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I've taken a lot of heat for making observations and asking questions. Isn't this what people want from the Blogosphere? Kevin M.D. does a much better job analyzing the news and staying current; Chris Rangel has a keener eye and more passion for the policy issues; Dr. Charles and The Madhouse Madman (congrats bud) explore the literary and humanistic aspects of their jobs. None of that is what I do here. I look at the nonsense that passes for medical news and ask questions whenever that news does not make sense to me, which is just about always.
What really is offensive is when I ask questions and OTHERS say I am claiming cover-up or conspiracy. I am doing neither of those things. Nothing I say cannot be traced along a logical thought-line with documentation both in the literature and by my extensive training and experience. That's part of what I offer. Let me also say here, publicly, what I wrote to one of my commentators, previously.
... it is my opinion that the BEST physicians reach out with their imaginations in their diagnoses.
I don't chase zebras*, but I always wait for them. And I've caught a herd of them in the last 20 years-- because I'm not afraid to question someone's established order of case presentation and history.
I still get thank-you cards and letters from patients who were zebras when I found them in some physician's barn of horses. In medicine there is a saying: you can't find something if you don't know what you are looking for. It sounds trite, but it holds a lot of import. Just because I ask COULD this unusual circumstance have an unusual diagnosis doesn't mean I am going to kidnap Bill Clinton and treat him with chemotherapybut if you don't think about those possibilities, you will never make those diagnoses.
---NOW LET ME TELL YOU WHY I AM RIGHT ABOUT THIS CASE--
The Most Dangerous Game
Yesterday, the physicians at Columbia Presbyterian admitted that one of my three possible scenarios was indeed, correct. They missed his complicated pleural effusion for five months.
either they failed to do appropriate follow-up and MISSED it for six months (unlikely); or, they have been hiding his problem while they exhaust all nonsurgical treatment options; OR ... Bill Clinton's exudative pleural effusion is from something else.
Yesterday, as reported in The Times, they physicians at Columbia made several points:
#1. Clinton's pleural abnormality was undetected until one month ago
#2. It is their contention that this abnormality has been present since the bypass surgery and is a direct complication of that surgery
#3. The presence of a chronic complicated loculated pleural collection after bypass surgery causing pleural thickening, inelasticity, and lung collapse (traction atelectasis) is very rare. How rare? REALLY rare. Said Dr. Craig Smith, Clinton's surgeon:
This is a very rare complication
(I've seen it) only a handful of times in 6,000 surgeries.
So, some of the best doctors in the world did a procedure (bilateral mammary artery harvests) that has a high risk of post operative occurrence of complicated effusions, then missed that effusion when it occurred (in their most famous patient ever), then failed to follow up that patient until he came back to them with chest pain and shortness of breath.
The panel of Presbyterian physicians made a major point of insisting that a persistent complicated pleural effusion causing pleural fibrosis and lung collapse is a rare complication -- and indeed it is.
HOWEVER, what they didn't say was that if they had detected the relatively commonly occurring complicated effusion immediately post-op then maybe this rare sequelae could have been avoided. This rare complication is actually probably the natural history of an undetected, untreated,complicated postoperative effusion.
So, cut the BS guys.
Here's how rare the effusions are according to the Archives of Internal Medicine:
All patientsunderwent internal mammary artery grafting. Early effusions(<30 days after CABG) occurred in 45 patients (63%) and lateeffusions (30 days after CABG) developed in 26 (37%).
So, his doctors knew that Clinton had a really good chance of developing an effusion with this procedure. So how did they miss it??
Rara Avis: We Try Harder
Most of the letters I've received have made the point that Clinton was likely noncompliant; however, given the frequency of complicated pleural effusions after bypass with the mammary arteries, the docs should have been hard on the case.
Surely Bill Clinton has had a chest X-ray abnormality for MONTHS; and surely he has had unequal basilar breath sounds for a similar period of time.
Did Clinton not EVER see an internist after his bypass? Does the former president NOT have a personal physician? Did that personal physician NOT listen to Bill's lungs? Would he not have noticed a DRAMATIC asymmetry in breath sounds between the right an dd left lower lobes?
I WAS RIGHT TO BE SKEPTICAL
Because I gave the benefit of the doubt to the surgeons and physicians taking care of Clinton, I almost completely dismissed the possibility that they would have MISSED this relatively common sequela of mammary artery harvesting.
