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425 426 appendix b r selecled essoys for anolysis

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426 Appendix B r Selecled Essoys for Anolysis Were the sites independent or linked to one another? Further testing was required. But at the end of these inquiries it remained the opinion of the team and particularly the clinic's pathologist that the cancer sites involved identical (metastasized) cells. Through this diagnostic process we learned that the judgment of whether the cancer had metastasized was based on judgments of visual similarity. There appeared to be no "gold standard"-no clear means to check the reliability of the pathologist's judgments. In addition, we learned that lung cancer with multiple sites in the lung was quite exceptional. No one was sure that such a diagnostic appearance meant metastasization. Using cancer textbooks, Medline, and an article in the Scientific Ameican, we came to the conclusion that the initial diagnosis was not well validated. We noted that the pathologists disagreed about the cell type, though the new pathologist assured me he was "90o/o certain" that the cells were identical and hence had the same source. But knowing there was no "gold standard," I was aware that this "90o/o" figure was just a subjective assessment of confidence and not a real measure of reliability. Based on my wife's reading about DNA testing in a colon and brain cancer study in the Sci- entific Americar we asked why DNA testing wasn't being done in this case. For rea- sons still unclear, the doctors at the cancer agency had not used such procedures in lung cancer cases. They now do. When they used DNA testing on my sister-in-law's lungs, it became clear (to the amazement of the pathologist) that the separate sites were not from the same source, but independent. The cancer had not metastasized and the risk of an operation to remove the cancer was iustified-it is over four years since her operation and my sister-in-law remains cancer free. I believe that the above story is (among other things) an educational success story. Our actions and reflections embodied the ideal of a liberal education: intel- lectual autonomy.
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