Ms H, a 28-year-old shop assistant, noticed a lump in her breast. She went to see her GP, Dr D, who recorded the following clinical note – ‘small pea-sized gland L axillary tail of L breast – wait and see.’
Shortly after this, Ms H became pregnant and regularly attended her GP surgery, seeing Dr D and another partner, Dr S. Ms H also attended her local hospital’s antenatal clinic. On one occasion when Ms H attended the surgery there is a note saying ‘gland L axilla – better now’. There is no indication as to whether this was based on Ms H’s opinion or an assessment by Dr D.
Three months after Ms H had her baby, she was seen by Dr S. She had an obvious lump in her left breast and Dr S referred her to a local surgeon. Dr S noted that the mass measured 1 inch by 1 inch.
The surgeon felt that Ms H’s left breast was ‘rather distorted, hard and clinically alarming, to say the least.’ Ms H had fine-needle aspiration cytology of the mass, which showed it to be a breast carcinoma.
She had a mastectomy and chemotherapy. Unfortunately, Ms H developed secondary metastases and died two years later.
When her family brought a legal claim against Drs D and S, we obtained GP expert opinion. This was critical of Dr D, saying, ‘ …it will be extremely difficult to defend Dr D in his failure to examine the patient properly, given the opportunity he had to do so.’ Dr S was thought not to be at fault, having seen Ms H only once after her initial report of the breast lump.
Expert opinion from surgery and oncology was certain that the delay in diagnosis had caused a poorer prognosis for Ms H. The antenatal clinic was thought to bear some fault for its failure to address the problem of the breast lump, but could not strictly be said to have breached its duty, as Ms H had never raised the issue there. We settled the claim.
- Referral – This case occurred in the UK in the early nineties. Since then, clear guidance has been given on the appropriate referral of cases of suspected cancer by the Department of Health.1 The guidance recommends urgent referral for any woman aged over 30 who has a discrete breast lump. Referral (not necessarily urgently) is recommended for younger women with a discrete lump. This should not be forgotten when assessing breast lumps in the younger patient.
- The limits of clinical assessment – Do not fall into the trap of overestimating your abilities and reaching a tissue diagnosis on the basis of an external palpation of a mass. No clinician has the ability to do this on an entirely consistent basis, hence the need for investigations to help even those with many years of experience in assessing breast masses. If you are offering reassurance based on a clinical assessment alone, ask yourself if it is truly valid and whether you would accept it if you were in the same situation as the patient.
- Follow-up – If you assess a patient with symptoms that could be due to cancer, and you feel that investigation is not immediately necessary, it’s good practice to ensure some form of concrete follow-up and re-assessment. This should be documented in the notes. There is nothing wrong with needing to assess symptoms and signs repeatedly before deciding on an appropriate management plan for a particular problem. This is better than a snap diagnosis and false reassurance for a potentially life-threatening problem.
- UK Department of Health. Referral Guidelines for Suspected Cancer. Available in original document and summary wall-chart form at www.gov.uk/government/organisations/department-of-health