- Email: [email protected]
The Eye of the Beholder
EDITORIAL
BRUCE J. HILLMAN, MD
The Eye of the Beholder For now we see through a glass, darkly. —1 Corinthians 13:12 This issue of the journal contains a fascinating Point/Counterpoint between two radiologists who read the same article in the New England Journal of Medicine but interpret its content very differently. How is it possible that Daniel Kopans, MD, and David Seidenwurm, MD, disagree so completely? Both are accomplished physicians with histories of critically reading and contributing to the imaging literature. The article is written in English, the native tongue of both reviewers. Presumably they both read the article completely. Hence, the data presented were the same for each. The article in question is Bleyer and Welch’s [1] “Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence.” The article calls into question whether the benefits of mammography outweigh the downside of false-positive diagnoses, with their associated cascade of follow-up imaging, anxiety, and cost. If nothing else, what Bleyer and Welch’s article tells us is that, despite screening mammography’s being a heavily promoted feature of women’s health, its value remains a hot-button issue. Surprisingly so. On the surface of things, screening mammography seems like such a
bargain. The screening examination itself is relatively low cost. Mammographic screening detects early-stage cancers. Numerous population-based studies have shown a mortality reduction. And there has been a decline in breast cancer mortality that coincides with the dissemination of our national screening program. If it weren’t for all those pesky false-positives . . . if only pseudodisease (breast cancer that exists but does not adversely affect women during their lifetimes) were not an issue, we could get past all this and move on to some other controversy. But these considerations do exist, and they are important. So the contentious, often angry debate continues, swinging first in one direction and then the other. The differences in Drs Kopans’s and Seidenwurm’s viewpoints are at least partly explainable by their worldviews. Kopans is a breast imager, and Seidenwurm is not. I speak from experience and with undiluted admiration when I say that, like the rich in F. Scott Fitzgerald’s Great Gatsby, breast imagers are different from you and me. During my tenure chairing ACRIN®, from 1999 to 2007, I had the opportunity to oversee the development, implementation, and analysis of clinical trials by luminaries of radiology’s various subspecialties. The people who chaired the subspe-
cialty committees and the principal investigators who led the individual trials were uniformly talented and dedicated. Even so, the breast imagers stood out. To a person, they breathed their work. Like The Blues Brothers’ Jake and Elwood, they believed they were on a mission from God. That Dr Kopans is among the more passionate of his unique species is evident in how he titled his piece: “The New England Journal of Medicine Article Suggesting Overdiagnosis From Mammography Screening Is Scientifically Incorrect and Should Be Withdrawn.” In contrast, Dr Seidenwurm tackles Bleyer and Welch’s article and Dr Kopans’s assertions surgically, letting his assessment of the science carry its own weight. In the end, reading this month’s Point/Counterpoint brings home what we already knew. Each of us tends to see things through a different lens, one developed through what we read, see, and experience. From my perspective, this makes very interesting reading. Vive la différence. REFERENCE 1. Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med 2012;367:19982005.
Bruce J. Hillman, MD, UVA-Radiology Research, Box 801339, Charlottesville, VA 22908; e-mail: [email protected].
308 0091-2182/13/$36.00
●
© 2013 American College of Radiology http://dx.doi.org/10.1016/j.jacr.2013.02.005
BRUCE J. HILLMAN, MD
The Eye of the Beholder For now we see through a glass, darkly. —1 Corinthians 13:12 This issue of the journal contains a fascinating Point/Counterpoint between two radiologists who read the same article in the New England Journal of Medicine but interpret its content very differently. How is it possible that Daniel Kopans, MD, and David Seidenwurm, MD, disagree so completely? Both are accomplished physicians with histories of critically reading and contributing to the imaging literature. The article is written in English, the native tongue of both reviewers. Presumably they both read the article completely. Hence, the data presented were the same for each. The article in question is Bleyer and Welch’s [1] “Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence.” The article calls into question whether the benefits of mammography outweigh the downside of false-positive diagnoses, with their associated cascade of follow-up imaging, anxiety, and cost. If nothing else, what Bleyer and Welch’s article tells us is that, despite screening mammography’s being a heavily promoted feature of women’s health, its value remains a hot-button issue. Surprisingly so. On the surface of things, screening mammography seems like such a
bargain. The screening examination itself is relatively low cost. Mammographic screening detects early-stage cancers. Numerous population-based studies have shown a mortality reduction. And there has been a decline in breast cancer mortality that coincides with the dissemination of our national screening program. If it weren’t for all those pesky false-positives . . . if only pseudodisease (breast cancer that exists but does not adversely affect women during their lifetimes) were not an issue, we could get past all this and move on to some other controversy. But these considerations do exist, and they are important. So the contentious, often angry debate continues, swinging first in one direction and then the other. The differences in Drs Kopans’s and Seidenwurm’s viewpoints are at least partly explainable by their worldviews. Kopans is a breast imager, and Seidenwurm is not. I speak from experience and with undiluted admiration when I say that, like the rich in F. Scott Fitzgerald’s Great Gatsby, breast imagers are different from you and me. During my tenure chairing ACRIN®, from 1999 to 2007, I had the opportunity to oversee the development, implementation, and analysis of clinical trials by luminaries of radiology’s various subspecialties. The people who chaired the subspe-
cialty committees and the principal investigators who led the individual trials were uniformly talented and dedicated. Even so, the breast imagers stood out. To a person, they breathed their work. Like The Blues Brothers’ Jake and Elwood, they believed they were on a mission from God. That Dr Kopans is among the more passionate of his unique species is evident in how he titled his piece: “The New England Journal of Medicine Article Suggesting Overdiagnosis From Mammography Screening Is Scientifically Incorrect and Should Be Withdrawn.” In contrast, Dr Seidenwurm tackles Bleyer and Welch’s article and Dr Kopans’s assertions surgically, letting his assessment of the science carry its own weight. In the end, reading this month’s Point/Counterpoint brings home what we already knew. Each of us tends to see things through a different lens, one developed through what we read, see, and experience. From my perspective, this makes very interesting reading. Vive la différence. REFERENCE 1. Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med 2012;367:19982005.
Bruce J. Hillman, MD, UVA-Radiology Research, Box 801339, Charlottesville, VA 22908; e-mail: [email protected].
308 0091-2182/13/$36.00
●
© 2013 American College of Radiology http://dx.doi.org/10.1016/j.jacr.2013.02.005