The grim reality is that 1 in 8 women will be diagnosed with breast cancer over a lifetime. Breast cancer is second only to lung cancer in causing cancer deaths among women, with 220,000 newly diagnosed cases and 40,000 deaths each year in the United States. Fortunately, death rates from breast cancer have been declining since the 1990s due to early detection, screening, and increased awareness.
Although the causes of breast cancer are not well known, some risk factors are understood. The majority of women with breast cancer have no direct family history of breast cancer. The risk of getting breast cancer increases with age. Two-thirds of women diagnosed with breast cancer are age 50 or older. Most of the rest are ages 39 to 49, with a much lower number of younger women diagnosed. Some other risk factors related to breast cancer include being female, radiation exposure, never being pregnant, having your first child after the age of 35, beginning menopause after age 55, postmenopausal hormone therapy, never having breastfed, obesity, drinking more than one alcoholic beverage a day, and having dense breast tissue that can mask the presence of a cancerous tumor.
Some of these factors can be controlled, but many cannot. For example, hereditary factors cannot be controlled. The BRCA1 and BRCA2 gene mutations account for about 20 to 25 percent of hereditary breast cancers and about 5 to 10 percent of all breast cancers. Much has been done in genetics research, specifically regarding identification of the BRCA genes, because women with these genes have a high probability of contracting breast and ovarian cancer. A woman who has a sister, mother, or daughter who had breast cancer—especially if the cancer was in both breasts, was premenopausal, or occurred in more than one first-degree relative—is two or three times more likely to develop breast cancer. Physicians should encourage individuals with this history to consider genetic counseling.
Occasionally, malpractice issues arise related to breast cancer. In the last six years of closed claims data from The Doctors Company involving breast cancer claims, most cases involved a diagnosis-related failure (92 percent) and multiple specialties (radiology, gynecology, general surgery, pathology, family medicine, and internal medicine).
Thirty percent of the cases included a misinterpretation of a diagnostic test, such as a mammogram, according to an analysis of factors leading to claims. This contributing factor primarily involves the specialty of radiology. Research has shown that screening mammograms may miss 10 to 20 percent of breast cancers.* A study in the New England Journal of Medicine compared traditional mammograms to digital mammograms. The digital mammogram is stored in a computer, can be manipulated better for visibility and clarity, and has a lower average radiation dosage, but it is more costly. The findings showed that digital mammograms were superior to traditional mammograms for three groups of women: those under 50 years of age, those with dense breasts (a risk factor for breast cancer), and those who were premenopausal or who were in their first year of menopause. Physicians should discuss with these patients the option of ordering a digital mammogram.
Patients may be confused about when to begin screening mammography because screening recommendations vary. The American Cancer Society and the Susan G. Komen Foundation recommend that women over 40 get annual mammograms, whereas the U.S. Preventive Task Force recommends that screening mammograms begin at age 50 and that younger patients should discuss with their physician when to initiate screening mammography. Mammograms are more apt to be diagnostic as women age, because the breast becomes less dense with aging, which increases the sensitivity of mammography.
Another issue seen in almost 30 percent of the breast cancer claims was a delay in ordering diagnostic tests, such as mammograms or breast biopsies. A general surgeon may have thought a breast lump was a cyst and recommended waiting rather than getting a biopsy, when in fact the lump was a breast tumor. In one case, a family practice physician thought a 38-year-old patient had fibrocystic disease and did not need mammography or referral. The tests were delayed and the patient’s breast cancer progressed. Breast cancer can only be excluded by biopsy.
Breast cancer remains a major concern for women and their families. Communication between providers and patients is vital. Physicians should work closely with their patients to obtain a comprehensive history, because many risk factors for breast cancer are known. Screening continues to improve outcomes. Early diagnosis and treatment are essential to promote patient safety and reduce risks.
* Baum JK, Hanna LG, Acharyya S, et al. Use of BI-RADS 3–Probably Benign Category in the American College of Radiology Imaging Network Digital Mammographic Imaging Screening Trial. Radiology. July 2011; 260(1): 61-67.
By Jacqueline Ross, PhD, RN, Senior Clinical Analyst, Department of Patient Safety, The Doctors Company.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.