CTVNews.ca Staff
Date: Tue. Mar. 27 2012 10:24 PM ET
When Sylvie Marotte discovered a painful lump in her left breast, she feared the worst.
But a Montreal-area radiologist who conducted her mammogram told her not to worry: it was just a bruise.
Still, the pain persisted for months and Marotte decided to get a second opinion and more tests.
The results floored her – she had breast cancer, which had already spread to her back. Eventually, it reached her brain.
Marotte's misdiagnosis was not the only one.
A sweeping review by the Quebec College of Physicians found 109 previously undetected cases of breast cancer in the province.
The majority of the misdiagnoses -- 96 cases -- were attributed to the work of one radiologist, who worked at three different private clinics and retired in 2010.
The other 13 cancer cases were discovered after the Quebec College of Physicians expanded its investigation to include other radiologists working in the same clinics.
The review concluded that those 13 cancers would not have been obvious in the initial scan.
Every woman who was misdiagnosed has been notified and is now undergoing treatment. It's too soon to tell how the delay in treatment will affect the patients, the college said.
"We're angry," Marotte told CTV News, sitting next to her husband at home, her bald head covered with a bandanna.
"If I received treatments months before, things may have been different."
College president Dr. Charles Bernard, said mammograms can be "very difficult" to read and it's not uncommon to find discrepancies in radiologists' findings.
Breast lesions, especially small ones, are often difficult to spot on a mammogram and it takes a lot of skill and expertise to read the scan correctly, the college said.
However, in the case of the retired radiologist, the error rate was too high.
"It's a very abnormal number of cases that were diagnosed (after) re-reading, and we are sad about that," Bernard told CTV News.
About 22,000 mammograms had to be re-examined after the College of Physicians was notified about suspected errors in the radiologist's work and ordered a sweeping review of the tests.
The probe looked at all of his cases between October 2008 and October 2010, as well as other mammograms done at the clinics where he worked.
Frederic Desjardins, President of the Quebec Association of Radiologists, said the radiologist often worked alone and had a heavy caseload.
The panel tasked with reviewing suspect mammograms has made 10 recommendations to avoid similar errors in the future. They include double-checking and digitizing mammogram images and linking private clinics with the public health system to avoid gaps in patient care.
"I can tell you that it was our quality system that detected the mistakes," Quebec's Health Minister, Dr. Yves Bolduc, told reporters Tuesday. "We want to improve that and the most important thing is that we want to give good care to every patient."
"We're going to look at the recommendations of the college of doctors and we're going to work with them."
This is not the first controversy involving breast-cancer tests in Canada.
Newfoundland launched a judicial inquiry a few years ago after mistakes were detected in 386 tests. Those errors affected patients who had already been diagnosed with breast cancer but may not have received the correct treatment following mistakes in hormone receptor tests.
More than a dozen recommendations were made to improve the health care system.
With reports from CTV's Genevieve Beauchemin and Cindy Sherwin and files from The Canadian Press
But a Montreal-area radiologist who conducted her mammogram told her not to worry: it was just a bruise.
Still, the pain persisted for months and Marotte decided to get a second opinion and more tests.
The results floored her – she had breast cancer, which had already spread to her back. Eventually, it reached her brain.
Marotte's misdiagnosis was not the only one.
A sweeping review by the Quebec College of Physicians found 109 previously undetected cases of breast cancer in the province.
The majority of the misdiagnoses -- 96 cases -- were attributed to the work of one radiologist, who worked at three different private clinics and retired in 2010.
The other 13 cancer cases were discovered after the Quebec College of Physicians expanded its investigation to include other radiologists working in the same clinics.
The review concluded that those 13 cancers would not have been obvious in the initial scan.
Every woman who was misdiagnosed has been notified and is now undergoing treatment. It's too soon to tell how the delay in treatment will affect the patients, the college said.
"We're angry," Marotte told CTV News, sitting next to her husband at home, her bald head covered with a bandanna.
"If I received treatments months before, things may have been different."
