In-hospital delay in the diagnosis of breast cancer

Causes and consequences of delayed diagnosis in breast cancer screening with a focus on mammographic features and tumour characteristics

PURPOSE

To study the prevalence, causes and consequences of delayed breast cancer diagnosis in the screening population.

METHODS

This retrospective study was performed in women who underwent biennial screening mammography between January 1, 2009 and June 30, 2019. Patients were divided into 3 groups; screen-detectedbreast cancer (SDC) without a diagnostic delay, a primary diagnostic delay(i.e. missed cancer at previous screening round)and a delay in diagnostic work-up after recall. Women with a true interval cancer (IC; i.e. not visible on prior examinations) were excluded. Outcome parameters included mammographic and tumour characteristics, lymph node status and surgical treatment.

RESULTS

In our sample of 4491 women with breast cancer (4292 SDC and 199 'missed' IC), respectively, a total of 1112 women experienced a diagnostic delay of ≥ 4 months. Compared to women without a diagnostic delay (n = 2720), the 176 women with a delay in diagnostic work-up showed overall similar mammographic abnormalities (P = 0.052). These groups show similar distributions in invasive tumours, tumour stage and lymph node status (P = 0.25, P = 0.95 and P = 0.93, respectively). Women with a primary diagnostic delay (n = 936) showed less calcifications (P < 0.001), and more masses with calcifications and architectural distortions on mammography (P = 0.01 and P = 0.04, respectively). Moreover, this group comprised larger tumours (P < 0.001) and lymph node metastases (P < 0.001), and more often underwent mastectomy (P < 0.001).

CONCLUSIONS

A primary diagnostic delay in breast cancer diagnosis results in less favourable tumour characteristics and relatively more mastectomies compared to no delay in breast cancer diagnosis and a delay in diagnostic work-up after recall.

Health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa: a systematic review

BACKGROUND

Breast cancer patients in sub-Saharan Africa experience long time intervals between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing treatment time intervals has not been widely investigated. This review aimed to identify existing information on health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region.

METHODS

PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization's six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program Quality-Assessment Tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding.

RESULTS

From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence diagnostic and treatment intervals in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost.

CONCLUSION

The present review shows that diagnostic and treatment intervals among women with breast cancer in sub-Saharan Africa are influenced by many related health system factors. Policy makers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region.

The Effects of Hospital Characteristics on Delays in Breast Cancer Diagnosis in Appalachian Communities: A Population-Based Study

PURPOSE

Despite being generally accepted that delays in diagnosing breast cancer are of prognostic and psychological concern, the influence of hospital characteristics on such delays remains poorly understood, especially in rural and underserved areas. However, hospital characteristics have been tied to greater efficiency and warrant further investigation as they may have implications for breast cancer care in these areas.

METHODS

Study data were derived from the Kentucky, North Carolina, Ohio, and Pennsylvania state central cancer registries (2006-2008). We then linked Medicare enrollment files and claims data (2005-2009), the Area Resource File (2006-2008), and the American Hospital Association Annual Survey of Hospitals (2007) to create an integrated data set. Hierarchical linear modeling was used to regress the natural log of breast cancer diagnosis delay on a number of hospital-level, demographic, and clinical characteristics.

FINDINGS

The baseline study sample consisted of 4,547 breast cancer patients enrolled in Medicare that lived in Appalachian counties at the time of diagnosis. We found that hospitals with for-profit ownership (P < .01) had shorter diagnosis delays than their counterparts. Estimates for comprehensive oncology services, system membership and size were not statistically significant at conventional levels.

CONCLUSIONS

Some structural characteristics of hospitals (eg, for-profit ownership) in the Appalachian region are associated with having shorter delays in diagnosing breast cancer. Researchers and practitioners must go beyond examining patient-level demographic and tumor characteristics to better understand the drivers of timely cancer diagnosis, especially in rural and underserved areas.

Clinical presentation and causes of the delayed diagnosis of breast cancer in patients with pregnancy associated breast cancer

OBJECTIVE

The objective was to assess the clinical presentation, delay of diagnosis, and the causes of delay in the diagnosis of patients with pregnancy-associated breast cancer (PABC) and patients with non-PABC.

PATIENTS AND METHODS

This was a face-to-face interview with women who had histologically confirmed BC. All respondents were interviewed at our hospital.

