Thursday, January 10, 2008

Why MDs miss breast cancer

The leading cause of physician delay in diagnosis of breast cancer continues to be inappropriate reassurance that a mass is benign without biopsy.
William Goodson, MD, Archives of Internal Medicine 2002; 162: 1343-1348

Several years back, a 40-something year old lady, new to my practice, came to see me for a physical. I was taken aback to find a large mass in one breast. When I asked her what was up with that lump, she replied that she'd had it for years and that her previous doctor assured her it was benign. No biopsy, just negative mammograms and clinical follow up over time.

As far as I'm concerned, you don't know that a mass is benign until you KNOW it's benign, as in tissue in hand and examined microscopically. With my urging, she saw a surgeon and had a biopsy, and it wasn't benign. The final diagnosis was ductal carcinoma in situ, fortunately, and she required no further treatment after the lump was removed.

My current patient of concern is a man who's noted a breast lump for months. He's had a mammogram and an ultrasound, and both were consistent with gynecomastia, a benign enlargement of male breast tissue. But...the surgeon not only said no big deal, come back if it gets bigger, but he also said that insurance wouldn't pay for further testing or excision as they would consider it a cosmetic procedure. Well it's bigger now, and I've urged him to go back to the surgeon to have it removed and not to take insurance won't pay as an answer.

Dr. Goodman concludes: Reducing delay in diagnosis will require less willingness to rely on clinical examination to decide that a mass is benign, [and] less reliance on benign mammography reports to decide not to biopsy a mass. The worst breast cancer I ever found in a woman--already spread extensively to lymph nodes--did not show up on mammography at all.


Dr. Smak said...

I had a 30-something patient with a similar situation: a large irregular firm lump on her breast. She had been bitten by a horse on her breast years prior and claimed that the swelling had never gone down. I couldn't imagine that was the case, but apparently she had a large hematoma at the time that organized into some impressive scar tissue.

After I got over the initial "Ouch! A horse bit you in the boob?!" I was quite nervouse due to the clinical feel of the mass. But, after extensive imaging, she is being followed annually by the breast surgeon. He's less impressed than I.

Mauigirl said...

I had a questionable mammogram followed by a sonogram that deemed the area of denseness in my breast to be benign. My doctor, knowing what a hypochondriac I am, said if I wanted I could go ahead and have a needle biopsy if it would put my mind at ease. I did it and am glad - it was benign. But I felt that you don't really know for sure unless cells are examined under a microscope!

I'm having a similar issue right now - a cyst on my ovary that hasn't gone away. I'd like to have the ovary removed! But that's major surgery (the doc doesn't think laparascopic surgery would work on me due to previous scar tissue from earlier surgery).

The ultrasounds keep saying it's a cyst but I don't know. I think I'm going to go for the surgery! I am a firm believer in "better safe than sorry!"