KAILUA KONA, HAWAII — Inform the radiologist about the specific location of any palpable mass in a patient's breast that prompted you to order a mammogram, Dr. R. James Brenner said at a meeting on medical negligence and risk management.
Avoid vague descriptions like “a general fullness in the breast upper right quadrant” and be more specific—“a palpable lump at 10 o'clock,” said Dr. Brenner, chief of breast imaging at the University of California, San Francisco.
If the radiologist doesn't know there's a palpable mass, the patient gets a screening mammography. But mention a palpable mass, preferably with a specific area for interrogation, and the radiologist can perform ultrasound and potentially detect carcinomas that can't be seen by mammography.
“I need to know from the gynecologist that he or she feels something there. Otherwise, this ultrasound is not performed, and the diagnosis is not made in a timely fashion,” he said. “This is an example where the clinician and the radiographic team either sink or swim together.”
American College of Radiology guidelines state that ultrasound examinations should be performed for mammographic masses or palpable masses that are insufficiently characterized on mammographic findings. Using ultrasonography for screening is not the standard of care, but is being investigated in a National Cancer Institute trial.
The most common reason for medical malpractice lawsuits is a delay in the diagnosis of breast cancer, according to data from the Physicians Insurance Association of America. The top two defendants are radiologists and ob.gyns. A large percentage of the litigation involves a palpable breast mass discovered by the patient, who then comes to the clinician for an evaluation. Litigated cases often lack documentation of a breast examination.
Clinicians should carefully document that they evaluated a patient for signs and symptoms of breast cancer, took a thorough clinical history, and referred the patient for genetic counseling if appropriate. Use a stamp or mnemonic in the chart to show that you examined the breasts and regional lymph nodes, Dr. Brenner suggested.
Try to reconcile clinical findings and imaging results. “The interplay between the clinical and mammographic findings often convert subthreshold findings to threshold findings. That needs to be appreciated,” he said at the meeting, sponsored by Boston University.
Insist on getting a phone call from the radiologist if there is any suspicious finding on mammography or ultrasound, because written or electronic reports can get lost or misplaced, he added.
When you do get a mammography or ultrasound report, initial it to indicate that you looked at it, and to show a potential jury that it was your decision to do something further or not to do more, Kimberly D. Baker, J.D., said in a legal commentary session after Dr. Brenner's talk.