{{Short description|Canadian public judicial inquiry}} The '''Cameron Inquiry''', formerly the '''Commission of Inquiry on Hormone Receptor Testing''', is a Canadian public judicial inquiry into the conduct of the Newfoundland and Labrador Eastern Health authority. The inquiry is investigating whether Eastern Health was at fault in the reporting of erroneous and delayed test results to breast cancer patients between 1997 and 2005, and in then failing to report the full scope of these errors. The inquiry developed ramifications for regional and national politics as the opposition Liberal Party questioned why the regional Progressive Conservative Party government had not intervened sooner in the crisis, and said that former deputy health minister Robert Thompson, who had been appointed to chair the inquiry, should stand down, prompting Newfoundland and Labrador premier Danny Williams to accuse the Liberals of a smear campaign.<ref name="Jones">{{cite news |title=Liberals cite cancer inquiry conflict |work=CBC News |date=9 April 2008 |url=https://www.cbc.ca/news/canada/newfoundland-labrador/liberals-cite-cancer-inquiry-conflict-1.772435 |archive-url=https://web.archive.org/web/20121113222710/http://www.cbc.ca/news/health/story/2008/04/09/cancer-conflict.html |archive-date=13 November 2012 |url-status=live}}</ref> The inquiry, chaired by Justice Margaret Cameron, was called in May 2007<ref name="Sweet">{{cite news |last=Sweet |first=Barb |title=Doctor regrets her part in decision not to disclose test results |url=http://www.thewesternstar.com/Health/2008-09-11/article-1473833/Doctor-regrets-her-part-in-decision-to-not-disclose-test-results/1 |work=The Telegram |location=St. John's |date= September 11, 2008 |archive-url=https://web.archive.org/web/20110810045052/http://www.thewesternstar.com/Health/2008-09-11/article-1473833/Doctor-regrets-her-part-in-decision-to-not-disclose-test-results/1 |archive-date=10 August 2011 |url-status=dead}}</ref> and released a report in March 2009.<ref>{{cite news |title=Government Releases Cameron Inquiry Report |publisher=Government of Newfoundland and Labrador |date=March 3, 2009 |url=http://www.releases.gov.nl.ca/releases/2009/health/0303n05.htm}}</ref>
==Background== In May 2005 Eastern Health discovered errors in hormone receptor breast cancer test results from a histology lab in St. John's, Newfoundland. The tests were designed to register patients' hormone levels, and determine whether they could benefit from potentially life-saving hormone oncology treatments.<ref>{{cite news |title=Never wanted test result problems disclosed, manager tells cancer probe |url=https://www.cbc.ca/news/canada/newfoundland-labrador/never-wanted-test-result-problems-disclosed-manager-tells-cancer-probe-1.701385?ref=rss |publisher=CBC News |date=23 October 2008 |access-date=6 February 2009 |archive-url=https://web.archive.org/web/20121113222748/http://www.cbc.ca/news/health/story/2008/10/23/predham-inquiry.html?ref=rss |archive-date=13 November 2012 |url-status=live}}</ref> The board commissioned the re-testing of results from up to 1,500 patients and alerted the office of premier Danny Williams of this development and of potential ensuing media interest.<ref name="alarm">{{cite news |title=Premier's office did not see alarm of cancer tests, inquiry told |publisher=CBC News |date=June 10, 2008 |url=https://www.cbc.ca/news/canada/newfoundland-labrador/premier-s-office-did-not-see-alarm-over-cancer-tests-inquiry-told-1.727835 |archive-url=https://web.archive.org/web/20080611124642/https://www.cbc.ca/canada/newfoundland-labrador/story/2008/06/10/matthews-inquiry.html |archive-date=11 June 2008 |url-status=live}}</ref> An hour after first contacting Williams's office, the board sent a second message with what communications director Karen Matthews described to the inquiry as a "stand-down" notice, saying the issue had been minimized; Matthews responded by withdrawing the office from high alert over the case.<ref name="alarm"/> Former health minister John Ottenheimer told the inquiry that he wished to publicize the testing failures when they emerged in May 2005, but deferred to Eastern Health's request that he leave them to handle the affair internally.<ref>{{cite news |title=Premier's office felt Eastern Health handling crisis, Cameron Inquiry told |url=http://www.thetelegram.com/index.cfm?sid=142601&sc=79 |work=The Telegram |access-date=6 February 2009 |archive-url=https://web.archive.org/web/20180909073855/http://www.thetelegram.com/index.cfm?sid=142601&sc=79 |archive-date=9 September 2018 |url-status=dead }}</ref>
