars in Roentgenology, Vol XXVIII, No 4 (October), 1993: pp 291-292
291
292
cian and the radiologist, to learn more about the natural history of the early lesions that we are now able to detect. Alternative strategies, such as careful observation, may be warranted in many of these lesions. Early detection of some diseases can be lifesaving, but we must detect real disease. We may be creating needless "churning" without significantly influencing the real outcome of a disease process. This, in
WALLACE T. MILLER
essence, can be real "harm" growing out of our innocent use of these new imaging techniques.
Wallace 7". Miller, M D Editor REFERENCE
1. BlackWL, Well HHG: Advancesin diagnosticimaging and overestimations of disease prevalence and the benefits of therapy New Engl J Med 328:1137-1243,1993