RESULTS

We interviewed 56 patients, 36 with non-PABC and 20 with PABC. Of the 20 patients with PABC, BC was diagnosed in 12 (60%) during pregnancy and 8 (40%) during postpartum. 18 of the patients (90%) with PABC presented mainly with a mass 3 (15%) with pain and ulcer, 5 (25%) with skin redness and thickening, 6 (30%) with nipple retraction and 4 (20%) with discharge 12 (60%) patients with PABC had delayed diagnosis and 8 (40%) of this delay was due to physicians' reassurance, and 2 (10%) because of fear of cancer. Similarly, 35 (97%) patients with non-PABC presented with breast mass, 3 (8.3%) with infrequent pain 4 (11.11%) with inflammation 2 (5.55%) with ulcer 2 (5.55%) with nipple discharge and4 (11.11%) with thickening of the skin compared with PABC patients. Only 4 (11.11%) in non-PABC had delayed diagnosis, and for half of them the delay was due to the fear of cancer. Two patients with PABC and non-PABC were afraid of cancer 16.66% and 5.55%, respectively. However, 8 (60%) of patients with PABC had delayed diagnosis compared to 0% of patients with non-PABC.

CONCLUSION

In this study, the majority of patients with PABC or non-PABC presented with a breast lump. Other symptoms were more common in patients with PABC than in patients with non-PABC. An increased awareness of clinicians may help reduce delay in the diagnosis of patients with PABC.

Medicolegal implications of accuracy of GP referral letters to specialist breast clinic

BACKGROUND

Referrals to symptomatic breast clinics have increased significantly in recent years with unchanged numbers of detected cancers. The general practitioner (GP) referral information relating to this increased patient volume causes anxiety and potentially creates confusion and future medicolegal issues if inaccurate.

AIMS

To compare GP triage category requests and clinical findings with those determined by the breast centre.

METHODS

1,014 consecutive referrals to a symptomatic breast service were included. GP triage request category and clinical findings were prospectively recorded and compared to cancer centre surgeon triage category, clinical findings and cancer detection rates.

RESULTS

GPs requested urgent appointments for 49 % of referrals, only 22 % were considered urgent on triage at the cancer centre. The triage category request was downgraded in 56 % of referrals from urgent to routine. Thirty-three cancers were detected, representing 3 % of referrals. Eighty-eight percent of cancers were identified in the group with positive clinical findings at the breast clinic. 24 % of the new referrals were for mastalgia alone. In the 55 % of referred cases where GPs reported a clinical abnormality, only 39 % of these had a clinical finding confirmed by the breast surgeon.

CONCLUSIONS

There is poor correlation between GP triage category request and those assigned by the breast unit. GP referrals indicating patients with a clinical abnormality was discordant with specialist findings in 61% of cases. The frequency of overstating of clinical findings by GPs is such that subsequent cancer diagnosis does not imply failure of a preceding triple assessment process.

Challenges to the early diagnosis and treatment of breast cancer in developing countries

This critical review of the literature assembles and compares available data on breast cancer clinical stage, time intervals to care, and access barriers in different countries. It provides evidence that while more than 70% of breast cancer patients in most high-income countries are diagnosed in stages I and II, only 20%-50% patients in the majority of low- and middle-income countries are diagnosed in these earlier stages. Most studies in the developed world show an association between an advanced clinical stage of breast cancer and delays greater than three months between symptom discovery and treatment start. The evidence assembled in this review shows that the median of this interval is 30-48 d in high-income countries but 3-8 mo in low- and middle-income countries. The longest delays occur between the first medical consultation and the beginning of treatment, known as the provider interval. The little available evidence suggests that access barriers and quality deficiencies in cancer care are determinants of provider delay in low- and middle-income countries. Research on specific access barriers and deficiencies in quality of care for the early diagnosis and treatment of breast cancer is practically non-existent in these countries, where it is the most needed for the design of cost-effective public policies that strengthen health systems to tackle this expensive and deadly disease.

