[A critical view on cancer screening: do we see the elephant in the room?] / Kritische blik op kankerscreening.

Cancer screening promises health benefits but it also delivers harms and costs. A substantial problem is overdiagnosis of tumors not needing treatment. There are well established principles for starting cancer screening, but we also need periodical evaluations and stopping rules. For that we must have the results of methodic empirical studies with proper estimates of benefits and harms. Proponents of screening emphasize its advantages but hold back on its drawbacks. Several studies have argued that a universal population screening approach, especially for breast cancer, is no longer tenable. We need a fresh and independent assessment of screening practices.

[Sterile gloves are not necessary in minor surgery]. / Steriele handschoenen bij kleine chirurgie niet nodig.

According to the practice guideline of the Dutch Workingparty on Infection Prevention (WIP) sterile gloves have to be worn during minor surgery by the general practitioner. This is based on the microbiological principles of Spaulding and is not supported by other evidence. Current literature suggests that using clean, nonsterile gloves, instead of sterile gloves, does not result in a greater risk of wound infection in primary closed wounds after minor surgery. Also, in daily practice, only 24% of general practitioners actually wear sterile gloves. We therefore propose to modify the guideline: using clean, nonsterile gloves during minor surgery is sufficient.

[Diagnosis of breast cancer missed in a young woman]. / Diagnose 'borstkanker' gemist bij een jonge vrouw. Klinisch denken en doen in juridisch perspectief.

The diagnosis of breast cancer in a 31-year-old woman was delayed, apparently because she did not comply with advice to come for a follow-up appointment after an initial diagnosis of adenofibroma. For this she held her general practitioner (GP) responsible. In the ensuing legal battle the court expert testified that the GP had complied with the appropriate practice guideline. Of particular importance was the fact that breast cancer at her age is very rare. In my view, however, it was erroneous to estimate the probability of cancer based solely on her age, since the a priori probability of cancer in women with a solid breast mass visiting their GP is approximately 10%. Exclusion of malignancy requires the most sensitive diagnostic strategy, unfortunately not applied in this case. The Dutch College of General Practitioners' practice guidelines on diagnostic strategies in breast cancer should be based on a more accurate estimate of breast cancer probability in specified groups and the requirement that the test strategy sufficiently rules out cancer.

When is the practice of pathology malpractice?

Because of its complex nature, surgical pathology diagnosis has an appreciable degree of fallibility and is increasingly subject to legal scrutiny. In litigation, the first practical step is to explain why and how this adversity could happen, and the second is the question of apportionment of responsibility and its legal consequences. As pathologists, we have to provide a methodology of investigation allowing a clear distinction between reasonable and unacceptable pathology practice without the twist of hindsight. For that we need to examine the different steps from test ordering to the final report. The most critical aspect of the enquiry is the act of diagnosis itself. What can reasonably be expected and what precautions have normally to be taken? Experts are often requested to re-examine the slides. For that we need a well-devised protocol enabling blinded review. Tort law has two important interconnected goals: compensation for damages and prevention of the same slip ever being made again. We can only properly learn from our mistakes if we carry out an unbiased investigation. Poor normative judgement of diagnostic failures will backfire on the profession.

[Multidisciplinary oncology teams: beware of endless discussions]. / Multidisciplinaire oncologische teams: niet polderen.

The continual and increasing complexity of diagnostic and treatment options in oncology demands careful communication, coordination and decision making. Cancer care could be improved by multidisciplinary teamwork. Although this sort of teamwork has many advantages in theory, we know very little about its effectiveness in practice. We have to answer questions such as how teams can accomplish their task most effectively and how we must manage organizations in such a way that team-based working contributes optimally to organizational effectiveness.

[Complaints about bureaucracy in health care? Time for a proactive medical profession]. / Klagen over bureaucratie in de zorg? Tijd voor een proactieve medische professie.

