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J Thorac Cardiovasc Surg 2004;128:341-344
© 2004 The American Association for Thoracic Surgery

Editorial

Caveat emptor: The treachery of work-up bias

^a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
^b Department of Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
^c Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Received for publication March 22, 2004; accepted for publication March 26, 2004.

^* Address for reprints: Eugene H. Blackstone, MD, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F24, Cleveland, OH 44195, USA
blackse@ccf.org

The first 300 words of the full text of this article appear below.

See related editorial on page 396.

 

Nomori and colleagues¹ demonstrate the relationship between contrast ratio derived from F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) in cT1 N0 M0 lung adenocarcinoma and pathologic TNM classification, carcinoembryonic antigen levels, lymphatic and vascular invasion, pleural involvement, and tumor differentiation. These observations constitute the scientific merit of the study. Quite properly, the authors go on to ask what the findings mean and, in particular, what clinical inferences they suggest. Based on what appears to be 100% sensitivity of the imaging test, they conclude that if the contrast ratio is less than 0.5, "limited lung resection could be indicated, lymph node dissection or mediastinoscopy could be reduced, or both."

At the heart of these seemingly logically derived clinical inferences lies treachery. We must be quick to state that these same or similar inferences would be drawn by more than 90% of the readership, not just in this context but also in the general context of interpreting the accuracy of any diagnostic test; the authors are well within the mainstream. It is the rare reader who knows that the lid has been blown off many diagnostic tests, particularly the ones cardiologists and cardiac surgeons have come to rely on in ischemic heart disease. Heretofore, our training and backgrounds have been deficient in interpreting the accuracy of diagnostic testing. We have been misled by our ignorance. The data have not been false, but the interpretation and inferences have been.

What went wrong

Nomori and colleagues¹ provide important details that give us not only insight into the value of their study but also a clue about the trap they have innocently set for the unsuspecting. The 44 patients presented are a highly selected subset of patients who had (1) major lung resection with mediastinal lymph node dissection and pathologic classification of . . . [Full Text of this Article]