Peri-implant galactocele following vacuum-assisted core biopsy of the breast: a cautionary tale

A lactating woman in her early 40s with a strong family history of breast cancer presented with a markedly swollen breast days after having a vacuum-assisted core biopsy performed to sample indeterminate microcalcifications in her left breast. Ultrasound showed a large peri-implant fluid collection which yielded milky fluid on aspiration consistent with galactocele formation. Histology of the core specimens revealed a fragment of fibrous capsule suggesting that the core biopsy had created a fistula between the breast tissue and the peri-implant space. Bromocriptine was given and the galactocele slowly resolved.

Diagnosis delay in Libyan female breast cancer

AIMS

To study the diagnosis delay and its impact on stage of disease among women with breast cancer on Libya.

METHODS

200 women, aged 22 to 75 years with breast cancer diagnosed during 2008-2009 were interviewed about the period from the first symptoms to the final histological diagnosis of breast cancer. This period (diagnosis time) was categorized into 3 periods: <3 months, 3-6 months, and >6 months. If diagnosis time was longer than 3 months, the diagnosis was considered delayed (diagnosis delay). Consultation time was the time taken to visit the general practitioner after the first symptoms. Retrospective preclinical and clinical data were collected on a form (questionnaire) during an interview with each patient and from medical records.

RESULTS

The median of diagnosis time was 7.5 months. Only 30.0% of patients were diagnosed within 3 months after symptoms. 14% of patients were diagnosed within 3-6 months and 56% within a period longer than 6 months. A number of factors predicted diagnosis delay: Symptoms were not considered serious in 27% of patients. Alternative therapy (therapy not associated with cancer) was applied in 13.0% of the patients. Fear and shame prevented the visit to the doctor in 10% and 4.5% of patients, respectively. Inappropriate reassurance that the lump was benign was an important reason for prolongation of the diagnosis time. Diagnosis delay was associated with initial breast symptom(s) that did not include a lump (p < 0.0001), with women who did not report monthly self examination (p < 0.0001), with old age (p = 0.004), with illiteracy (p = 0.009), with history of benign fibrocystic disease (p = 0.029) and with women who had used oral contraceptive pills longer than 5 years (p = 0.043). At the time of diagnosis, the clinical stage distribution was as follows: 9.0% stage I, 25.5% stage II, 54.0% stage III and 11.5% stage IV.Diagnosis delay was associated with bigger tumour size (p <0.0001), with positive lymph nodes (N2, N3; p < 0.0001), with high incidence of late clinical stages (p < 0.0001), and with metastatic disease (p < 0.0001).

CONCLUSIONS

Diagnosis delay is very serious problem in Libya. Diagnosis delay was associated with complex interactions between several factors and with advanced stages. There is a need for improving breast cancer awareness and training of general practitioners to reduce breast cancer mortality by promoting early detection. The treatment guidelines should pay more attention to the early phases of breast cancer. Especially, guidelines for good practices in managing detectable of tumors are necessary.

[Influence of clinical and biographical factors on the delay in starting adjuvant chemotherapy treatment among breast cancer patients]

BACKGROUND AND OBJECTIVE

Previous studies have related the delay in starting chemotherapy (>3 months from date of surgery) with worse survival. The study objective is to analyse the delay in the start of chemotherapy and associated biomedical, sociodemographic and cultural factors.

PATIENTS AND METHODS

A cohort of women operated on for breast cancer, candidates for receiving adjuvant chemotherapy and participants in a clinical trial of non-pharmacological intervention, were surveyed regarding the delay in starting their chemotherapy, measured by the number of days from date of surgery. Differences in function of the clinical and biographical variables were studied.

RESULTS

In 197 women, mean delay was 42.32 (15.29) days; this was associated with tumour stage (i, 40.06 days; ii, 44.76 days; iii, 38.7 days; P=.049), age (≤ 35, 37.36 days; 36-64, 41.49 days; ≥ 65, 52.61 days; P=.007) and occupational situation (active, 36.91 days; unemployed, 45.5 days; pensioner, 40.07 days; housewife, 43.17 days; P=.038). For patients older than 65 years, the delay in starting adjuvant chemotherapy was longer than for those in the 2 lower age groups -less than 35 years, and between 35 and 65 years- (P=.023 and P=.009 respectively). In the multivariate analysis, the variables associated independently with the delay in starting chemotherapy were again age (P=.019), tumour stage (P=.037) and occupational situation (P=.022).

CONCLUSION

Patients began receiving adjuvant chemotherapy within the time period (3 months from surgery) defined as appropriate, and during which no evidence exists of worse survival results. Length of delay varied according to age, tumour stage and occupational situation.