I therefore had to question whether or not there was some other reason for a complicated pleural effusion, and any doctor worth his mojo would immediately think of cancer. Period.
I tell you what. I'm still skeptical that they actually missed this bad problem and I wouldn't be at all surprised if, later today, they tell us that Bill Clinton's pleura is SOCKED IN with tumor.
Let me say something else. EVERYONE is downplaying the severity of this procedure (thoracocoscopy / thoracotomy). Hilliary Clinton, displaying naivete and lack of any medical insight at all said yesterday:
"It is a routine procedure although it is an uncommon complication,"
Since when is a thoracotomy routine? I mean what is the definition of routine? Clinton is undergoing general anesthesia for a VATS with likely conversion to a thoracotomy (you know, widen the incision, spread the ribs and violate the thorax?). They will be performing a therapeutic pneumothorax with the risk of persistent pneumothorax, bronchopleural fistula, infection, stroke...I could go on ... Here's one reference to decortication:
Postoperative complications included 8.7% wound infections and 1.2% recurring empyema. Operative mortality was 1.2%. The indication for decortication to improve pulmonary function alone is questionable. As a rule it is based upon 2 factors--both elimination of infectious foci and improving function.
So stop foisting this on us as routine. A rectal exam is routine. This is major surgery.
Good luck to you Bill. I hope I am wrong. And I wish you well.
*There is a maxim in medicine that says: when you hear hoofbeats, think horses not zebras. The idea is that common things are common and a goodphysician should not be confabulatng wild explanations for situations that probably have a routine cause.
However, GOOD physicians understand that the statistical distribution of diagnostic possibilities fall under a probabilistic curve that includes many rare and unusual entities. Thus, although one should not CHASE zebras, it is my cntention that neither will a good physicians fail to CATCH a zebra should one run by.
Yesterday, I posted about the strange announcement concerning Bill Clinton's new "medical" problem.
We're told that he has a pleural effusion (see yesterday's post to explain what this is) that needs decortication to fix.
There are a lot of problems with this diagnosis and the chronology given by the Clinton's press pushers.
But first let's talk about the dramatic change in Bill Clinton's appearance.
Downhill in a Hurry
Have you noticed that the chubby, robust Bill Clinton has, of late, been looking quite wan and acting more like Jimmy Carter? Do you think this is because Clinton is still recuperating from his bypass?
Here's what Bill looked like not so long ago, during his presidency.
Here's what he looks like now.
Remember how crazy everyone got because of the abrupt change in Viktor Yushchenko's appearance over the course of six months? Well this is PRETTY CLOSE, wouldn't you say?
I know that a lot of people ascribe this dramatic withering to Bill Clinton's bypass, but, I'll tell you, I've seen a LOT of bypass patients over the years, and I would say that most of them bounce back to normal after 1-2 months, and ESPECIALLY if they are previously healthy 58 year-old men with uncomplicated surgery and hospitalization.
Yeah, I know, Clinton saw the light and went on the South Beach Diet and stopped eating Twinkies...but isn't good diet and exercise supposed to make you look YOUNGER and BETTER?
If this is the result, maybe we should be sending Clinton cartons of Yodels!
But I believe there is much MORE to this story. because as perplexed as I have been, personally, about the rapid deterioration of Bill Clinton's appearance, I have been loath to propose a more ominous diagnosis than "post-bypass, post-South Beach Diet inanition"...until some new SIGN arose to lead me to the diagnosis.
Now we have that sign.
An Improbable Diagnosis and a Radical Treatment = A Bad Sign
NPR interviewed one of the MD's from Columbia Presbyterian yesterday who said that they only discovered Clinton's pleural effusion one month ago when the former president began to experience shortness of breath while running up hills. Hmmmm...personally, my 10 year-old SON gets short of breath running up hills, but we'll pass on that for a minute.
With the onset of this symptom it was discovered that Clinton had a left-sided pleural effusion. That was ONE month ago and FIVE months after Clinton's coronary bypass.
This effusion has caused pleural stiffness and resultant lung collapse in the left lower lobe. As I explained yesterday, medically, pleural stiffness only occurs when the pleural effusion is COMPLICATED with blood, infection, or tumor.
Problems with this Scenario
Complicated pleural effusions occur shortly after surgery. Why? Because it is hard to be BLEEDING or INFECTED for five months and have it go unnoticed. There really is no reason that can easily be blamed on Clinton's bypass for him to develop a complex (bloody or infected) pleural effusion FIVE MONTHS LATER.
