Final report – Investigation into mammograms

The Collège des médecins du Québec confirms that there was a problem and recommends improvements in quality control

March 27, 2012

The findings of the investigation ordered by the executive committee of the Collège des médecins du Québec to review the results of over 22 000 mammograms done in three clinics in Montreal and Laval, between 2008 and 2010, revealed that a total of 109 cases of breast cancer were detected and managed, as they were diagnosed.

“In November 2010, as soon as we heard that errors may have been made in mammogram interpretations, we immediately launched the investigation to ensure that all the women who underwent these tests could receive the treatment their condition required as quickly as possible,” pointed out Dr. Charles Bernard, president and chief executive officer of the Collège. “We are well aware that this inquiry was a cause of anxiety for many women. But today’s report confirms that we had to do it, and we thank the patients for their understanding and collaboration.” The radiologist whose work led to the investigation stopped practicing in October 2010, before the investigation began.

“Our primary concern has always been to ensure that the women who had these mammograms are informed, supported and accompanied until they receive all the services and health care they need,” stated Dr. Louise Charbonneau, investigator for the Collège des médecins.

“The investigation revealed that improvements could still be made to prevent this type of situation from happening again,” added Dr. Huguette Bélanger, investigator. “As well as stepping up what is already being done, we formulated 10 additional recommendations. The main objective of the recommendations is to establish a formal, systematic and closer connection between radiologists in private clinics and referral centres in the field in order to provide radiologists with appropriate feedback and support.”

The report’s key recommendations are:

  • that a formal connection be established between screening centres, referral centres and private mammography clinics to promote monitoring and feedback with respect to the performance of screening centres and their radiologists;
  • that four expert radiologists be appointed to cover the entire territory of Québec and ensure continuous monitoring of the quality control of mammogram interpretations;
  • that all mammograms must be systematically digitalized to allow immediate consultation of films if necessary.

“The Collège will monitor the application of the recommendations and has obtained confirmation of the collaboration of the Association des radiologistes du Québec and the Ministère de la Santé et des Services sociaux,” announced Dr. Yves Robert, secretary of the Collège des médecins.

Another aspect of the investigation dealt with more than 500 CT scans. In this case, instead of rereading the exam, the approach was different. The investigators got in touch with all treating physicians to reassess the need for redoing the test, this was done for 158 patients. Recommandations are made to regulate updating of all imaging equipments to medical directors of imaging clinics and the Ministère de la Santé et des Services sociaux.

The Collège’s representatives would like to thank all those who collaborated in the investigation, in particular the two investigator physicians, the Association des radiologistes du Québec and the 41 radiologists who re-examined the mammogram results, the Ministère de la Santé et des Services sociaux du Québec which quickly authorized the resources to conduct the investigation, the Agence de santé et des services sociaux de Laval which established and managed the coordination centre for the investigation, the referral centres which increased their availability for women who required further tests as well as the staff and medical department of the three clinics concerned: Radiologie Fabreville (Laval), Radiologie Jean-Talon Bélanger and Radiologie Domus Médica (Montreal).

The full report is available here.

The Collège des médecins du Québec is the province’s professional order of physicians. Its mission is to promote quality medicine in order to protect the public and help improve the health of Quebecers.

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Information: Ms. Leslie Labranche
Public Relations Coordinator
Collège des médecins du Québec
Media line: 514 933-4179
Cell: 514 915-2170

 
 

© 2009 Collège des médecins du Québec