Am Fam Physician. 2014 Jul 1;90(1):53-54.
For the second year in a row, my 38-year-old patient insisted on having a mammogram, even though she has no family history of breast cancer and no other risk factors. I recognized her anxiety and tried discussing it with her, but she was not interested in exploring the basis for her feelings. As it happened, the second mammogram showed a new density, which, after coned down views and a biopsy, was revealed to represent fibrocystic changes. After that, my patient increased her office visits, convinced she had a susceptibility to cancer. When the test became available, she began requesting breast magnetic resonance imaging (MRI), which I ordered against my better judgment. Recently, she was diagnosed with ductal carcinoma in situ (DCIS), and she is triumphant, insisting that she knew she would get cancer and that the MRIs saved her life. I can't argue with her perception of her illness, but I don't want to enter into a similar situation with another patient. Was it unethical for me to acquiesce to her requests? Is there an ethical ground for insurance to refuse payment for unnecessary tests?
This case boils down to being realistic about what new screening tools and techniques can and can't do, and understanding their actual value in diagnoses. I'd argue that it is not unethical to accommodate a patient's requests, as long as the physician's approach to the patient, the pathology, the technology, and the decision-making process was pragmatically sound and prudent. However, careful negotiation, patient education, and relationship-building should support the physician's response.
Mammography is considered a standard screening tool for breast cancer.1 Medicine will always develop increasingly more sophisticated tools, but they often serve different purposes and have varying levels of effectiveness. The current literature does not provide evidence to support routine use of MRI for breast cancer screening; however, the American Cancer Society recommends that women with noninvasive
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1. LeFevre ML, Calonge N, Dietrich AJ, Melnikow J. Mammography screening for breast cancer: recommendation of the U.S. Preventive Services Task Force. Am Fam Physician. 2010;82(6):602, 609.
2. American Cancer Society. http://www.cancer.org/. Accessed January 20, 2014.
3. Carlson RW, Allred DC, Anderson BO, et al. NCCN Breast Cancer Clinical Practice Guidelines Panel. Breast cancer. Clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2009;7(2):122–192.
4. Esserman LJ, Thompson IM Jr, Reid B. Overdiagnosis and over-treatment in cancer: an opportunity for improvement. JAMA. 2013;310(8):797–798.
5. Virnig BA, Tuttle TM, Shamliyan T, Kane RL. Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes. J Natl Cancer Inst. 2010;102(3):170–178.
6. May WF. Contending images of the healer in an era of turnstile medicine. In: Klein EP, Walter JK, eds. The Story of Bioethics: From Seminal Works to Contemporary Explorations. Washington, DC: Georgetown University Press; 2003:149–164.
7. Pellegrino ED, Thomasma DC. For the Patient's Good: The Restoration of Beneficence in Health Care. New York, NY: Oxford University Press; 1988.
8. Pellegrino ED, Thomasma DC. The Virtues in Medical Practice. New York, NY: Oxford University Press; 1993.
9. American Board of Internal Medicine Foundation. Unnecessary tests and procedures in the health care system. What physicians say about the problem, the causes, and the solutions. http://www.choosingwisely.org/wp-content/uploads/2014/04/042814_Final-Choosing-Wisely-Survey-Report.pdf. Accessed May 13, 2014.
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