See No Evil – Speak No Evil
January 1, 2010 Journal Watch summarizes a remarkable article entitled “Investigation of incidental findings on cardiac CT.” The article was based on a study conducted at a Canadian institution where the investigators evaluated the incidence, clinical importance, and costs of these incidental findings.
It’s first important to note that these researchers used the word incidental as equivalent to the word, occult. In medical imaging, an occult finding is an unexpected finding that has clinical consequence. Such findings are made with great frequency and have dramatically improved the lives of many. For example, a chest x-ray searching for a rib fracture reveals a lung cancer mass which was otherwise completely unexpected. A CT scan of the abdomen performed because of a complaint abdominal pain reveals a dissection of the thoracic aorta.
The Canadian researchers are strangely troubled by the discovery of unexpected conditions. The test they are evaluating is cardiac CT. Imaging data obtained during a cardiac CT includes imaging information of structures or tissues outside the heart. in an examination of 966 consecutive patients who underwent cardiac CT during 12 months at a single Canadian institution, incidental findings were noted in 401 patients. 12 of the patients were found to have clinically significant conditions, many of them, life-threatening without treatment.
Even if one accepts the very conservative assessment that only 12 of the patients were found to have clinically significant conditions, that means that 3% of everyone who had a cardiac CT performed had a condition that might have seriously harmed or killed them if it had not been accidentally seen in this study.
The researchers do not see the benefit derived by the 3% as a bonus. They don’t question that all the patients benefited from having a cardiac CT. In fact, no one questions that this method of scanning provides an important and noninvasive method of evaluating patients suffering coronary calcification and arterial disease. However, 68 patients exhibited incidental findings such as nodules or cysts in the lungs or liver. There’s the rub.
Confronted with 68 patients of the 401 who had abnormalities deemed to be indeterminate (undetermined significance) researchers worry that the abnormalities found might lead some to conduct further testing or evaluation. The solution, as they see it, is to not format the data concerning non-cardiac tissue and structures. They want to ask patients to consent to keeping the non-cardiac information invisible. If they see no “evil”, they need speak no “evil.”
I think this is insanity. What do you think?
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Out of the 12 with clinically significant imaging findings, how many of these findings could have been detected via a GP checkup not involving high doses of radiation?
“However, 68 patients exhibited incidental findings such as nodules or cysts in the lungs or liver. There’s the rub.”
Yes that is the rub – exactly. Those 68 patients underwent risky biopsies to determine their findings were incidental. That amounts to 68 unnecessarily-richer surgeons and 68 potential adverse reactions to anesthesia! If I were a surgeon, I would not be ethically comfortable with a ratio of 68 /401.
It’s not OK when the screening itself leads to follow-up scans, invasive biopsies and surgeries that cause sickness and maybe even death in people who were not at risk in the first place. Clearly there needs to be a better criteria for screening only the people in a risk group who may benefit the most.
The findings were occult because they had not been recognized. Assuming they would have been detected by physical exam when by definition they had not been otherwise discovered is an illogical and dangerous assumption.