After retesting, Eastern Health concluded that 386 patients had received erroneous results,<ref name="Sweet"/> of whom 117 required a change to their treatment programs<ref>{{cite news |title=Oncologist apologizes to patients at breast cancer inquiry |publisher=CBC News |date=19 September 2008 |url=https://www.cbc.ca/news/canada/newfoundland-labrador/oncologist-apologizes-to-patients-at-breast-cancer-inquiry-1.694726 |access-date=6 February 2009 |archive-url=https://web.archive.org/web/20121104051007/https://www.cbc.ca/health/story/2008/09/19/laing-apology.html |archive-date=4 November 2012 |url-status=live}}</ref> In December 2006 the board held a series of media briefings on the hormone receptor test errors, downplaying the seriousness and extent of the problems.<ref>{{cite news |title=Little comfort level with cancer numbers, MD tells inquiry |url=https://www.cbc.ca/news/canada/newfoundland-labrador/little-comfort-level-with-cancer-numbers-md-tells-inquiry-1.732139 |publisher=CBC News |date=26 May 2008 |access-date=6 February 2009 |archive-url=https://web.archive.org/web/20121104051027/http://www.cbc.ca/news/health/story/2008/05/26/inquiry-numbers.html |archive-date=4 November 2012 |url-status=live}}</ref>
Despite the apparent conclusiveness of the inquiry report, epidemiological evidence to support such conclusions is lacking. The testing errors are expected in medical practice, and retesting of tissues over long period of time remains a controversial exercise due to the following factors leading to bias: 1. fluid state of medical technology 2. change in medical practice patterns and criteria for test interpretation 3. effects of prevalence in diagnostic testing. If one examines the test performed in 1998 using the technology of 2008, the inherited time bias is unavoidable. Nevertheless, even despite these biases, the clinical epidemiology of medical testing robustly predicts the expected test errors (due to test characteristics rather than due to problems with test performance) and these are closely matching the observed errors uncovered by Cameron Inquiry.
Any medical test with 90% sensitivity and 90% specificity (and this was declared as a standard performance of ER and PR test in breast cancer in 2010 by ASCO) will not be expected to result in only 10% of false negative and 10% of false positive results. The expected test errors are subject to effect of prevalence in medical testing. Actual prevalence of ER positive breast cancer is in a range of 80%. By re-testing negative results the pathologists, in fact, tried to determine negative predictive value (NPV) of the test (i.e. derive how many negative test results were true negative against reference laboratory). NPV is not a fixed or stable parameter of the test, as it will change with prevalence (interested readers can be referred to Bayesian methods in diagnostic testing). By making simple NPV formula calculations using the above listed test parameters one can derive negative predictive value of only about 60 - 65% (for a 90% sensitive and 90% specific test under condition of 80% prevalence of ER positive breast cancers in North American population). The expected error (false negative results) under such condition of prevalence will be close to 35-40% (1- negative predictive value).
Formula Negative predictive value = True negative/ (Total tested negative) x 100, %
This should not be confused with the fixed parameters of test performance - sensitivity and specificity.
Reference : Hunink M. et al. Decision Analysis in Health and Medicine, 2012.
==Press reports== In May 2007 the Canadian Broadcasting Company (CBC) published reports showing that Eastern Health knew the error rate for the screening tests to have been around 42%, considerably higher than the figure they disclosed in the December 2006 media briefings.<ref name="alarm"/>
The provincial government then called a judicial inquiry, commencing November 2007, into Eastern Health's actions.
