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Breast Cancer Detection

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Breast Cancer Detection

There are two basic categories of breast cancer: noninvasive and invasive.  Non-invasive breast cancer cells are confined within the normal structures of the breast either in the breast lobules that make milk or the breast ducts that carry milk down the nipple.  Importantly these cancer cells do not invade the surrounding normal tissue.  When breast cancer occurs in the ducts and is noninvasive, this type of cancer is referred to as ductal carcinoma in situ, DCIS.  Noninvasive breast cancer which occurs in the lobules is commonly referred to as lobular carcinoma in situ, CIS.  Obviously, the issue with carcinoma in situ is that over time this cancer has the capacity to become an invasive breast cancer.

With invasive breast cancer, the cancerous cells have invaded normal surrounding tissue in the breast.  Once the cells have invaded the normal surrounding tissue, the cells have the ability to spread throughout the body either through to the lymph nodes or blood vessels and therefore to other organs.  When the cancerous cells spread outside the breast, that cancer spread is known as metastasis.

Early diagnosis and treatment of breast cancer creates an opportunity to prevent noninvasive cancer cells to progress to invasive disease and may also prevent invasive disease to progress to metastatic disease.  Accordingly early diagnosis and treatment improves the prognosis and prolongs survivability of the patient.

While breast cancer is most commonly diagnosed in women over 50 years of age, approximately 2% of intraductal cancer cases occur in women between the ages of 20 and 34 years old.  This totals about 1200 cases per year.  The incidence of breast cancer in women under the age of 40 has been on the increase since 1983.

The reason for discussing breast cancer in young women is that breast cancer is more difficult to diagnose than in older women particularly because young women have more nodular or cystic breasts than older women.  As a consequence, the accuracy of diagnostic test such as mammograms is much lower than in older women.  For example, the accuracy of mammograms in women in their 30s is only 55% as compared to 90% in women over 60.  With these statistics in mind, mammograms in this younger population are very unreliable.

This issue becomes important with respect to two issues: first misdiagnosis of breast cancer in younger women and secondly, fully informed consent with respect to the unreliability of mammograms in younger women.  While ultrasound is recommended for dense breasts and cystic breasts in young women there are still limitations as to how effective ultrasonography can protect young women from a misdiagnosis of cancer.

Currently, MRI technology has been proven to be the most reliable in diagnosing cancer in dense breasts, but it is expensive.  It is thought the digital mammography is the most effective way to detect breast cancer in its earliest stages.  Digital mammography assists in early detection by incorporating computer technology into x-ray mammography.  With digital mammography, the image is recorded electronically and stored in the computer rather than an image on film.  This type of digital mammography is a significant improvement in the detection of breast cancer in women with dense breasts and younger women who typically have dense breasts.

Women at high risk for breast cancer should get a mammogram every year, and women at high risk with dense breasts may benefit from MRI examination .  Women at moderately increased risk should talk to their doctors about the benefits of adding an MRI screening to the yearly mammogram.  It should be noted that MRIs can still miss some cancers that a mammogram can detect.  There are special breast MRI machines which are able to produce higher-quality images than normal MRI equipment however many imaging centers and hospitals do not have dedicated breast MRI equipment.  Because MRI imaging is more expensive than mammography many insurance companies will only pay for MRI screening if the patient is shown to be at high risk.  Patients whose carriers do not cover MRI screening should be told so that they can make the decision for themselves.

  • Risk factors — Multiple factors are associated with an increased risk of breast cancer. These include:Age and gender
  • Race and ethnicity
  • Benign breast disease
  • Personal history of breast cancer
  • Reproductive and hormonal factors
  • Family history and genetic factors
  • Exposure to ionizing radiation
  • Environmental and lifestyle factors

With respect to the signs and symptoms of breast cancer, most patients present with either an abnormal mammogram or with a lump discovered during a self breast exam.  About 15% of the women are diagnosed by the presence of a breast mass which is not detected on mammography while another 30% are diagnosed with the breast mass which is discovered between mammograms.

The classic characteristics of a breast mass would include a hard, movable single dominant lesion with irregular borders however such a mass could also be benign.  Locally advanced disease includes axillary nodal enlargement or skin findings in inflammatory breast cancer such as erythema or redness, thickening, or dimpling of the overlying skin.

If there is a suspicious area on the mammogram or through presentation from a self breast exam, the biopsy is necessary.