Why are they rushing Clinton to the OR to do a relatively risky (general anesthesia) decortication procedure? The algorithm for stubborn pleural effusions calls for CONSERVATIVE THERAPY with decortication a LAST DITCH EFFORT when all else fails. This just doesn't make sense in the context of the story...unless
The doctors are worried...
I work in a cardiac hospital. I've seen 1,000 patients a year undergo coronary artery bypass surgery and there are two things I can tell you:
1. Most people bounce back incredibly quickly -- especially 58 year-old previously healthy males -- and are themselves again in a month or two at the most
2. I have NEVER seen or heard of someone suddenly developing a complex pleural effusion six months after the surgery.
Pants On Fire
So... are they telling us the whole story?
I DON'T THINK SO!
Does Clinton have cancer...or AIDS?
Why is he so skinny and listless?
And why are they rushing him in for this surgical pleural resectioninstead of doing everything in their power to fix it without surgery and general anesthesia (which is what I would insist upon if it were MY pleura)?
They may be trying to make a diagnosis.They may be very worried and need to rush to a diagnosis because...
Maybe they are taking him to surgery to get a piece of that pleura to look at in pathology, under the microscope, because... they suspect that this pleural problem is much more than an unlucky by-product of cardiac surgery (done at one of the best places in the world for that particular surgery).
Maybe they are looking for metastatic melanoma.
Or Kaposi's Sarcoma.
Maybe they should let us know a little more before this catches fire on that tinder pile that is the Internet...
ADDENDUM: For those of you who remember the late, great heartthrob, Rock Hudson -- whose diagnosis of AIDS seemed to spur the world into finally recognizing and admitting to the prevalence of the disease-- here are his "before and after" AIDS diagnosis images, reminding me of Bill Clinton:
Responding to some friendly fire that creitisized my Clinton photos as being too far apart in time, I offer you the following comparison from his book cover of last November, to his photograph from one month ago:
Here is his face on last year's book
And here he is recently...
Everyone I talk to agrees that the change is dramatic given the time span over which it has occured.
As reported today, Bill Clinton needs new surgery to fix a complication of his coronary artery bypass. But is it really a complication, or is the cause something worse?
The news tells us that Clinton "will undergo a medical procedure" that could require a three to ten day hospital stay...WHOA...that's quite a range especially for something trivialized as a procedure?
To me, a procedure is a needle biopsy or an endoscopy; you know, in and out --overnight at best. But ten days?? There's more to that than meets the eye.
Here's what Clinton's people are saying:
The procedure, known as a decortication, will remove scar tissue that has developed as a result of fluid buildup and inflammation, causing compression and collapse of the lower lobe of the left lung
This is fairly serious stuff and decortication of the pleura of the lung is not a "procedure," it is an operation; so, let me spend a little time translating this condition so everyone can understand its severity.
Bill's Imprisoned Lung
What they are saying, in essence, is that Clinton has an intractable fluid collection separating the "leaves" of his thoracic pleura ( = a fibrous bag that surrounds the lungs).
Furthermore, they are telling us that the "fluid" between the leaves of pleura is, or has gotten, nasty -- either because of blood or infection making the normally resilient and pliable pleura hard and inelastic.
In this illustration, you are looking at one of the lungs. The lung is centrally located and the "pleural leaves" are outlined in color.
When the pleural leaves fill up with nasty fluid and become inelastic this causes the underlying lung to collapse ( called atelectasis).
So, although they may poo-poo Clinton's problem, it is no joke to have inflamed or bloody fluid surrounding your lung, creating a prison cell for your lung which then collapses under the pressure.
The Scope of It
<----HERE IS what one sees in the pleural space, through the thorascope. Good luck to the surgeons, eh?
Briefly, what it seems that they are planning to do is called a VATS procedure (video-assisted thoracoscopy) during which surgeons insert a scope between the ribs and scrape out the pleura through the small incision. This is a fairly new approach for pleural decortication and one would assume these surgeons are comfortable with it...however...
There remains the question: Bill Clinton needs a pleural decortication to remediate a persistent pleural effusion. What are the chances this problem is related to his bypass surgery? If it is not related to bypass surgery than what could be the cause?
Clinton's office said the condition is an occasional consequence of open-heart surgery
Okay, I can buy a pleural effusion after bypass surgery. Not too uncommon. Especially when the surgeon uses the internal mammary arteries for the bypass, as was done in Bill Clinton's bypass.