Patient and provider delays in breast cancer patients attending a tertiary care centre: a prospective study

OBJECTIVES

To find out factors that are responsible for the patient or provider delays in the diagnosis of breast cancer in India.

DESIGN

This prospective study was designed to be conducted over a period of two years including a cohort of 100 patients with locally advanced breast cancer. The delays were assessed using questionnaires prepared according to the Indian scenario.

SETTING

A prospective study in an Indian setting.

PARTICIPANTS

One hundred patients with locally advanced breast cancer receiving neoadjuvant chemotherapy were included after providing informed consent and receiving ethical committee clearance.

MAIN OUTCOME MEASURES

The most common factor responsible for delays in diagnosis was observed to be the health providers, although illiteracy and lack of adequate healthcare services also contributed significantly. Unregistered medical practitioners or quacks contributed significantly to the delays in reporting and diagnosis of the disease.

RESULTS

One hundred patients of locally advanced breast cancer were evaluated using standardized questionnaires to assess the delays in diagnosis. Provider delays were found to be significant (the unregistered doctors or quacks being a significant cause of delays).The average time lapse before diagnosis for rural patients was higher (67.5 days) compared to urban patients (53.7 days). The literacy levels of the patients also had a significant impact on the delays at diagnosis. The delay in illiterates was 60.6 days compared to 49.5 days for literates.

CONCLUSIONS

The most common factor responsible for delays in reporting and diagnosis was observed to be at the end of the health providers, although illiteracy and lack of adequate healthcare services also contributed significantly. Unregistered medical practitioners or quacks contributed significantly to the delays in reporting and diagnosis of the disease.

Diagnostic delay of breast cancer - an analysis of claims to Swedish Board of Malpractice (LÖF)

AIM

Delay in the diagnosis of breast cancer may have important clinical and medico-legal implications. This study examined the decisions made by reviewers at the Swedish agency (LÖF) that handles claims of medical malpractice where claimants seek compensation for alleged suffering and/or negative clinical impacts of diagnostic delays.

MATERIAL AND METHODS

In 1995-2006 a total of 134 women filed claims for negative effects resulting from delays in the diagnosis of breast cancer. Review of the claims led to approval of delay in the primary diagnosis for 62 women and of recurrence for 28 women. The clinical symptoms that were overlooked and other causes of delay that had any relation to therapy, prognosis and economic compensation were identified. The verdicts reached were analysed.

RESULTS

The median delay in the diagnosis of the primary disease was 11 months and for recurrent disease 3.5 months. Delay in diagnosis of the primary disease was considered to have an impact on the therapy in 23%. The prognosis was postulated to have been adversely affected 11% of the patients for whom the delay was longer than 12 months. Delay in diagnosing the recurrence was contributing to delay in starting therapy and to unnecessary suffering in 32%. The delay in diagnosis was mainly caused by incomplete clinical or radiological examination and by misinterpretations of the examination results. Economic compensation was given in 90%. There was a warning or admonition to the responsible doctor in a third of the cases referred to the judgement court.

CONCLUSION

This study demonstrates that claims for compensation for delay in diagnosis of breast cancer in Sweden occur in about 1/1000 new patient. The delay in the diagnosis of the primary tumour was considered to have an impact on the magnitude of therapeutic measures in almost 25% of the women who filed claims. Economic compensation for the patients' injuries was given in ninety percent of the cases. In women for whom there was a delay in diagnosing the recurrence there was consequently a delay in starting the palliative therapy.

Diagnosis delay of breast cancer and its associated factors in Malaysian women

Background

Breast cancer is the leading cause of cancer mortality among women in Malaysia. Delayed diagnosis is preventable and has major effects on patients' prognosis and survival. The objectives of our study were to identify the magnitude of delayed diagnosis and its associated factors in women with breast cancer in Malaysia.

Methods

This study had a cross-sectional design. Respondents had histologically confirmed breast cancer and were registered at five medical centres between 2005 and 2007. All breast cancer patients who attended hospital clinics at the East Coast were included. Patients at Kuala Lumpur hospitals were selected by systematic sampling. A standardised questionnaire was developed to interview respondents. We measured the time from the first recognition of symptoms to the first general practitioners' consultation and to the histological diagnosis of breast cancer. Diagnosis delay was defined when there was more than 6 months from the recognition of symptoms to the histological diagnosis. Multiple logistic regression was used for analysis.