AREAS OF MALPRACTICE

1. Informed consent

Given advances in imaging studies, one of the newer theories centers on informed consent.  Women with dense breasts have and should have other options for detecting so-called malignant lesions.  For example, a reading from the radiologist which states:

Standard views of the left breast were obtained and computer aided detection was used.  This is the patient’s baseline study.  The breast tissue is extremely dense, which could obscure a lesion on mammography.  There are no radiographic signs of malignancy.  Screening mammography is recommended as per usual guidelines.  Impression: no mammographic findings to suggest malignancy.
In such a case, the report is sent from the radiologist to the family doctor or gynecologist.  The red flag in this report is the description of the breast tissue as “extremely dense”.  With such a finding, the patient should be informed as to alternative and supplementary imaging tests such as ultrasound, digital mammography and or MRI.  Whether or not it will be covered under the patient’s insurance plan is a separate issue.. A classic mammogram in cases of dense breast tissue may be totally non-diagnostic.  If the patient is under 40, with dense breast tissue, the mammogram may also be nondiagnostic.  The failure to explain the significance of a finding of dense breast tissue can be the basis for an informed consent claim.

In one recent case, the patient, a 43-year-old woman with dense breasts, had a mammogram in the summer read appropriately as a negative mammogram and two months later felt a lump which revealed a malignancy with digital mammography.  With respect the radiology, the patient did receive appropriate standard of care but unfortunately the cancer was hidden by dense breast tissue.  The cancer would have been identified earlier if the patient had a correlating breast ultrasound. Studies show that 7 to 10% of breast lesions both benign and malignant can be picked up on ultrasound yet be completely obscured on digital mammography in dense and extremely dense breast tissues.  Significantly, our expert radiologist reviewed the digital mammogram where the patient presented with a palpable breast lump, and he could not confidently identify a suspicious clearly detectable lesion.  The ultrasound however clearly showed this breast cancer that the mammogram failed to clearly demonstrate.

Some states like Connecticut have passed a state mandate for patients with dense and extremely dense breast tissue on digital mammography have the right to have breast ultrasound covered by health insurance.  The number of lesions picked up by breast ultrasound after the patient has digital mammography has been reported to be high.  However, ultrasound is not generally accepted as a breast cancer screening tool and is used to further evaluate suspicious areas.

2.  Failure to properly read mammograms

Although the failure to properly read and interpret the mammogram may be argued to be retrospective, expert radiologist’s testifying on behalf of patients can readily find a misreading of the mammogram in the right case.  In a recent case where the patient returned for a diagnostic workup by radiology, a digital mammogram showed a probable mass in the central left breast and the radiologist correctly identified the abnormality in addition to microcalcifications in the upper outer quadrant of the breast.  Although, when the patient returned for further diagnostic workup the study showed that the left breast in the region of interest measured 2.1 cm in its greatest dimension as well as indeterminate microcalcifications in the upper outer quadrant of the breast.  Review of the mammograms from previous years demonstrated a 1.4 cm lesion in the same area which was visible the year before but not conspicuous two years before.  The radiology expert gave an opinion that the failure to recognize the conspicuous 1.4 cm lesion fell below the standard of care; however, the reading to use before did not fall below the standard of care.  The resulting delay in diagnosis was one year during which time the mass grew from 1.4 cm to 2.1 cm as measured on the ultrasounds.  Sentinel lymph nodes were positive at the surgical biopsy and the cancer was staged at stage III.

3.  Proper follow up and communication to patient

Other cases involve the proper follow up, the recommendations from radiologists and communication to the patient about conditions found by the radiologists.  At times a patient is referred by either her gynecologist or her family doctor for mammograms after complaints from the patient about lumps, nipple discharge or other breast symptoms.  Within each mammogram report, there is a recommendation from the radiologist about follow-up whether routine or more specific.  In some instances, there is sub optimal visualization of breast cysts because of the patient’s status such as pregnancy, and a six-month follow-up may be ordered by the radiologist and recommended by the radiologist.  In most circumstances, the radiologist does not communicate directly to the patient and that responsibility falls to the referring physician.  At the end of each report there is a categorization called a BIRADS classification.  This classification objectively identifies the need for follow-up.

If you or a loved one has been a victim of a breast cancer misdiagnosis, we can help. Please contact Andres & Berger in New Jersey today for a free initial consultation on your legal rights and options.

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