But a persistent effusion causing "pleural inflammation" and lung collapse requiring surgery? Odds are getting a little more strained in this territory.
C'mon...Tell Us The Truth
Post-bypass effusions come in three flavors: immediate, delayed, and persistent. Immediate are just that: right after the bypass, resolving in days to weeks. Persistent effusions last more than days to Weeks but BOTH of these types of effusions usually go away by themselves. One study concerning the prevalence of these effusions stated:
Over the 12-monthfollow-up (after surgery), the effusions tended to resolve
Bill Clinton's surgery was six months ago. So either he has an unusually persistent post-operative effusion OR he has a delayed effusion.
Here's where a mystery starts to unfold. An important article in the Annals of Internal Medicine made a distinction between early and late occurring pleural effusions post bypass-graft:
EARLY effusions are generally the BLOODY COMPLICATED type (called exudative). Late effusions are non bloody and simple (called transudative). The early/bloody effusions are the ones that lead to pleural inelasticity. The delayed (late) effusions DON'T lead to the inelasticity.
So what are we left to conclude? A major study reported in the journal Chest had this to say about post-bypass pleural effusions (italics mine):
Pleural effusions after coronary artery bypass graft surgeryshould be treated conservatively. Other causes for these effusionsshould be sought only if the patient is febrile, the effusionis large, or if it fails to resolve in the appropriate timeframe.
I DID NOT HAVE SEX WITH THAT WOMAN
So, what's the truth?
If Clinton's pleural problem is secondary to his bypass surgery then either they failed to do appropriate follow-up and MISSED it for six months (unlikely); or, they have been hiding his problem while they exhaust all nonsurgical treatment options; OR ... Bill Clinton's exudative pleural effusion is from something else.
What are the possibilities?
Cancer, including: lymphoma and leukemia and AIDS-related malignancy (he DID fool around a lot);
Strange infections such as: Mycoplasma (TB), Rickettsiae, Chlamydia, and Legionella
Liver disease and Pancreatic disease (not likely with left-sided problem)
There are others. But unless the Docs at Columbia let us in a little on some of the clinical history and pathology follow-up, as usual, we will probably be left speculating on the White House lawn.
Every time Ted Kennedy comes up in the news, I see the image of him leaving the hospital wearing that phony neck brace after he left Mary Joe Kopechne to drown at Chappaquiddick.
It is particularly galling that the gin soaked Senator, who cowardly swam away from a dying young woman, should wind up on the Senate's Health committee where the slavish ideologue regularly pontificates out the bathroom window of the ivory tower.
I Can't Hear You, Edward
Yesterday, the ranking Democrat on the Senate Health, Education, Labor and Pensions committee was pontificating about prescription drugs, vying for MORE legislation, of course. Did no one savor the bitter irony of this manslaughterer castigating drug companies for tragedy?
''It's hard to deny that the massive ad campaign led millions of patients to take the cox-2 drugs who didn't need them, with tragic results," Kennedy said
Someone there is who could not listen to Edward Kennedy's vocal public concern of tragedy.
Torters will find this interesting, I'm sure...click on this fellow to the left for a torter's greeting to a doctor...
For years, radiologists have faced liability lawyers who use the accusation of OVERWORK as a bludgeon to force a settlement. The Torters threaten to point out to the jury the large number of mammograms (or other studies) that one radiologist might read in a year. This, the lawyers threaten, will be clearly explained to the jury as being a function of greed. Interpreting too many mammograms, the argument goes, leads to reader fatigue and errors that would otherwise not be made.
Going Both Ways
What the liability sewers don't tell the jury is that there are millions of women who need mammograms every year, but there are a limited number of radiologists. In fact, there is a general shortage of radiologists everywhere -- and there is a particular shortage of radiologists willing to interpret mammograms given their low reimbursement and high liability risk.
No matter. The accusation is enough, usually, to force a settlement (= award minus 40%).
But now what? UCSF says radiologists SHOULD read a lot of mammograms because reading MORE studies improves accuracy. Hmmm...so practice makes perfect? What's a venal lawyer to do?
I guess the Torter's will now sue me for reading too few mammograms -- because, as we all know, they couldn't care less what the truth is as long as they can make a compelling argument that will net them their cut: (= settlement x .40). It will be interesting to watch this switch in tactics.
