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Re: “Incidental Extracolonic Findings on CT Colonography: The Impending Deluge and Its Implications”
LETTERS TO THE EDITOR More on the Risks Associated With Radiation I have greatly enjoyed reading the recent sensible and practical article on the issue of radiation safety [1]. Despite the known risks, imaging using x-rays provides unique and valuable medical information, and if used wisely, the benefits of radiation greatly outweigh the risks. I would love to have seen the article include and discuss two additional “risks.” Many articles, especially those wishing to emphasize the risks of radiation, fail to highlight the many known risks of everyday life. Sharing this information with a concerned patient will greatly help reduce any anxiety regarding the radiation risk. About 50,000 people die annually in traffic accidents; almost nobody considers this risk when driving to the hospital for an imaging study. Many excellent Web sites summarize other risks of daily living. Let us also not forget the normal background radiation to which we are all exposed. A chest x-ray requires the same radiation as only a few days of natural background radiation. The second, and I believe very important, risk is the risk for an erroneous diagnosis being made because too low a radiation exposure has been used to create the images. Unfortunately, this risk receives very little attention in the recent literature. My comments are in no way to be read as a criticism of outstanding recent campaigns by groups such as Image GentlySM to draw attention to radiation risks. The risk for a potentially very small increase in the possibility of radiation-induced cancer many years hence must always be balanced against the much greater risk for making an erroneous diagnosis today because image quality was
poor as a result of inadequate radiation. This is a very difficult topic because we often will not know what we have missed. Phantom studies are fine but cannot easily be applied to clinical practice. We must not allow ourselves to enter into competition with other radiology groups to see who can use the lowest radiation exposures: this will expose our patients to the great risk of a missed diagnosis today. Mervyn D. Cohen, MD, MBChB Indiana University School of Medicine Department of Radiology 702 Barnhill Drive Room 1053 Indianapolis, IN 46202 e-mail: [email protected] REFERENCE 1. Thrall JH. Radiation exposure: politics and opinion vs science and pragmatism. J Am Coll Radiol 2009;6:133-134. DOI 10.1016/j.jacr.2009.04.002 ● S1546-1440(09)00173-2
Re: “Incidental Extracolonic Findings on CT Colonography: The Impending Deluge and Its Implications” In the conclusion to his article in the January 2009 issue of JACR titled “Incidental Extracolonic Findings on CT Colonography: The Impending Deluge and Its Implications,” Dr Berland [1] writes, with regard to the consequences of the use of computed tomographic colonography (CTC), that it will be “accompanied by a deluge of new incidental findings, many of which will be . . . suspicious for important disease or . . . difficult to interpret.” Asking a physician not to be interested in or comment on extra or unforeseen findings during an examination is unconscionable.
© 2009 American College of Radiology 0091-2182/09/$36.00 ● DOI 10.1016/j.jacr.2009.04.002
Computed tomographic colonography is in a different class than “whole-body” screening. When considering Dr Berland’s [1] remarks about using intravenous contrast, we should remember that we are “screening.” Case histories, such as the one Dr Berland [1] references concerning a department chairman, are “off base”; we all have our stories to tell. The greater the number of studies to which Dr Berland [1] must refer to make a case against CTC, the more he clouds the vision we need when screening for a dangerous disease such as colon cancer. Physicians know that screening will find the “clinically important vs unimportant.” Physicians on the front line of medicine know how to process information; we do that kind of thing every day, and we can handle it. When we have a better tool to use, such as CTC, we should use it. What Dr Berland [1] writes is like telling doctors not to look for anything except what they expect to find. It is like not looking at the esophagus when you suspect a duodenal ulcer. It begs the question, Why are we screening at all? It is like asking women not to undergo screening mammography because one might find only benign densities. It is like asking people not to undergo screening colonography because one might find only benign polyps. It is like asking gastroenterologists not to look at the cecum when they have found cancer of the sigmoid during colonoscopy to explain blood in the stool. As for other medical specialists, it is like asking internists to request only blood hemoglobin rather than 463
464 Letters to the Editor
complete blood counts when they expect only possible anemia. It is like asking dermatologists to look for melanoma and overlook psoriasis. It is like asking family practitioners to look for life-threatening disease and disregard their patients’ conjunctivitis. It is like asking urologists to look only at the ureters and not the kidneys when patients have symptoms of stones. And I could go on through the remainder of the specialties. Madness, the article is madness. Dr Berland [1] is asking physicians not to do something that we have been specifically taught to do: to be observant and thorough. We were taught to do a complete history and physical examination during medical school. When considering screening for colon cancer, let us use the best tool we have, which is CTC. Let us look ahead 5 years; most probably, at that time, screening with the conventional fiber optic or flexible colonoscope will be a thing of the past. Just because CTC is difficult and takes a long time to do correctly is not a sufficient reason not to use it for screening. As physicians, we are called to do difficult things. Mammography is difficult to do correctly, as is colonoscopy. Who gets the money, the gastroenterologist or the radiologist? The controversy among physicians, if there really is any controversy, is all about money. If there is controversy with third-party payers, it is that they do not want to spend the premium money, or it is too costly. If there is controversy with large health care plans, one may hear “We cannot afford it” or “It will raise the cost of health care” or “It will raise taxes.”
