i Mammo: The Mammogram You Never Had
An article in several parts
Part III and Conclusion: Mammographic Serfdom
Tofu, Turkey, and Planet X
In the mid 1980's, an arcane new technology transformed the music and recording industry. Music CD's, with digital music pressed onto their silvery surfaces, emerged from avant garde record stores like UFO's from Planet X. The public was asked to abandon its long love affair with vinyl LP's; and worse...to forgo that sweet, unstable, quirky player-box: the turntable. In its place, astonishingly soulless and siliconized, was the CD player, a computerized device as far removed from the record turntable as tofu is from a Thanksgiving turkey.
Despite aesthetic shortcomings and poorly understood technology, digital music and CD's quickly and thoroughly transformed the recording, delivery, and storage of music. It was a revolution spurred by those twin engines of the market system: consumer demand and feedback. Convenience, portability, and reproducibility were honed to consumer preference in a marketplace where competition also took care of prices. CD players -- like all new technological products -- started at prices over $1,000, but quickly were available for less than $300. These same forces drove innovation, resulting in today's market gigaton bombs: the iPod and iTunes.
Divergent Paths, Asymmetrical Outcomes
In Part I of this series I drew a parallel between the advent of industry-changing technologies in music recording and breast imaging: the music CD and Full Field Digital Mammography (FFDM).
In this example, however, the parallels diverge after introduction of the technology. FFDM stands as a technology, now five years post introduction, that boasts all of the advantages of the digital format, with very few drawbacks. Yet FFDM has neither become widespread, nor has it evolved rapidly in the years since it broke into the FDA's universe of approved devices. This, despite the fact that routine use of FFDM will mean:
- Fewer images and less radiation overall
- No lost, damaged, or mislabeled films
- Portability
- Reproducibility
- New ways to detect cancer (manipulating the digital image); and
- "Double-reads" by Computer Aided Detection (CAD) software
As I wrote about in Part II of this series, "double-reading" is a highly desirable method to improve cancer detection, but it is not feasible currently. However, with digital mammography, CAD is effortlessly available* with the push of a button. After the digital mammogram is recorded, the radiologist makes a decision about the study (mainly: are there areas of suspicion?), then, with a keystroke, the image is "re-read" by the computer. The CAD software marks out, on the film, areas of question. The radiologist then observes the computer's markings to make sure there are no areas that were missed in the original interpretation. A large study recently confirmed the efficaciousness and value of these CAD over-reads. The conclusion? CAD increases the total number of breast cancers identified over a lone interpretation by a radiologist.
What power did digital music and recording have that digital mammography lacks? Why did one breakthrough technology snare the public's imagination while the other plods along, it's advantages and potentials relatively ignored?
Is it too Expensive and Less Good?
The digital mammography machine is a lot more expensive than the format it seeks to supplant. An X-ray mammogram unit can be purchased for somewhere around $70-100,000. Digital mammography units are closer to $500,000, and adding on additional workstations to view and manipulate the images further increases the cost.
There are some imaging concerns, also. Many radiologists feel that although detection of calcifications (one of the ways one finds breast cancer) with digital mammography is improved over x-rays, the perception of masses and small opacities is not as good. Also, the resolution (how well two tiny areas can be seen as separate things) of film systems is slightly better than digital systems.
Could these two factors be holding back the imammo revolution? Hardly.
Issues with new technology are not uncommon, as the example of digital music demonstrates. Neither are high prices. Usually, these market deficiencies are dealt with rapidly and efficiently by consumer demand and feedback along with manufacturer competition. Currently, the benefits of FFDM outweigh the problems standing in the way of its widespread adoption, and the issues of price and image resolution surely would quickly be resolved if digital mammography were presented to the marketplace for absorption. It reminds me of the famous Spartan threat to Laconia that went something like this: "If we breech your walls we will capture your city and enslave your people." The Laconians -- being laconic -- answered:
If.
Out of the Loop
The reason that digital mammography remains in the starting gate, along with, in some aspects, another powerful high-tech procedure, MRI of the breast, is because of the market place distortions in medicine.
Unlike other markets, in medicine the consumer is unhooked from the formative and evolutionary processes. Consumers don't purchase the technology directly, nor are their preferences and desires fed back to the manufacturers and vendors. Instead, third party payers (insurance companies, HMO's, and the like) lead consumers by the nose to the mammography centers that have cut the best deal, or have the best relationship with the patient's insurance company or doctor. There is little of that essential market component: choice.