Results

In total, 328 respondents were included. The mean (standard deviation) age was 47.9 (9.4) years. Most respondents were of Malay ethnicity, were married housewives with a median family income of RM1500 a month. Most respondents had ductal carcinoma (89.3%) and the stage distribution was as follows: 5.2% stage I, 38.7% stage II, 44.8% stage III and 11.3% stage IV. The median time to consultation was 2 months and the median time to diagnosis was 5.5 months. The frequency of diagnosis delay of more than 3 months was 72.6% and delay of more than 6 months occurred in 45.5% of the cases. The factors associated with diagnosis delay included the use of alternative therapy (odds ratio (OR) 1.77; 95% confidence interval (CI): 1.06, 2.94), breast ulcer (OR 5.71; 95% CI: 1.59, 20.47), palpable axillary lymph nodes (OR 2.19; 95% CI: 1.23, 3.90), false-negative diagnostic test (OR 5.32; 95% CI: 2.32, 12.21), non-cancer interpretation (OR 1.68; 95% CI: 1.01, 2.78) and negative attitude toward treatment (OR 2.09; 95% CI: 1.15, 3.82).

Conclusions

Delays in consultation and diagnosis are serious problems in Malaysia. Diagnosis delay was influenced by complex interactions between many factors. Breast awareness and education are required to promote early detection, diagnosis and treatment before the tumours enlarge and metastasis.

Pregnancy-associated breast cancer: significance of early detection

Pregnancy-associated breast cancer (PABC) is defined as cancer of the breast diagnosed during pregnancy and up to 1 year postpartum. Delays in diagnosis are frequently associated with increased morbidity and mortality. The aim of this article is to determine the significance of early detection of PABC and to alert health care providers to include PABC in the differential diagnosis when evaluating a breast mass in the perinatal period. This integrative literature review evaluated 15 research studies by using the hypothetical deductive model of clinical reasoning to determine factors related to diagnosis of PABC. As women delay childbearing, the incidence of PABC increases with age. In the reviewed studies, breast cancer was diagnosed with greater frequency in the postpartum period than during any trimester in pregnancy. Delay in diagnosis is complicated by axillary lymph node metastasis, high-grade tumors at diagnosis, and poor outcomes. Early detection is a significant predictor of improved outcomes. Diagnostic modalities such as ultrasound, mammography, and biopsy can be safely used for diagnostic purposes in the evaluation of potential cases of PABC during pregnancy.

Delayed diagnosis of breast cancer in women recalled for suspicious screening mammography

PURPOSE

To determine the frequency, pathology and causes of a delay in cancer diagnosis in women recalled for suspicious screening mammography.

METHODS

We included all 290,943 screening mammograms of women aged 50-75 years, who underwent biennial screening mammography between 1st January 1995 and 1st January 2006. During a follow-up period of at least 2 years, clinical data, breast imaging reports, biopsy results and breast surgery reports were collected of all 3513 women with a positive screening result. Tumour stages of breast cancers with a diagnostic delay (defined as breast cancer confirmation more than 3 months following a positive mammography screen) were compared with those of cancers diagnosed within 3 months following referral and with interval cancers.

RESULTS

A diagnostic delay occurred in 97 (6.5%) of 1503 screen-detected cancers. These 97 false-negative assessments comprised significantly more ductal cancers in situ (26.8%) than did cancers with an adequate assessment after recall (15.5%, p=0.004) or interval cancers (3.7%, p<0.001). Compared with interval cancers, cancers with a false-negative assessment had a more favourable tumour size (T1a-c, 87.3% versus T1a-c, 46.4%; p<0.001) and showed significantly fewer cases with axillary lymph node metastases (22.5% versus 48.2%; p<0.001). Between hospitals having performed the workup of at least 500 referred women each, the percentage of women with a false-negative assessment varied from 5.0% to 9.1% (p=0.03). In these hospitals, improper classification of lesions at diagnostic mammography comprised 64.4% of false-negative assessments.

CONCLUSION

We found that 6.5% of recalled women experienced a delay in breast cancer diagnosis, with significant performance variations between hospitals.