And what of priority? Where does the patient come in? What happened to our ideals about the way we care for people? The ACR has been of great help to me and the physicians and patients we serve. However, the ACR has not helped anyone by publishing Dr Berland’s [1] article. I am very sorry to have had the burden of writing this letter to the editor of JACR. The ACR and the JACR have done many things to advance medicine, but publishing Dr Berland’s [1] article is not one of them. Angus W. Graham Jr, MD, Manatee Diagnostic Center Riverside Medical Center Suite 4300 300 Riverside Dr E Bradenton, FL 34208 e-mail: [email protected] REFERENCE 1. Berland LL. Incidental extracolonic findings on CT colonography: the impending deluge and its implications. J Am Coll Radiol 2009;6:14-20. DOI 10.1016/j.jacr.2009.03.003 ● S1546-1440(09)00120-3
Author’s Reply I appreciate the opportunity to reply to Dr Graham and to others who were disturbed by the message of “Incidental Extracolonic Findings on CT Colonography: The Impending Deluge and Its Implications” [1]. If authors should be pleased when their work engenders strong feelings, I might be very pleased indeed. However, I believe that Dr Graham inaccurately attributes motives and opinions to me that are not suggested by this article. I enthusiastically support computed tomographic colonography (CTC), helped establish our program, and personally interpret these studies. The article was written to
raise awareness about the problem of extracolonic findings (ECFs) on CTC, not to question CTC itself. The problem of ECFs will be further magnified by large-scale screening, as supported by projections such as by Pickhardt et al [2], who estimated that we may eventually screen more than 3.5 million people per year. Regarding some of Dr Graham’s specific comments, he states that “not to be interested in or comment on extra or unforeseen findings . . . is unconscionable,” that I am “asking physicians not to . . . be observant and thorough,” and that “physicians know that screening will find the ‘clinically important vs unimportant’ [and] . . . we can handle it.” I do not suggest disinterest or a casual approach, but rather replacing a haphazard “we can handle it” attitude with a detailed strategy using consensus and medical evidence regarding which ECFs should be pursued. Dr Graham implies that all findings should be reported. Yet many leaders in CTC even agree that polyps of 5 mm or smaller should not be reported. A similar approach to some ECFs may be appropriate. “Case histories, such as the one Dr Berland [1] references concerning a department chairman, are ‘off base.’” I included this story because the author’s purpose in publishing his own story was to share his message. Catastrophic morbidity and the loss of life from pursuing incidental findings are not theoretical risks. How do we balance the value of screening to help a sick patient vs injuring a healthy person? While diagnosing individuals, we must also appreciate whether we will help improve overall outcomes for the screened population. “He clouds the vision we need when screening for a dangerous disease.” To suggest that screening is unconditionally worthwhile does not optimally serve our patients
poor as a result of inadequate radiation. This is a very difficult topic because we often will not know what we have missed. Phantom studies are fine but cannot easily be applied to clinical practice. We must not allow ourselves to enter into competition with other radiology groups to see who can use the lowest radiation exposures: this will expose our patients to the great risk of a missed diagnosis today. Mervyn D. Cohen, MD, MBChB Indiana University School of Medicine Department of Radiology 702 Barnhill Drive Room 1053 Indianapolis, IN 46202 e-mail: [email protected] REFERENCE 1. Thrall JH. Radiation exposure: politics and opinion vs science and pragmatism. J Am Coll Radiol 2009;6:133-134. DOI 10.1016/j.jacr.2009.04.002 ● S1546-1440(09)00173-2
Re: “Incidental Extracolonic Findings on CT Colonography: The Impending Deluge and Its Implications” In the conclusion to his article in the January 2009 issue of JACR titled “Incidental Extracolonic Findings on CT Colonography: The Impending Deluge and Its Implications,” Dr Berland [1] writes, with regard to the consequences of the use of computed tomographic colonography (CTC), that it will be “accompanied by a deluge of new incidental findings, many of which will be . . . suspicious for important disease or . . . difficult to interpret.” Asking a physician not to be interested in or comment on extra or unforeseen findings during an examination is unconscionable.