It goes further than that. Because consumers have no informed idea as to what constitutes a good mammogram, and appropriate interpretation, they cannot judge the product of this process. Is there a woman anywhere who can answer of her women's center:
Who is interpeting your mammogram?
What is the interpreter's qualifications?
Is that interpreter competent?
What type of machinery is in use?
Who is the technologist performing the study?
Is every mammogram satisfactory, or are there glitches in the process?
What degree of certainty is there as regards any particular diagnosis in any particular patient?
And most saliently: what is the track record of this facility and how is that track record documented?
If no one ever knew what good or appealing music sounded like, or the basic parameters of that decision, digital music and CD's would have gone nowhere. Likewise, with little notion of the determinents and results of quality in mammography, consumers cannot intelligently express their opinions and desires.
This is how backwards the consumer in medicine is. Not only can one not make an intelligent and rational decision between x-ray and digital mammography, most women don't even know if the mammogram they got, last year, was done competently or interpreted appropriately.
The government is aware of this gross information deficit. Their interpretation? It is the government's opinion that women are not sophisticated enough to grasp these issues and to make their own choices. That's why legislators allowed Mammactivists (disease-specific lobbyists) to foist myriad laws onto the system, mandating thousands of pages of standards and complex, byzantine rules and regulations that attempt to legislate women's centers and mammographers into quality -- a task that most economists willl tell you, is inefficient, costly, and fraught with perils.
These laws had a predictable outcome: Compliance required raising the cost of running a women's center. To offset this (un)anticipated result of do-good legislation, the government -- through Medicare, which sets reimbursement standards -- instituted price controls limiting the amount a center can collect. Add to price controls the government's later conclusion that less expensive mammography would be more widely accessible (so they lowered reimbursement even more), and the result? A product that is produced as cheaply as possible, if at all.
The final nail being driven into the coffin of FFDM is liability lawsuits. Mammography is, by most estimates, second only to childbirth as a source of litigation. Every mammographer lives in fear -- each and every moment -- of receiving THE registered letter from Torter, Sorter, and Distorter, the lawsuit lions who perform retrograde scavenging of mammograms in breast cancer cases looking to find images they believe are confusing enough to befuddle juries and bludgeon insurers into settlements.
If people were informed and had choices, new technology would spread like wildfire, and breast cancer detection would get better. Fewer women would die from breast cancer. All the groups who lobby so hard and work so fervently against this cancer plague could do more by advocating simple market reforms than is done with all the walkathons, pink ribbons, and think tank group seminars together.
Worse Than Serfdom
It is profoundly cynical to conclude that the public's intelligence and ability are insufficient to evaluate and choose in matters of health care and medical technology. This cynicism prohibits any talk of such reform; That and the entrenched lobbyists on all sides -- including physicians.
It is also sad that on the horizon -- only one politician away -- lies the pernicious spectre of nationalized health insurance. This type of reform leads in the other direction, to less choice, fewer options, and more ignorance. Read my post regarding the British mammography program whose monolithic socialist health care system, until just recently, refused to accept even the rudiments of breast cancer screening. Many, many lives surely were lost as a result.
There is only one direction less choice and less information leads. Someone once called it serfdom.
But in the case of medical technology, and mammography, it's a road to death.
*Plain film x-ray mammograms can be digitalized with the use of an analog-to-digital converter, and these images can then be subject to CAD analysis by a computer. However, the converters are expensive, involve several extra steps and additional manpower, and have not entered into widespread mainstream use.
Please note I re-edited this post slightly after its morning publication to improve clarity without changing any substantial facts or statements.
Posted by: CodeBlueBlogMD | April 20, 2005 at 02:36 PM
Ahh. . . . the austrian economist doctor. Brilliant post--you put your finger on why medicine fails as a market in theis country.
But, why do you blame lawyers? (There must be a psychological disorder that affects doctors and that causes an aversion to the law resulting in irrationality and lapses in thought and judgment.)
Suits have nothing with the problem--that information regarding doctor performance and that a functioning market requires--is not accessible to consumers. The existence of malpractice does not encourage or discourage disclosure of generic health care data.
The problem is with the incentives of insurance companies (and their de facto employees) doctors. INsurance companies have an incentive to reduce cosst within the barest acceptable quality standards. Doctors have an incentive to stay on insurance companies good side to make sure they have patients--this involves HIDING empirical evidence about their performance.
