Unfortunately, physician delay is responsible for some of the morbidity of breast cancer among women. Treatment delays may result from misinterpretation or misuse of tests. Most often, physician delay results from a decision that a mass is benign without appropriate testing. Young women who are presenting to their physician for reasons other than a breast mass are more likely to be mismanaged. Because of the recent widespread use of mammography, there may be a change in the reasons for a physician delay in breast cancer diagnosis. Goodson and Moore studied causes of physician delay in the diagnosis of breast cancer among women already having regular mammography.
Among 434 women and one man who had 454 breast cancers during the course of the study, delay in diagnosis occurred with 42 (9 percent) of the cancers. Twenty-one women (5 percent) were told, without biopsy, that their mass was benign. In 14 women (3 percent), mammograms did not demonstrate a new mass or suspicious calcifications. Four patients had errors on pathologic evaluation of biopsy tissue. Poorly obtained fine-needle aspiration specimens were responsible for initial absence of malignant cells in five women.
Data analysis revealed that women who presented with a complaint of a breast mass were three times more likely to endure a physician delay in a diagnosis compared with women whose mass was found on mammography or during a clinical physical examination. As expected, physician delay was more common when mammograms were incorrectly read as benign, but delays also occurred in some women whose mammograms were correctly read but the patient received inappropriate reassurance that the findings were benign.
The authors conclude that even with the use of widespread screening mammography, physician delay in accurately diagnosing a malignancy is caused by inaccurately identifying a documented mass as benign. Because this delay occurred more commonly in patients with self-identified masses, physicians should evaluate these cases more thoroughly. Mammography may not be enough, and a lower threshold may be necessary for obtaining a biopsy. Although surgical and core biopsies are options, diagnostic tissue sampling by fine-needle aspiration performed by a trained professional is the least invasive sampling technique. To reduce physician delay, the authors suggest using the “FERVR” guide (see accompanying table).
|Focus clinical breast examination on the presence or absence of a mass, without interpretation of what it might be.
|Expect tissue sampling for all palpable breast masses.
|Recommend tissue sampling for all palpable masses, even if the mammogram shows no signs of cancer.
|Verify that physicians doing fine-needle aspirations have specific training in the procedure.
|Reevaluate patients after a short interval if a tentative decision is made that an area identified by a patient falls within the narrowly defined rules of predictable variations of breast structure.