Errors in cancer diagnosis: current understanding and future directions

PURPOSE

Errors in cancer diagnosis are likely the most harmful and expensive types of diagnostic errors. We reviewed the literature to understand the prevalence, origins, and prevention of errors in cancer diagnosis, focusing on common cancers for which early diagnosis offers clear benefit (melanoma and cancers of the breast, colon, and lung).

METHODS

We searched the Cochrane Library and PubMed from 1966 until April 2007 for publications that met our review criteria and manually searched references of key publications. Our search yielded 110 studies, of which nine were prospective studies and the remaining were retrospective studies.

RESULTS

Errors in cancer diagnosis were not uncommon in autopsy studies and were associated with significant harm and expense in malpractice claims. Literature on prevalence was scant. For each type of cancer, we classified preventable errors according to their origins in patient-physician encounters in the clinic setting, diagnostic test or procedure performance, pathologic confirmation of diagnosis, follow-up of patient or test result, or patient-related delays.

CONCLUSION

The literature reflects advanced knowledge of contributory factors and prevention for diagnostic errors related to the performance of procedures and imaging tests and emerging understanding of pathology errors. However, prospective studies are few, as are studies of diagnostic errors arising from the clinical encounter and patient follow-up. Future research should examine further the system and cognitive problems that lead to the many contributory factors we identified, and address interdisciplinary interventions to prevent errors in cancer diagnosis.

The results of a structured diagnostic pathway designed to minimise the chance of breast cancer misdiagnosis

AIM

To describe results from a structured clinic pathway designed to minimise inaccuracies and diagnostic delays in the diagnosis of breast cancer.

METHODS

Patients referred to our breast clinic undergo clinical, imaging and biopsy assessment according to a standard protocol. Over 4 years, patients who were discharged with a benign diagnosis and later found to have breast cancer were reviewed.

RESULTS

A total of 4366 new referrals were seen in the symptomatic breast clinic and 571 (13%) new cancers were diagnosed. Fourteen of the new cancer patients had been seen in the clinic previously (range 7-48 months) and discharged with a benign diagnosis. None of these tumours appeared to result from misdiagnosis of a lesion previously assessed to be benign. The rate of development of cancer in the cohort discharged with a benign diagnosis was closely similar to that in the normal United Kingdom population.

CONCLUSIONS

A structured breast clinic pathway can produce a rate of diagnostic accuracy closely approaching 100%.

Lymphoma: variations in time to diagnosis and treatment

This study examines illness trajectories of patients with lymphoma and assesses whether UK government targets to reduce waiting time for diagnosis and treatment are achievable and appropriate. One hundred and ninety-four patients, residents in West Yorkshire, aged more than 25 years and newly diagnosed with lymphoma during 2000 were included. Data collected from interviews, primary care and hospital records were used to examine time between critical events on the illness trajectory and characteristics of patients not meeting proposed targets. Forty-two per cent of patients did not receive a hospital appointment within 2 weeks of general practitioner referral, 26% were not treated within 1 month of diagnosis and 64% were not treated within 2 months of referral. Target achievement differed by diagnostic group, and trends were seen by age and deprivation. The interval from onset of symptoms to treatment averaged more than 1 year and approximately half of this occurred before first medical contact. Results suggest that significant improvements are needed to achieve targets. Although existing targets particularly address referral and treatment intervals, these were the shortest intervals on the trajectory. Generalized targets may be inappropriate and unachievable for lymphoma as they do not consider individual disease characteristics or allow for variations in the urgency with which treatment is needed.

Mammography in symptomatic women attending a rapid diagnosis breast clinic: a prospective study

INTRODUCTION

We determined whether it is safe to avoid mammograms in a group of symptomatic women with a non-suspicious history and clinical examination.

PATIENTS AND METHODS

Symptomatic women aged 35 years or over newly referred to a rapid-diagnosis breast clinic underwent mammography on arrival in the clinic. A breast radiologist reported on the mammograms. An experienced clinician who was unaware of the mammogram findings examined patients and decided whether a mammogram was indicated or not. If not, a management plan was formulated. Mammogram findings were then provided to the clinician and any change to the original management plan as a result of mammography was recorded.