There's nothing stopping you, or anyother medical service provider, from posting your performance metrics. But, you chose not.
If they made such info public, consumers would demand the best and increase costs--something insuarance companies would hate.
Insurance should be mandatory, preferably ONLY for catastrophic illness, and completely private.
Posted by: Alban Berg | April 20, 2005 at 03:53 PM
I really appreciate your providing all this information!
A few years ago, full body scans (MRI) were advertised as buy one/give one as gift. My husband and I seriously considered gifting each other but were discouraged by our respective physicians from obtaining (the trendy)diagnostic full body scan . According to our personal physicians, the jury was out regarding the safety and accuracy of these expensive scans. Is the real issue accuracy of MRI imaging or the interpretation of these images?
You linked to MRI mammo - which, if I'm not mistaken indicates it is the technology of choice for mammo.
Can MRI also stored as digital media?
I have had the traditional mammo done several times. When directing me to my first mammo, my physician informed me that it would make a good baseline record for future tests. That first film (if still available from 1992) resides in another state. I would much prefer to have (even at my own expense) the most accurate and portable record as an option available to me.
MRI (to a lay person) seems like the ultimate imaging technology for diagnostics. However, in having been discouraged from the full body MRI scan, I'm a wee bit confused.
Is the MRI mammo acceptably accurate because it is specific to the breast area?
Is there excessive exposure when there is a full body scan?
With the limited time available to read each scan, regardless of the technology, is the reason for the question of accuracy regarding full body scans - the amount of time allotted to read?
In an earlier post (Part I) I asked if there was a term besides 'digital mammography' that I should ask my doctor about. A yahoo seach shows that it's available by that term in NYC . . .http://www.mimrad.com/digital.html
Does this link reflect what you are discussing re: digital mammograms?
Again, thank you. You provide an very valuable service with this blog. I started reading with the Schiavo case. I now check your site daily. :)
Posted by: amom | April 20, 2005 at 06:18 PM
Alban:
I didn't blame lawyers. I have no aversion to the law. I named tort attorneys as one of the powerful forces that have created the mammography crisis, and that help keep the market system from operating in medicine.
I am specifically referring to those lawyers ONLY who specialize in malpractice liability cases. They are a particular breed and I have met many of them -- enough to form a solid opinion about their motivations, intentions, and professional behavior.
Lawsuits have much to do with the problem. The lawsuits, the threat of lawsuits, and the settlement of lawsuits affects everything I do every day I work. I know of no radiologist who interprets mammograms who does not feel this way. I have no reason to make this up, or exaggerate; my purpose here is exposition.
This is a much more powerful force than statistics would reveal, especially because almost all cases are settled then SEALED as part of the settlement. If one reads 20-50 mammographic studies a day -- not uncommon in this era when no radiologist is willing to take on these examinations -- the year's total can be over 10,000. If one has a sensitivity rate of 95% (in baseball you can get to the Hall of Fame by batting .350!)then one can expect to miss 5 findings in every 100 that present themselves. This would translate to about 500 "misses" per year. If one of every five of these "missed" findings is important (cancer vs not cancer), then, with a 95% sensitivity, one could "miss" up to 100 cancers per year.
This translates, over the course of a few years, to thousands of mammograms floating out there that could be adduced as evidence of "malpractice." Proof of what I am illustrating was documented in a well-known study that showed almost 50% of mammographically identified cancers could be seen, in retrospect, on the previous year's mammogram.
Since most cases are settled, and there is no trial, "community standards" do not come into play. So, an unscrupulous, or ignorant person can use almost any cancer along with the year's previous mammogram to trump up malpractice and force a settlement.
The effect of this is psychological, and monetary. Why would a radiologist read mammograms for a $15-20 fee when one can read CT's and MRI's for 5-10x more? Believe me, the malpractice insurance for mammographers is steep, and it adds to the overhead of the women's center, furthering the economic disincentive to own and operate mammogram facilities.
Insofar as revealing information to the public, I am all for it. I think it is essential, and important. But, it cannot be unilateral. Without a backround, or grounding, consumers cannot hope to gain a rational foothold to be able to understand, interpret, and use the information correctly. The effort needs to be widespread, in all fields, and the effort needs to be universal, with government, media and professionals opening up and helping in the task. The ignorance is so deep, at this point, it is going to take a massive effort to reverse.
