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Patient’s Aggressive Choice Could Remove a Diagnostic Safety Net

This month, we feature a popular “Case of the Month” from the archives written by CAP’s former General Counsel Gordon Ownby.

When reporting their findings, it is common to see consulting physicians recommend further testing. Absent such an explicit recommendation, a patient’s decision to bypass conservative measures can spell trouble for all.

When a diagnostic mammogram on a 57-year-old woman with no family history of breast cancer identified a suspicious abnormality on the left breast, the patient’s primary care physician, Dr. PC, referred her for a core biopsy. Dr. P, a pathologist, diagnosed a left breast invasive ductal carcinoma. Dr. P assigned a provision grade of “II/III” and noted that “histologic grading is provisional owing to the limited sampling inherent in needle core biopsies. This may change when the entire lesion is evaluated.” Dr. P’s report made no other references regarding further tests to confirm cancer. Dr. C, the clinician performing the needle core biopsy, cited Dr. P’s diagnosis in the addendum to his report on the procedure and also wrote: “Suggest MRI, to see the extent and additional disease. Then referral to breast surgeon.”

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Impressions from the subsequent bilateral MRI ordered by Dr. PC included a normal right breast and a “known solitary malignancy” in the left breast. The radiologist included in her recommendations: “The patient is a candidate for a wire localized lumpectomy. I would have her follow up with her breast surgeon.”

The patient visited a surgeon, Dr. S, 10 days later and discussed surgical options, including a lumpectomy and nipple-saving mastectomy. Before deciding anything, the patient consulted with a plastic surgeon and a genetics counselor. Though when she returned to Dr. S several weeks later the results of genetics testing were not yet available, and the patient told the surgeon that she wanted a double mastectomy, rejecting a local wire lumpectomy.

Surgery some two weeks later included bilateral nipple-saving mastectomy and left sentinel node biopsy by Dr. S and breast reconstruction with tissue expanders by a plastic surgeon. The surgical pathology report, however, showed no cancer in the removed tissue or lymph node. As for the left breast, the post-surgical report described findings of multinodular adenomyoepithelioma and atypical ductal hyperplasia. A second review performed at a university hospital confirmed the absence of carcinoma. Results of genetic testing returned several weeks later showed no BRCA mutations.

When Dr. S subsequently sent the original core biopsy to the university hospital for a new read, the pathologist there commented on a differential diagnosis of adenomyoepithelioma: “Imaging and clinical correlation is advised. Recommend performing IHC markers such as P63, Calponin, and SMMHC to confirm diagnosis of adenomyoepithelioma.”

The patient sued Dr. P, alleging that a misdiagnosis resulted in the loss of her breasts. The legal matter was resolved informally.

In many cases alleging a medical error, a subsequent reading of the record will reveal opportunities for avoiding a bad result. In this case, a lumpectomy option, as described in the MRI report and discussed by Dr. S, stands out. Even earlier in the record, Dr. P’s comment on getting a more accurate histological grade “when the entire lesion is evaluated” — was apparently not focused enough to trigger the patient’s other providers to pursue further tests.

Given the patient’s desire to pursue her most aggressive option — the double mastectomy — no one will know if an explicit recommendation in Dr. P’s report for further tests would have put the patient’s care on a different course. But without such qualifications, the report ended up shouldering a big responsibility.