OB/GYN’s Failure to Follow-up Results in Advanced Breast Cancer

Case Summary

This case involves a pre-menopausal woman who underwent three consecutive negative breast cancer screening mammograms that her OB/GYN ordered. During the entirety of the diagnostic process, the patient had a palpable breast mass.

Her OB/GYN did not order any additional imaging, biopsy, or genetic screening despite the palpable mass. Shortly after the third negative mammogram, the patient received a diagnosis of invasive stage 3B ductal carcinoma.

Case Theory

Physicians diagnose an average of 180,000 new cases of breast cancer each year in the United States. Breast cancer is attributed to almost 50,000 deaths annually. Due to advances in breast cancer diagnoses and treatments, survival rates of cancers identified and treated early continue to improve.

Physicians typically utilize diagnostic mammography (DM) for women over the age of 30. In patients who present with a palpable lump, a timely and accurate diagnosis is vital.

When a DM is read as negative and inconsistent with the clinical findings, further investigation is warranted. BRCA (Breast Cancer) genetic testing has shown that younger women with a family history of breast cancer are clearly at risk.

Ultrasonographic studies are most useful for evaluating cystic breast masses. For solid masses, diagnostic biopsy techniques include fine-needle aspiration, core biopsy, and excisional biopsy.

Ductal Carcinoma In Situ

Ductal carcinoma in situ (DCIS) is regarded as the earliest form of breast cancer. DCIS is noninvasive and has not spread from the milk duct. Physicians can treat most women with DCIS with surgery, radiation, and hormone therapy. With these treatments, there is a high curative probability and a 10-year survival rate of 98-99%.

However, if left untreated, DCIS cells can undergo abnormal changes. This causes DCIS cells to become invasive breast cancer. The more aggressive cancers can spread to lymph nodes and muscles in as little as three years.

Here, the delay in the diagnosis of ductal cancer caused the patient to defer treatment. The delayed treatment effectively diminishes the patient’s prognosis, treatment, and options.

Stage 3B ductal carcinoma is an invasive cancer that can be treated, However, a large part of this population will experience recurrence of cancer after treatment. The 10-year survival rate drops to 80% or less, depending on the location and type of cancer cell.

In this case, the failure to properly investigate an undiagnosed breast mass is a deviation from the standard of care. Here, the OB/GYN did not perform either genetic counseling or clear identification of a clinically palpable mass. The inaction is a deviation from the standard of medical care.

Expert Witness Q&A

• What steps and follow-ups should an OB/GYN order to appropriately work up a palpable breast mass in a similar clinical scenario?
• What is the standard of care in the presence of a mass with a negative diagnostic mammogram?
• How could the delay in this cancer affect the patient’s prognosis?
• Would an ultrasound or a biopsy have identified the mass sooner?

Expert Witness Involvement

OB/GYN

An OB/GYN expert can speak to the standard of care in diagnosing potential cancers of the breast with inconsistent imaging. This expert can discuss the standard protocol to avoid delay in diagnosis and care.

Oncology

An oncologist with expertise in breast cancer treatment can speak to the sequelae from the delay in diagnosis, differences in treatment options, and prognostic outcome for the patient.