An almost indecipherable blurb that should not have made it out of the newsroom has Danny Curtis, of California, filing a lawsuit to address injuries incurred when a surgeon removed one of his testicles that was predicted to harbor cancer, but did not:
A man is suing an area hospital and one of its surgeons, claiming one of his testicles was wrongly removed during surgery.
Danny Curtis claims Dr. Albert McBride, a surgeon at Kern Medical Center, did not conduct a biopsy before arranging urgent surgery to remove a testicular tumor in July 2004, according to the lawsuit filed in Kern County Superior Court.
Doctors later discovered that the tumor was not malignant and did not need to be removed, according to court documents.
We really cannot say much about such a complex case given the exiguous amount of data revealed by the story, but two medical blogs made a valiant effort. Kevin, M.D. and The Doctor Is In do a good job of outlining the appropriate medical data concerning the diagnosis and treatment for suspected testicular cancer. Take home lesson? In short, one does not first biopsy intratesticular masses. Given the evidence, presurgical biopsy is associated with worse outcomes, so one must go straight to surgery once the lesion is detected. Case closed.
It's Easy to Lose a Testicle...or Kidney...or
Which brings me to MY two cents on this issue. People are shocked when they learn that Danny Curtis lost a perfectly good testicle in this seemingly unacceptable way. But it isn't at all bizarre to me. In fact, there are a lot of ways you can lose your testicle in this situation.
Analogously, there are a lot of ways you can lose your gall bladder, your ovary, your lung, and your kidney. It's easy.
In my opinion, the urological surgeon has little culpability in Danny's case, as long as standard procedure was followed. Because the urological surgeon does not make the diagnosis of an intratesticular mass, the radiologist does. And this is the complex issue that may finally be at the nub of the aforementioned lawsuit. And it also leads us to explain how it's easy to lose body parts when you don't understand what is going on, how it is going on and how it can go wrong. Easy.
How much do you think that Danny Curtis knows about testicular ultrasound? Does he know that an ultrasound probably sealed the fate of his testicle? How many patients out there, who need or have an ultrasound, can answer the following questions:
What is an ultrasound test?
What kind of machine is used during an ultrasound test?
Who actually performs the examination on your body? What is that person's training and expertise? Is it regulated?
What happens to (or with) the images generated by the ultrasound machine?
Who LOOKS at the images? Is it usually the doctor who SENT you for the exam?
Do you think that the doctor who scheduled the examination could capably interpret the images?
Can ANY doctor interpret ultrasound images?
Who is the best person to interpret an ultrasound and what is his or her training and certification?
Most people cannot answer these questions. Why not? If I asked you similar questions about your home air conditioning unit, I think you would do well. And there's not even a gonad at risk!
Ultrasound is a derivative of sonar, the technology used to locate, track, and characterize things underwater. To interpret an ultrasound, one looks at an indirect image that is a reconstruction of reflected sound waves. Just think of all those submarine movies with a sweaty sailor poring over the blips that might represent a sperm whale...or a nuclear-tipped torpedo.
It's analogous to medical ultrasound -- in more ways than one. The ultrasound machine uses sound waves to locate, track, and characterize THINGS inside your body. And there's a sweaty radiologist at the other end trying to figure out if the amorphous blip is a simple lesion...or a deadly cancer.
Testicular ultrasound needs to be done by an experienced technologist and interpreted by an experienced radiologist. Notice I said interpreted. Because that's what one does with an ultrasound: interpret the image. Even in the best of situations, some testicular tumors are difficult to see or PERCEIVE.
The Answer Is NOT Printed On The Film
Here's an US:
Sorry for the small image, but you get the picture. Radiologists are gazing at little collections of echoes and trying to decide if the pattern is normal or abnormal or even cancer -- in which case the testicle needs to be removed -- without a biopsy.
A testicular tumor, on ultrasound, appears as an area of slightly decreased echoes -- in an area of many echoes. The diagnosis is one of degrees. One observes an area that does not seem to be as echogenic as a neighboring area. If one can reliably document this phenomenon in two different axes of the testicle (like longitudinal and transverse), then a presumptive diagnosis is made.
So if you get a testicular ultrasound, and you don't know which questions to ask and what the right answers are, then you are gambling that all the stars are aligned that day, because there are fifty ways to lose your testicle.
What are some of them?
WHOSE GOT THEIR EYES ON YOUR NADS?
