Madam, - Medical science is inexact. Diagnostic testing in pathology and in imaging has false positive and false negative rates. Clearly, the blame game is supreme in relation to the breast cancer service at Portlaoise. The wrong lessons will be learned if brutal honesty is, as usual, replaced by self-serving propaganda and spin.
On November 1st, 2007, a report from St Vincent's University Hospital, Dublin on the subject of false negative mammography and symptomatic breast carcinoma was published in the Journal of Surgical Oncology. The patients concerned were seen between 1994 and 2004 and 124 of then had false negative mammograms. Following a retrospective review, 42 per cent of these were re-categorised as suspicious. False negative mammography led to a delay in diagnosis of greater than two months for 12 patients.
On August 11th, 2007, the Lancetpublished a study from Germany on the subject of ductal carcinoma of the breast, in which 56 per cent of the 193 women with a pathology diagnosis of ductal carcinoma in situ (DCIS) were diagnosed by mammography and 92 per cent by MRI scanning. All 43 high-grade DCIS cases missed by mammography were diagnosed by MRI.
The accompanying commentary from the Netherlands states that "almost all invasive carcinomas are believed to begin as DCIS. . .Treatment of DCIS by complete resection or, when breast-conserving therapy is used, radiotherapy, is deemed appropriate for all DCIS lesions."
The uncertainty regarding many diagnoses is central to the practice of medicine, which is an art with an ever-increasing scientific overlay.
Did the staff and management at Portlaoise hospital in the recent past seek a consultant radiologist dedicated and trained in breast disease imaging? Did staff work under duress without adequate back-up and support? How old is their imaging equipment? Was an upgrade sought?
If absolute diagnostic certainty is the legal requirement for medical diagnosis, then the practice of medicine becomes impossible. Rather than criticising the public for opposing the closure of local services, HSE officials and politicians would be better occupied ensuring than adequate clinical networks are set up using the appropriate information technology including, in the Portlaoise case, teleradiology and links with appropriate experts for case conferencing.
Even in narrow specialities, experts often disagree. Using Portlaoise as a Trojan horse to close small hospitals would be credible if there were adequate services elsewhere. But there are not. - Yours, etc,
Dr BILL TORMEY, Consultant Chemical Pathologist, Glasnevin Avenue, Dublin 11.