All that being said, I would STILL welcome the opportunity to open everything up to the public. I have no problems defending what I do, how I do it, and what my results are. I would also like to be free to point out medical and therapeutic inconsistencies, and errors, I see, when I see them. But, get serious. What would be the first thing that would happen? There would be a conference for liability lawyers in Miami Beach so they could plan strategies and plot ways to use this information in liability suits against me (doctors). Web sites would pop up advising liability lawyers in the proper way to manipulate this data to prove malpractice. Tis is not fantasy. As you know, such conferences go on all the time and these websites are common.
Let's not be like academics who pretend reality is not an issue. The reality is that with the malpractice laws the way they are, and the incentives as they are -- and people being people -- revealing data and quality control issues in a naked format would result in a legal disaster.
That's why it isn't done.
And those are the reasons why liability lawsuits and lawyers are a large part of the crisis in mammography.
Posted by: CodeBlueBlogMD | April 21, 2005 at 08:21 AM
Dear CodeBlueBlog,
Thank you for your thoughtful response. Fair enough. Certainly under the current regulatory climate making info. public is an invitation for law suits. Or, at the very least, doctors have nothing to gain from disclosure.
But, the cause for this is our third-party player regime which makes the insurance company the purchaser of medical services--not torters to use your locution.
Undoubtedly, the threat of suits affects doctor's behavior. But, why is that bad? if, as you point out, consumers are out of the loop as far as quality and, therefore, the consumer cannot discipline doctors through the market, what else but lawsuits will discipline doctors. If I go to a doctor and have no idea about his quality, how do I know he'll do a good job--the best I have is that if he screws up, I'll sue him and take away is Lexus.
The answer you usually get is doctor's own professionalism will ensure quality. Hmmmm. Undoubtedly, there is some of that, but serious economic research has indicated that self-policing rarely works. The moral hazards are too great.
Finally, you estimates about 5% error are fascinating--thank you for your openness, which is extraordinary and brave. but, to be frank, the number is appalling. You certainly seem highly intelligent and are certainly the most intelligent medblogger out there (at least you don't use purple prose to describe your exquisite sensibility about dying people)--but that's a terrible rate of error for any industry. Would WALMART tolerate 5% error in its inventory count? Would an accountant tolerate a 5% error is an earnings statement?--Would we tolerate 5% of all airplane crashing--would we tolerate 5% failure rate (meaning contraction of the underlying disease) even for vaccines? NO.
Of course, the mechanism that force industries to expend that extra effort to go to 99.9% accuracy (always the hardest hurdle) is the market. Of course, medicine is a monopoly--the medical professional decides who can practice it. Monopolies tend to lower quality and output and raise prices. A natural corollary of your argument is elimination of all licensure. Are you game, doctor?
Posted by: | April 21, 2005 at 03:38 PM
Settlements are sealed at the request of the defendant 90% of the time. They will continue to be sealed because insurers make them a part of almost all settlement offers. To suggest that community standards don't come into play is silly. The insurer knows that the standard of care in med mal is based on a reasonable physician in that locality.
Care to tell us how many cases are based on previous mammograms missing cancer? Or is that just a claim without a fact behind it?
"I named tort attorneys as one of the powerful forces that have created the mammography crisis, and that help keep the market system from operating in medicine." If you eliminated every lawsuit against any health care provider out there, you still would not have a "market system" in medicine. Lawsuits, legitimate or not, are a fraction of the cost of medicine and have almost nothing to do with the lack of a free market. Limiting access to the courts, however, is the first step towards a national health care system. The next step is when a whole bunch of pensioners get dumped on the federal government. Probably about 3-5 years from now, unless GM can start producing cars that sell.
Posted by: Curious JD | April 22, 2005 at 12:20 AM
"Finally, you estimates about 5% error are fascinating--thank you for your openness, which is extraordinary and brave. but, to be frank, the number is appalling."
That's the nature of the problem. Tiny tumors do not show up much on x-rays, and normal breast tissue has a lot of variability that does show up. Is that a tumor? Or did bits of fatty tissue just happen to line up in a way that looks like a tumor?
Setting the threshold lower would mean fewer false negatives (missed cancerous tumors), but it would also mean more false positives (unnecessary fear, biopsies, and mastectomies). You have to set the sensitivity threshold somewhere in between and try to minimize overall cost. There is no magic way to get perfect results.
Posted by: Daniel Newby | April 27, 2005 at 08:31 PM
Hey...I'm really young, probably too young to comment on this site, but I'm a huge fan of 24 and CSI. I think that the people blogging on the site would love the Forensic Files on Court TV. Of course TV is my life right now...haha.
