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An inflammatory situation

01 May 2011

Mrs D was a 47-year-old school teacher with two children. She noticed a lump in her right breast while she was in the shower. The lump was tender when she pressed it and she became concerned that it could be something serious. One of her aunts had had breast cancer at about her age and this added to her concerns. She booked an appointment to see her GP the following day.

The next day Dr B, her GP, saw her at the surgery. She told him about her painful breast lump and expressed her concerns that it could be something serious. Dr B told her that “breast cancer doesn’t hurt” and recorded a diagnosis of mastitis in her notes. He did not examine Mrs D’s breasts and gave her a seven-day course of flucloxacillin. He did not arrange any follow-up or give any “safety-netting” advice that she should return if the situation did not improve.

Mrs D took the antibiotics, but her breast lump and discomfort remained the same. She assumed that any infection had been treated and that it would eventually settle down. She had been reassured that there was nothing of concern since Dr B had told her that cancer doesn’t hurt.

Over the next five months, Mrs D attended her surgery twice and saw different doctors each time. On one occasion she presented with a sore throat and on the other she was suffering with knee pain. The issue of her breast lump was never brought up again and Mrs D did not mention it.

A month later she moved house and consequently moved to a different practice. She organised a routine check-up. When she met the new GP she mentioned the breast lump. The GP examined her breasts thoroughly and noted a large, hard, craggy mass in the upper outer quadrant of her right breast that felt fixed to the deeper tissues. The skin overlying it was dimpled and erythematous. The GP made an urgent referral to the breast clinic and Mrs D was seen within two weeks.

Mrs D underwent fine needle biopsy and scans and was unfortunately diagnosed with carcinoma of the breast, with metastatic spread to her liver and bones. She was given aggressive treatment with chemotherapy and radiotherapy, but sadly the prognosis was poor.

Mrs D was devastated and very angry that her cancer had not been diagnosed earlier. She felt that the delay in her diagnosis had contributed to the spread of her cancer and the subsequent poor prognosis. Mrs D made a claim against all three doctors at her previous surgery. The two doctors that saw Mrs D after the first appointment alleged that they thought the problem had been resolved. The case was settled for a substantial sum.

Learning points

  • Mastitis is a rare condition in this age group and is more likely in a woman who is breast feeding. Although pain in breast cancer is atypical, it is not unheard of, particularly in inflammatory disease. An urgent referral at the first appointment would have been the appropriate action.
  • Every patient with a breast complaint needs careful examination to aid the diagnosis and this must be documented. Family history must be taken into consideration.
  • It is important to ensure that symptoms compatible with a potentially serious condition have, in fact, resolved. A follow-up appointment a week after giving the antibiotics would have made it clear that the lump was more serious than a simple mastitis. Inflammation can be associated with malignancy.