RESULTS

In two-thirds (67%) of 218 patients, the clinician felt a mammogram was indicated. Half (46%) of these mammograms showed an abnormality; of these abnormal mammograms, 41% were breast cancer. Among the third (n = 71) of mammograms felt not to be indicated, 3 showed abnormalities of which 2 were breast cancer. One cancer was not suspected clinically or mammographically but was diagnosed on cyto/histopathological assessment.

CONCLUSIONS

A significant proportion of patients attending a symptomatic breast clinic have a non-suspicious history and normal clinical findings on examination. However, even in this group avoiding mammograms risks missing clinically occult breast cancers. It would appear sensible to offer mammograms to all symptomatic women over 35 years of age.

Approach to Fine-needle Aspiration Cytology-negative Cases of Breast Cancer

OBJECTIVE

To clarify the clinical usefulness of fine-needle aspiration (FNA) cytology of breast tumours and the management of FNA cytology-negative cases suspected of or equivocal for malignancy.

METHODS

FNA cytology was performed in 94 patients between 1995 and 2002. We calculated the sensitivity, specificity and accuracy of FNA cytology for the diagnosis of malignancy. We also compared clinical and radiological findings between false-negative and true-negative cases.

RESULTS

The sensitivity of FNA was 91% (72/79), specificity was 93% (14/15), accuracy was 91% (86/94), positive predictive value was 99% (72/73) and negative predictive value was 67% (14/21). There were seven false-negative cases and one false-positive case. Findings that aroused suspicion of malignancy were more frequent in the false-negative cases, especially from mammography and magnetic resonance imaging (MRI).

CONCLUSION

FNA cytology was an accurate preoperative diagnostic procedure for the evaluation of breast masses. In FNA cytology-negative cases, repeated FNA, core needle biopsy or excisional biopsy needs to be performed based on MRI findings.

Mammography screening in the Netherlands: delay in the diagnosis of breast cancer after breast cancer screening

In a prospective study we determined the frequency and causes of delay in the diagnosis of breast cancer after suspicious screening mammography. We included all women aged 50–75 years who underwent biennial screening mammography in the southern breast cancer screening region of the Netherlands between 1 January 1996 and 1 January 2002. Clinical data, breast imaging reports, biopsy results and breast surgery reports were collected of all women with a positive screening result with a minimum of 2-year follow-up. Of 153 969 mammographic screening examinations, 1615 (1.05%) were positive screens. Breast cancer was diagnosed in 770 (47.9%) of 1607 women for whom follow-up information was available, yielding a cancer detection rate of 5.0 per 1000 women screened. Breast cancer was diagnosed within 3 months following a positive screen in 722 cases (93.8%). The diagnostic delay was 4–6, 7–12 and 13–24 months, respectively, in 11 (1.4%), 24 (3.1%) and nine (1.2%) patients. In four other patients (0.5%), breast cancer was diagnosed after a repeat positive screen, resulting in a diagnostic delay of 25–27 months. Reasons for a diagnostic delay >3 months were erroneous mammographic interpretation of suspicious lesions as benign or probably benign lesions (33 cases), benign biopsies from a malignant lesion (10), and omission to biopsy or remove a lesion that was suspicious at breast imaging (4) or core biopsy (1). We conclude that there is room for improvement in the workup of patients with a positive screening mammography, as seen from data in this screening region. To improve the workup, we suggest that other breast cancer screening programmes also identify delay in breast cancer diagnosis after a positive screen.

Diagnostic delay in breast cancer

BACKGROUND

Delay in the diagnosis of breast cancer has important clinical and medicolegal implications. This study assessed the frequency, causes and effects of delay in the diagnosis of breast cancer in a specialist breast unit.

METHODS

Details of women who attended the breast clinic between 1988 and 1999 inclusive, and for whom the interval between first attendance and diagnosis of invasive breast cancer was greater than 2 months, were reviewed. Potential causes of delay were identified and the consequence of the delay assessed. The clinical features were compared with those of patients diagnosed with breast cancer during a 2-year period from 1999 and 2001.

RESULTS

Breast cancer was diagnosed in 5283 women during the interval reviewed; delay in diagnosis was suggested in 72 women (1.4 per cent). Women with a delayed diagnosis were younger (P < 0.001) and had a smaller tumour at diagnosis (P = 0.011) compared with all women diagnosed with breast cancer between 1999 and 2001. There were no differences in the rate of axillary node positivity or the need for mastectomy. Women unsuitable for conservation therapy in the delayed group had a significantly longer interval to diagnosis (P = 0.006).