Posted by: usher | April 28, 2005 at 07:14 AM
Dear DN,
1. Typical doctor's response, but really quite flawed. The choice to biopsy a suspicious looking mass is really a question of personal risk aversion. Why can't doctors say (more often), there's a mass that looks like a bunch of fatty tissue, but maybe it's a small tumor. What do you want to do, acknowledging that a biopsy has risks both physical and (I guess) of false positives? Doctors rarely have answers. The problem is that they often act as if they do.
2. Yes, the number is appalling. Yes, the technical challenge is great. My only point (repeating the one made by CodeBlog) is that if there were a free market in medicine so that anyone could practice it and treatment would not be subject to our program of socialized medicine, medicare, we'd have better technology.
Posted by: Alban Berg | April 28, 2005 at 11:34 AM
"Setting the threshold lower would mean fewer false negatives (missed cancerous tumors), but it would also mean more false positives (unnecessary fear, biopsies, and mastectomies). You have to set the sensitivity threshold somewhere in between and try to minimize overall cost."
No offense, DN, but that's a horrible, patronizing argument. Who is the "you" and whose cost are you trying to minimize?
The balance between false negatives and false positives should be set by the individual-- at least in a free market system. There is no "magic answer" to how much risk one wants to assume and at what cost because only an individual can answer that question--not doctors!
Part of the trouble with medicine today is that this question of risk is too often taken out of the hands of individuals and given to insurance companies and doctors--neither of whom are competent to find the ideal level of acceptable risk for any particular individuals,
Posted by: | April 28, 2005 at 05:26 PM
1. The trouble is that the probabilities themselves become rather uncertain for low-risk results. The typical patient is already baffled by statistical recommendations. Telling them that one study says their risk of cancer is 1 in 500 and another says it is 1 in 2000 doesn't help them make an informed decision. Meanwhile one biopsy study might show a 1 in 17000 risk of death and another might show a 1 in 300 risk of complication. Add to that the fact that studies LIE. The uncertainty compounds; there is no right decision. For the patient to contribute to the decision for a marginal result is basically just taking the dice out of the doctor's hand. (There's nothing wrong with that. It is just the way it is.)
2. A good place to start would be rolling back the courts' interpretations of the Commerce Clause. According to our judicial masters, if a radiologist takes a mammogram and gives the woman a report right there on the spot, he has just engaged in interstate commerce. Therefore the lobbyists in D.C. get to regulate it to their hearts' content, using Congress's commerce clause power. (Silly me, thinking that interstate commerce should actually involve, you know, crossing a state line.) I suspect that fixing this will take either a civil war or divine intervention.
Posted by: Daniel Newby | April 28, 2005 at 06:10 PM
Hey Doc??
I have been waiting with great anticipation for your next post!
Where are you??
Zami :)
Posted by: Zami | May 10, 2005 at 11:18 PM
a very intriguing post, providing lots to think about. of course the lawyer-types can only consider one aspect of your thorough commentary - malpractice. and once again they rally to the cause of doctor-bashing with a telling threat to 'take away your lexus'. i'm learning not to blame them for their ignorance though. they have no concept of the decade we give up to become doctors, nor the daily responsibilities we struggle with in making medical decisions that 'do no harm'. their wish for a world full of black-and-white, right-and-wrong, justice-and-injustice leads them to bend and distort the very truths they once went to law school to uphold. babies aren't gauranteed a birth free of complications and breasts aren't gauranteed to be free of cancer. life is not lived in absolutes, and medicine is not practiced with complete certainty. they don't get this. they'll come back at you with indefatigable rationalizations and half-truths. specialized medical courts are going to be a reality, because i believe they will compensate injured patients fairly, more often, and with greater efficiency. they will help to establish real standards of medical care via evidence-based medicine applied by expert judges. doctors will be fairly sanctioned with the horrible ones weeded out. the real losers will be the as$holes who bring frivolous lawsuits and the multimillionaire trial lawyers who prey upon juries' emotional quotients and salivating desires to redistribute wealth from the doctors they are so convinced make more money than them.
Posted by: Retorting Doc | May 12, 2005 at 04:10 PM
Zami, perhaps he will have more to say about the 'fractures' of both ankles, both knees, both sacroiliac joints and ribs when the Terri Schiavo autopsy xrays are published.