==Conduct of the inquiry== The inquiry saw dozens of witnesses between November 2007 and October 2008. In May 2008 the provincial government questioned the length of time the inquiry was taking, with justice minister Jerome Kennedy suggesting that continuing with the tone, style, and procedure of the inquiry could cause the health system to collapse.<ref name="Kennedy">{{cite news |title=No curbs on lawyers, Cameron inquiry tells N.L. |publisher=CBC News |url=https://www.cbc.ca/news/canada/newfoundland-labrador/no-curbs-on-lawyers-cameron-inquiry-tells-n-l-1.699004 |date=May 24, 2008 |access-date=6 February 2009 |archive-url=https://web.archive.org/web/20080526073329/https://www.cbc.ca/health/story/2008/05/24/cameron-ruling.html |archive-date=26 May 2008 |url-status=live}}</ref> Chair Margaret Cameron declined the government's application to prevent inquiry lawyers from cross-examining witnesses, which had been presented as an attempt to expedite the inquiry.
Opposition leader Yvonne Jones accused premier Williams of trying to "undermine" the inquiry by questioning testimony and witness examination procedures, including one occasion on which Williams described the inquiry in May 2008 as a "witch hunt."<ref name="witchhunt">{{cite news |title=Williams rejects bullying accusations over cancer inquiry |url=https://www.cbc.ca/news/canada/newfoundland-labrador/williams-rejects-bullying-accusations-over-cancer-inquiry-1.720078 |publisher=CBC News |date=13 May 2008 |access-date=6 February 2009 |archive-url=https://web.archive.org/web/20080513193755/http://www.cbc.ca/health/story/2008/05/13/williams-inquiry.html |archive-date=13 May 2008 |url-status=live}}</ref> Jones also said that former deputy health minister Robert Thompson, a Progressive Conservative who had been commissioned to oversee the inquiry, had a conflict of interest and should stand down. Williams responded critically to what he called an attempt by Jones to smear senior public health officials.<ref name="Jones"/>
Peter Dawe of the Canadian Cancer Society objected to Williams's perceived attempts to speed up the inquiry, saying that patients deserved a full investigation however long it took.<ref name="witchhunt"/>
==Inquiry report== The inquiry finished hearing testimony in October 2008 and was due to report by March 1, 2009.<ref>{{cite news |title=Not given lab results until this year, final witness tells cancer probe |url=https://www.cbc.ca/news/canada/newfoundland-labrador/not-given-lab-results-until-this-year-final-witness-tells-cancer-probe-1.715150 |publisher=CBC News |date=31 October 2008 |access-date=6 February 2009 }}</ref>
==Lawsuit== In 2007, after the revelation that Eastern Health had deliberately concealed the scope of the testing errors, hundreds of patients filed a class action lawsuit against Eastern Health over the affair.<ref>{{cite news |title=Judge needed for clarity in breast cancer negotiations: lawyer |url=https://www.cbc.ca/news/canada/newfoundland-labrador/judge-needed-for-clarity-in-breast-cancer-negotiations-lawyer-1.712807?rss=1 |publisher=CBC News |date=8 October 2008 |access-date=6 February 2009 |archive-url=https://web.archive.org/web/20121104052503/http://www.cbc.ca/news/canada/newfoundland-labrador/story/2008/10/08/crosbie-suit.html?rss=1 |archive-date=4 November 2012 |url-status=live}}</ref> A $17.5 million settlement was reached in 2009.<ref>{{cite news |title=N.L.'s Eastern Health Authority settles $17M lawsuit |url=https://www.cbc.ca/news/canada/newfoundland-labrador/n-l-s-eastern-health-authority-settles-17m-lawsuit-1.836672 |publisher=CBC News |date=31 October 2009 |access-date=5 September 2012 }}</ref>
==See also== *Margaret Cameron (jurist) *Health and Community Services Eastern Region
==References== {{reflist|2}}
==External links== *[http://www.cihrt.nl.ca/ Commission of Inquiry on Hormone Receptor Testing] - the Cameron Inquiry
Category:Political history of Canada Category:Politics of Newfoundland and Labrador Category:Canadian commissions and inquiries Category:Judicial inquiries Category:Newfoundland and Labrador political scandals Category:Health in Newfoundland and Labrador Category:Medical controversies in Canada