CONCLUSION

The likelihood that conservation therapy will be appropriate is reduced when the hospital delay in the diagnosis of breast cancer is more than 240 days. All patients with a palpable mass require triple assessment to minimize delay in diagnosis of breast cancer.

Can case management be used to facilitate diagnostic testing in publicly funded breast cancer screening programs?

The earlier breast cancer can be diagnosed and treated, the better the odds for survival. The literature has shown many of the barriers to timely diagnosis are not individual behaviors but problems in delivery of health care. Case management has been suggested to facilitate diagnostic testing and treatment. Models of case management exist in other practice settings but have not always been rigorously described or evaluated. Determining optimal models for case management has been established federally as a research priority to ensure medically underserved women are promptly diagnosed and treated. One model has been developed and pilot-tested in this setting. This article will describe elements of case management and the characteristics of a publicly funded screening program that make use of case management to facilitate timeliness of diagnostic testing different from case management in other settings. These differences have implications for successfully implementing case management in public programs.

Core biopsy vs fine needle aspiration cytology in a symptomatic breast clinic

AIM

The adequacy of physical examination, mammography and fine needle aspiration cytology (FNAC) (conventional triple assessment) in the diagnosis of breast cancer has been questioned. We have performed a prospective study directly comparing FNAC and core biopsy in our symptomatic breast clinic.

METHOD

Between 15/5/00 and 17/1/01, 330 consecutive patients with breast lumps were assessed by physical examination, ultrasound, and mammography if over 35 years, and FNAC and core biopsy with or without ultrasound guidance.

RESULTS

Three hundred and forty four specimens yielded the following FNAC and core biopsy results: C1-109, C2-144, C3-6, C4-17, C5-68; B1-97, B2-150, B3-7, B4-3, B5-87. The FNAC results corresponding to the 87 B5 samples were as follows: C1-5, C2-2, C3-0, C4-12, C5-68. All C5 samples were associated with a corresponding B5 result. All except one cancer in this series was diagnosed at a single clinic visit.

CONCLUSION

In this series, core biopsy diagnosed symptomatic breast cancer more accurately than FNAC.

Surgeon-controlled ultrasound-guided core biopsies in the breast--a prospective study and a new use for surgeons in the clinic

AIMS

This study was to assess the accuracy of a surgeon performing ultrasound-guided core biopsies of the breast.

METHODS

A prospective audit was carried out of 555 patients who underwent an ultrasound-guided core biopsy for a discrete solid mass [under 30 mm maximum diameter] by a single surgeon. The surgeon controlled the core biopsy needle and an ultrasonographer or radiologist provided the imaging with ultrasound.

RESULTS

The accuracy of the surgeon in sampling the lesions [n = 555 core biopsies] was independent of the size of the lesion. This saved 272 patients having unnecessary surgery for a benign lesion.

CONCLUSION

The practical involvement by the surgeon in breast ultrasound and performing core biopsies has reduced pressure on the breast radiologists, reduced the number of diagnostic surgical open biopsies and made the clinic more interesting for the surgeon. With increased surgical confidence in breast ultrasound, most small and impalpable cancers have pre-operative skin marking rather than X-ray wire localization prior to undergoing wide local excision. Trainee breast surgeons should be encouraged to learn breast ultrasound and core biopsies.

Litigation for pneumothorax as a complication of fine-needle aspiration of the breast

Background

Pneumothorax is a rare but recognized complication of diagnostic needle aspiration of the breast. Two recent court cases alleging negligence have reached opposing opinions on very similar findings.

Methods

A Medline literature search was carried out.

Results

The reported incidence of pneumothorax after diagnostic aspiration of the breast in seven series varied between three in 100 and one in 10 000, but the weight of evidence tended towards the latter rate. Two studies reported that the complication is more common in the hands of trainees. It is not always possible to maintain the aspirating needle parallel or tangential to the chest wall. Pleural puncture may be more common than is apparent, and is most common in the tail of the breast in a thin woman.

Conclusion

It is important that breast clinicians are aware of the risk of pneumothorax but, provided proper care has been taken, this complication is not the result of a negligent act.