Posted by: peak oil | May 14, 2005 at 06:34 PM
hey, what happened? did you get tired of writing?
c'mon CBB this is one great blog. don't stop
Posted by: Mad House Madman | May 15, 2005 at 06:38 PM
Hey peak oil, where did you hear about the 'fractures' of Terri Schiavo? Have a link?
Yes, I have been waiting much anticipation for Terri's autopsy, although given the secrecy surrounding the autopsy, I have little hope that the evidence or report will provide any conclusive results. Somewhere I had heard that they weren't going to allow the x-rays to be published. I hope that I heard wrong. Or at least somehow they find their way onto the internet.
And, I keep hoping the Doc will provide us with his analysis.
;)
Posted by: Zami | May 16, 2005 at 07:22 AM
Zani, there have been many claims of multiple fractues. These were common on the Court TV discussions though some of the nastier posters have been banned. They can be found on and were promulgated by the codeblueblog discussions. Or on TV programs as when Hannity interviews the Shindlers. It is likely that these claims are bogus. One physician posting on CBB gave a convincing physiologic explanation for the bilateral hot spots.
Posted by: peak oil | May 16, 2005 at 02:36 PM
Link http://www.sptimes.com/2002/11/13/TampaBay/Attorney_claims_a_bea.shtml
Posted by: peak oil | May 16, 2005 at 06:42 PM
Thank you, peak oil.
:)
This is the link to an article I read yesterday about the medical examiner, why he wouldn't allow the family to have an additional examiner present, who he is, why he is so "ethical", why he won't let the "politics" of Terri's case "influence" him, and why it will take at least 3 more weeks for the autopsy report.
http://www.theledger.com/apps/pbcs.dll/article?AID=/20050510/NEWS/505100343/1004
(via MichelleMalkin.com May 18)
Article is now missing.
Hmmmmmmmmmmmmm
Zami
Posted by: Zami | May 19, 2005 at 09:11 AM
I am getting worried. Where is CBB. Combat fatigue. If my math is correct there were about 1800 posts related to Terri Schiavo. It was not easy to find the gems buried in the noise. Kate Killibrew M.D. had some interesting comments regarding the findings on the nuclear bone scan. It might be worthwhile to see a critique of her analysis. Scroll down from
http://p100.ezboard.com/fpeakoilpetroleumandpreciousmetalsfrm10.showMessage?topicID=485.topic
Posted by: peak oil | May 22, 2005 at 09:09 AM
Correction http://codeblueblog.blogs.com/codeblueblog/2005/03/csi_medblogs_co_1.html#comments
Posted by: peak oil | May 22, 2005 at 11:36 AM
Thank you for the link, peak.
I am worried, too. I hope it is just needing or taking a vacation and nothing else.
Been more than a month.
Is there a doctor in the house??
Zami
Posted by: Zami | May 25, 2005 at 07:28 AM
Amom
MRI is not the ultimate imaging technology it depends on what structures you are interested in. It is generally accepted that MRI images are superior to assessing soft tissue structures, while CT scans are superior for assessing bone structures.
MRI has no radiation exposure, CT scans are what you are referring to. MRI's are just really powerful magnets. Unless you have any metal (pacemakers) in your body you are pretty much safe.
As for your doctors recommendations. One problem is that even if abnormalities are found, most are not significant. However, doctors will feel obligated to practice defensive medicine and send you for a work up, which carries with it a whole new set of risks and discomforts. For example, suppose the image shows something in the colon, then you might be sent for an unnecessary colonoscopy.
In practice MRIs are suppose to be done when the are 'medically indicated."
You can still get it done, if nothing else you will have a nice set of images to compliment you wedding photos. Its still pretty cool to see the body from that perspective
Posted by: g | June 04, 2005 at 02:51 PM
http://www.reason.com/hitandrun/2005/03/the_schiavo_cas.shtml
Posted by: | July 09, 2005 at 11:43 AM
I am not sure why anyone would think that a colonoscopy is unnecessary. If someone has a change in bowel habits, or other symptoms that might be worrying, then the colonoscopy can at least help in relieving the worry that one might have bowel cancer. Also, this is used to detect more than cancer. It is also useful in detecting other diseases of the bowel. It is the same with the endoscopy. That is how it was detected that I had an inflammation of the stomach lining caused by an ulcer. I was not aware that I had an ulcer until I had that test. It is through the detection of this problem that further problems are avoided.
These tests are uncomfortable but in the long run they do give peace of mind if there is no cancer detected.
Posted by: AussieAussie | July 15, 2005 at 03:41 AM