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Quebec Mammogram Tally: 109 Cancers Missed

March 29, 2012
Written by: , Filed in: Breast Imaging, Diagnostic Imaging, Practice Management
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During his last two years of reading mammograms, a now-retired Quebec radiologist missed 96 cases of breast cancer, according to the Canadian province’s College of Physicians.

Colleagues at the radiologist’s three clinics missed an additional 13 cancers. That’s 109 missed cancers among 22,040 mammograms conducted between October 2008 and October 2010.

As we’ve reported, the college began its review in November 2010 after a random quality-control review turned up problems. The error rate for Raymond Bergeron, MD, the radiologist who missed the 96 cancers, was five times above the province’s accepted maximum level. The error rates for his colleagues were within provincial norms.

Dr. Bergeron, who is in his mid-70s, retired on October 9, 2010.

The review also included about 500 CT scans. Of the patients scanned, 158 were called back for a rescan. The original scans were done on such old equipment that they were useless.

The College of Physicians released its report on Tuesday. You can read it here (if you read French).

Dr. Bergeron’s clinics were private, not part of the province’s public breast cancer screening program, according to The Globe and Mail newspaper of Toronto . The College of Physicians report said Dr. Bergeron kept incoherent files and notes, carried too heavy a workload, and failed to follow provincial standards.

Despite that, college spokesman Yves Robert, MD, almost seemed to be excusing Dr. Bergeron in a statement to CBC News:

Probably he had a very high pressure to read a high level of films in a short period of time. It seems he had difficulty recruiting colleagues to help him do the job, so probably he was just overload[ed]. And this is the kind of situation that is at risk of making mistakes.

Yeah, probably. I mean, it’s not as if any other radiologist has ever faced “a very high pressure to read a high level of films in a short period of time.”

Dr. Robert explained to The Globe and Mail that reading mammograms is really difficult. “They’re looking for a snowflake in a snowstorm. It takes an incredible amount of expertise to find it, and you can always miss something. That’s why it’s important to have breast cancer screening every two years.”

Wait. What? He’s saying it’s important to have breast cancer screening every two years in order to catch mistakes made by radiologists? Let’s hope this just a really, really bad translation from the original French.

Quebec Health Minister Yves Bolduc said the fact that the college’s review detected the mistakes shows that the system is working.

Um, no. Actually, the review showed that the system is not working. In fact, the review recommended 10 improvements in mammography standards, record-keeping, and oversight of radiologists.

In the meantime, if I were a woman living in Quebec, I’d get my mammograms elsewhere.

Related seminar: Breast & Women’s Imaging Seminar


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One Response to “Quebec Mammogram Tally: 109 Cancers Missed”

  1. Angel O. on March 31st, 2012 at 7:53 am

    I find it surprising that the missed 96 cancers represent 5x acceptable missed rate. Whta time interval are we talking about? Let’s round it to 100. That’s 20 cancers! Who finds that acceptable?! It must be a mistake.