© 2009 American College of Radiology 0091-2182/09/$36.00 ● DOI 10.1016/j.jacr.2009.04.002
Computed tomographic colonography is in a different class than “whole-body” screening. When considering Dr Berland’s [1] remarks about using intravenous contrast, we should remember that we are “screening.” Case histories, such as the one Dr Berland [1] references concerning a department chairman, are “off base”; we all have our stories to tell. The greater the number of studies to which Dr Berland [1] must refer to make a case against CTC, the more he clouds the vision we need when screening for a dangerous disease such as colon cancer. Physicians know that screening will find the “clinically important vs unimportant.” Physicians on the front line of medicine know how to process information; we do that kind of thing every day, and we can handle it. When we have a better tool to use, such as CTC, we should use it. What Dr Berland [1] writes is like telling doctors not to look for anything except what they expect to find. It is like not looking at the esophagus when you suspect a duodenal ulcer. It begs the question, Why are we screening at all? It is like asking women not to undergo screening mammography because one might find only benign densities. It is like asking people not to undergo screening colonography because one might find only benign polyps. It is like asking gastroenterologists not to look at the cecum when they have found cancer of the sigmoid during colonoscopy to explain blood in the stool. As for other medical specialists, it is like asking internists to request only blood hemoglobin rather than 463
464 Letters to the Editor
complete blood counts when they expect only possible anemia. It is like asking dermatologists to look for melanoma and overlook psoriasis. It is like asking family practitioners to look for life-threatening disease and disregard their patients’ conjunctivitis. It is like asking urologists to look only at the ureters and not the kidneys when patients have symptoms of stones. And I could go on through the remainder of the specialties. Madness, the article is madness. Dr Berland [1] is asking physicians not to do something that we have been specifically taught to do: to be observant and thorough. We were taught to do a complete history and physical examination during medical school. When considering screening for colon cancer, let us use the best tool we have, which is CTC. Let us look ahead 5 years; most probably, at that time, screening with the conventional fiber optic or flexible colonoscope will be a thing of the past. Just because CTC is difficult and takes a long time to do correctly is not a sufficient reason not to use it for screening. As physicians, we are called to do difficult things. Mammography is difficult to do correctly, as is colonoscopy. Who gets the money, the gastroenterologist or the radiologist? The controversy among physicians, if there really is any controversy, is all about money. If there is controversy with third-party payers, it is that they do not want to spend the premium money, or it is too costly. If there is controversy with large health care plans, one may hear “We cannot afford it” or “It will raise the cost of health care” or “It will raise taxes.”
And what of priority? Where does the patient come in? What happened to our ideals about the way we care for people? The ACR has been of great help to me and the physicians and patients we serve. However, the ACR has not helped anyone by publishing Dr Berland’s [1] article. I am very sorry to have had the burden of writing this letter to the editor of JACR. The ACR and the JACR have done many things to advance medicine, but publishing Dr Berland’s [1] article is not one of them. Angus W. Graham Jr, MD, Manatee Diagnostic Center Riverside Medical Center Suite 4300 300 Riverside Dr E Bradenton, FL 34208 e-mail: [email protected] REFERENCE 1. Berland LL. Incidental extracolonic findings on CT colonography: the impending deluge and its implications. J Am Coll Radiol 2009;6:14-20. DOI 10.1016/j.jacr.2009.03.003 ● S1546-1440(09)00120-3
Author’s Reply I appreciate the opportunity to reply to Dr Graham and to others who were disturbed by the message of “Incidental Extracolonic Findings on CT Colonography: The Impending Deluge and Its Implications” [1]. If authors should be pleased when their work engenders strong feelings, I might be very pleased indeed. However, I believe that Dr Graham inaccurately attributes motives and opinions to me that are not suggested by this article. I enthusiastically support computed tomographic colonography (CTC), helped establish our program, and personally interpret these studies. The article was written to
raise awareness about the problem of extracolonic findings (ECFs) on CTC, not to question CTC itself. The problem of ECFs will be further magnified by large-scale screening, as supported by projections such as by Pickhardt et al [2], who estimated that we may eventually screen more than 3.5 million people per year. Regarding some of Dr Graham’s specific comments, he states that “not to be interested in or comment on extra or unforeseen findings . . . is unconscionable,” that I am “asking physicians not to . . . be observant and thorough,” and that “physicians know that screening will find the ‘clinically important vs unimportant’ [and] . . . we can handle it.” I do not suggest disinterest or a casual approach, but rather replacing a haphazard “we can handle it” attitude with a detailed strategy using consensus and medical evidence regarding which ECFs should be pursued. Dr Graham implies that all findings should be reported. Yet many leaders in CTC even agree that polyps of 5 mm or smaller should not be reported. A similar approach to some ECFs may be appropriate. “Case histories, such as the one Dr Berland [1] references concerning a department chairman, are ‘off base.’” I included this story because the author’s purpose in publishing his own story was to share his message. Catastrophic morbidity and the loss of life from pursuing incidental findings are not theoretical risks. How do we balance the value of screening to help a sick patient vs injuring a healthy person? While diagnosing individuals, we must also appreciate whether we will help improve overall outcomes for the screened population. “He clouds the vision we need when screening for a dangerous disease.” To suggest that screening is unconditionally worthwhile does not optimally serve our patients