College president Dr. Charles Bernard, said mammograms can be "very difficult" to read and it's not uncommon to find discrepancies in radiologists' findings.
Breast lesions, especially small ones, are often difficult to spot on a mammogram and it takes a lot of skill and expertise to read the scan correctly, the college said.
However, in the case of the retired radiologist, the error rate was too high.
"It's a very abnormal number of cases that were diagnosed (after) re-reading, and we are sad about that," Bernard told CTV News.
About 22,000 mammograms had to be re-examined after the College of Physicians was notified about suspected errors in the radiologist's work and ordered a sweeping review of the tests.
The probe looked at all of his cases between October 2008 and October 2010, as well as other mammograms done at the clinics where he worked.
Frederic Desjardins, President of the Quebec Association of Radiologists, said the radiologist often worked alone and had a heavy caseload.
The panel tasked with reviewing suspect mammograms has made 10 recommendations to avoid similar errors in the future. They include double-checking and digitizing mammogram images and linking private clinics with the public health system to avoid gaps in patient care.
"I can tell you that it was our quality system that detected the mistakes," Quebec's Health Minister, Dr. Yves Bolduc, told reporters Tuesday. "We want to improve that and the most important thing is that we want to give good care to every patient."
"We're going to look at the recommendations of the college of doctors and we're going to work with them."
This is not the first controversy involving breast-cancer tests in Canada.
Newfoundland launched a judicial inquiry a few years ago after mistakes were detected in 386 tests. Those errors affected patients who had already been diagnosed with breast cancer but may not have received the correct treatment following mistakes in hormone receptor tests.
More than a dozen recommendations were made to improve the health care system.
With reports from CTV's Genevieve Beauchemin and Cindy Sherwin and files from The Canadian Press
Read more: http://www.ctv.ca/CTVNews/TopStories/20120327/quebec-breast-cancer-tests-120327/#ixzz1qNeYIhwZ
1. What is the link to Crisis
Management?
This is a
major crisis that needs to be used to educate the public and future
radiologists. Its link to crisis management is crisis at such a large scale.
This article points out 109 misdiagnosis of breast cancer. When screening first
started the biggest fear was false-positives, this means that the test results
were positive for cancer but the findings were false. This led to a lot of
stress and unnecessary tests and biopsy's. This is the complete opposite, false
negatives, where the result of the negative but these results are false.
2. What stage of Crisis
Management does the system appear to be at?
In my opinion this situation is at the full crisis level. Even though no
deaths have been linked to this misdiagnosis, it’s only a matter of time before
deaths are reported. To know that one radiologist made an error in potentially
more than 96 cases is staggering. The impact of not being diagnosed and getting
treatment earlier will linger with all 109 patients who were misdiagnosed.
3. How well does the system
appear to be handling the situation?
The system seems to be handling the situation decently well. It has
called all the patients who were diagnosed by the radiologist and the system is
reviewing 22,000 mammograms. This is showing the health care systems commitment
to public health. It could do a bit more in detailing implementations or at
least addressing the development of implementations to deter these situations
from occurring.
4. What level of crisis
preparedness does the system appear to have?
These kinds of crisis are more or less black swan events. Although false
negatives do occur, this scale is very high. 109 patients being misdiagnosed
and 96 of them being from the same radiologists is a true black swan
(unanticipated event).
5. What personal
reactions/feelings does the description trigger in you?
This article triggers worry and anger about the situation created
by one single radiologist. The worry is in regards to what is being done to
deter future cases of this situation; the anger is over the consequences of one
radiologist misdiagnosing that many patients.
6. What advice would you offer
to those involved?
I would
advise schools to implement a more stringent system in educating its
radiologists on how to detect breast cancer and at what point of ambiguity they
would refer the patient to a second radiologist. For health care providers I
feel sympathy since they have an added cost of reviewing 22,000 mammograms, but
I would suggest they implement a more standardized testing procedure that
encompasses global best practices when screening for breast cancer. The article
illustrates transparency which is very important to the public to ensure they
put pressure on Health Canada to improve standards.
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