Health care is in profound transition, its organization changing from being service-oriented to outcomes-oriented. Doctors are complaining of too much bureaucracy. However, the increasing complexity of healthcare demands rationalization, standardization and optimization of processes. At the same time, the practice of medicine is increasingly politicized. If doctors are the key to healthcare reform, how then are they to be motivated? It is imperative that they become more proactive and engage in leadership. They are the first to ensure that the main goals of medicine remain evidence-based prevention and cure of disease. Passivity will create opportunity for bureaucracy.

[Missed malignant melanoma: legal considerations]. / Gemist maligne melanoom, juridisch bezien.

Malignant melanoma may be missed both clinically and histopathologically. The appearance of metastases after local excision of a skin lesion which was not recognized as melanoma indicates a diagnostic error. In a lawsuit three things have to be proven: that the doctor has behaved negligently, that the patient has been damaged and that there is a causal relation between the two. After local excision of a lesion that subsequently proves to be a metastasized melanoma, no damage ('loss of chance') occurs because neither local surgery nor adjuvant therapy influences disease-free survival. These particularities are of importance in legal judgments.

Risk analyses for screening sigmoidoscopy based on a colorectal cancer (CRC) population.

OBJECTIVE: Although colonoscopy can be effective in the prevention of colorectal cancer (CRC), it requires many endoscopic facilities, has a high patient burden and risk of complications, and it is expensive. The aim of this study was to determine the risk for proximal CRC and to identify subgroups in which screening sigmoidoscopy can be effective. MATERIAL AND METHODS: A database search was carried out on all patients who underwent endoscopy of the lower gastrointestinal (GI) tract between 1997 and 2005. All patients diagnosed with CRC were included. Variables including age, gender and the presence of distal colonic neoplasia were used for risk analyses. RESULTS: In total, 783 patients were diagnosed with CRC. Tumour was located in the proximal colon in 68/255 (27%) of the patients <65 years. Of the patients <65 years, 22% (57/255) had proximal CRC without synchronous distal lesions and would thus have been missed by sigmoidoscopy screening. Among patients >65 years, 41% (216/528) were diagnosed with proximal CRC, significantly more often in women than in men (p <0.001). In 35% of patients (185/528) proximal CRC without distal colonic neoplasia was found, significantly more than in those under 65 years of age (p <0.001). CONCLUSIONS: Significantly more proximal localized CRC would have been missed by sigmoidoscopy screening in elderly patients, especially in women. In subjects <65 years of age, sigmoidoscopy screening allows detection of almost 80% of CRC cases and might suffice as a screening method.

Attendance at surveillance endoscopy of patients with adenoma or colorectal cancer.

OBJECTIVE: Surveillance of patients treated for adenoma or colorectal cancer (CRC) is intended to reduce the incidence of CRC. Responsibility for the adherence to surveillance advice is often left to the patients and family physician. It is not known whether this type of passive policy affects the efficacy of surveillance. The aim of this study was to determine the yield of surveillance without active invitation to follow-up endoscopy. MATERIAL AND METHODS: The study comprised a cohort follow-up of patients under 75 years of age with adenomas or CRC at index endoscopy in the period 1997-99. Adherence and intervals of follow-up endoscopy were determined up to December 2004. RESULTS: During the inclusion period 2946 patients underwent lower endoscopy. In total, 393 patients were newly diagnosed with colorectal polyps (n=280) or CRC (n=113). Polyps were classified as adenomas in 167/280 (61%) patients. Forty-five (27%) of the adenoma patients underwent surveillance endoscopy within the guideline interval, 63 (38%) underwent delayed endoscopy, and 59 (35%) did not have any follow-up at all. CRC was diagnosed in 113 patients. Thirty-six patients who died during the first year or were diagnosed with metastases were excluded from the analysis. Twenty-three (30%) of the remaining 77 patients underwent endoscopic surveillance according to the guidelines, 40 (52%) had delayed surveillance endoscopy, and 14/77 (18%) did not undergo surveillance endoscopy at all. CONCLUSIONS: In surveillance for colorectal neoplasia, active follow-up invitation is important. Given the low follow-up rate in our series, passive follow-up policies may lead to under-performance of surveillance programs. An active and controlled follow-up is advisable.