Testicular ultrasound needs to be interpreted by someone who has learned how to read the images. Sounds logical, right? Formal training takes place almost exclusively in radiology residencies.
Then again, even radiology residents sometimes don't get enough training in testicular ultrasound, and it may take a radiologist a few years to really get good at the task.
So, if the person interpreting your ultrasound did NOT train as a radiologist or does NOT have experience interpreting the exam, he or she may look at a normal echo-variation and interpret it as a cancer --------------->LOSE TESTICLE
"I'M NOT SURE IF THIS IS ABNORMAL" ... ERR ON THE SIDE OF...
Sometimes the answer simply is not clear-cut. There is an area that looks a little abnormal, but is it really? Maybe. Maybe not. Should the interpreter err on the side of over calling or under calling subtle abnormalities? Almost always, one will over call --------------->LOSE TESTICLE
DON'T TOUCH THAT DIAL!
The technologist who is performing the ultrasound has to gage the background "echo level" needed to study each body part. This is done with manual adjustment of the gain. If the technologist sets the gain too high, a cyst (benign) can look like a solid mass (cancer) ------------------>LOSE TESTICLE
FAT IN ALL THE WRONG PLACES
It is difficult to get clear images in an obese patient. The sound beams have to traverse the layers of fat, and in doing so they get "lost." This causes degradation of the images (formed by the sound bouncing off the testicle and making it back to the machine). The echo drop-out can lead to "holes" in the scan. These can be misinterpreted as lesions ------------------>LOSE TESTICLE
I HAVE THIS ITCH
Likewise, a patient can have a rash or an incision or some other skin condition prohibiting good contact (this is essential for ultrasound exams) of the ultrasound machine with the scrotal skin. Less skin contact means fewer good echoes sent and received and again, echo drop-out can lead to "holes" in the scan. These can be misinterpreted as lesions ------------------>LOSE TESTICLE
DOC IN THE BOX = GONAD IN THE BOX
The "clinic" you go to for your ultrasound is owned by a schizophrenic zoophagous hermit who lives in -- and directs the clinic from -- Antarctica. He operates the facility only for profit. To maximize his return he buys second hand, dilapidated ultrasound machines on the world-wide medical imaging equipment black market. He hires inexperienced technologists, and radiologists who are on the lam. Because the machine generates bad images with "echo-holes", the technologist doesn't understand what he is doing, and the radiologist is still sobering up, a normal contour change is called a tumor -------------> LOSE TESTICLE
Bottom line? A lot of things can go wrong. There are a lot of ways you can lose your testicle. And you'd never know what hit you.
You see, there are issues in quality control that you've never dreamed of and you have no inkling exist, and this is unlike any other service area or product in the free market system. Because ultrasound of the testicles does not exist in the free market arena. So these little MAJOR items and issues of quality assurance and control are the ghosts in these machines, acting in innumerable ways unknown to the consumer, because the consumer doesn't care... because the consumer is so frozen out of the decision to choose and understand quality in medicine that even a testicle cannot be called safe.
Experience, equipment, expertise, and acts of God. There are fifty ways to lose a testicle, but you can whittle them down to one: acts of God.
But you gotta learn. Get educated. Choose. Be free.
DON'T LEAVE IT UP TO GOD. TAKE CONTROL OF YOUR MEDICAL CARE NOW.
“If only something—something would happen to you, and wake you out of your beauty sleep! If you could have a child, and it would die. Let it grow, let a recognisable human face emerge from that little mass of India rubber and wrinkles. Please—if only I could watch you face that. I wonder if you might even become a recognisable human being yourself. But I doubt it.”
Look Back in Anger
Following standards in place in the U.S. for 25 years, The National Health Care Service in Britain recently upgraded mammography technology, widened the age for screening mammography and began using two view technique, which has resulted -- as I reported yesterday -- in 11,000 cases of breast cancer diagnosed earlier, in 2004, than would have been found in years past without the upgrades.
The lethality of breast cancer is proportional to the "stage" at which the cancer is detected. Roughly, stage = size and spread, and BOTH of these parameters increase with time. Translation? The earlier you find the breast cancer, the earlier the stage of disease.
Here are the breast cancer survival rates by stage. Look carefully:
5-year Relative Survival Rate
If the National Health Care Service in Britain had spent the money to upgrade their screening program (instead of insisting that the U.S. system was "over the top") even 10 years ago, at least 110,000 women would have been discovered with breast cancer at a higher level in the above algorithm.