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Marrying Story with Science: The Impact of Outdated and Inconsistent Breast Cancer Screening Practices in Canada. Curr Oncol 2022; 29:3540-3551. [PMID: 35621676 PMCID: PMC9139242 DOI: 10.3390/curroncol29050286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/26/2022] [Accepted: 05/03/2022] [Indexed: 11/17/2022] Open
Abstract
Behind the science of breast cancer in Canada, as well as globally, are the stories of thousands of women, their families, and their communities. These include stories from those who have died or those suffering from the realities of stage III and stage IV breast cancer due to late detection, misinformation, and dismissal. The reality for these women is that, whilst grateful for the latest developments in cancer research, much of this knowledge is not reflected in policy and practice. Canadian guidelines do not reflect the recommended screening by experts within the field and inequities in screening practices and practitioner knowledge exist in different areas within Canada. Told through the stories of women with lived experiences of late-stage breast cancer and supported by scientific evidence, this paper explores the impact of outdated breast cancer screening practices on the lives of women. Recent patient advocacy is driving changes, such as notifying women of their breast density in a few jurisdictions in Canada, but we call for the whole medical community to take responsibility and ensure breast screening is optimised to save more lives.
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Bhattarai S, Klimov S, Aleskandarany MA, Burrell H, Wormall A, Green AR, Rida P, Ellis IO, Osan RM, Rakha EA, Aneja R. Machine learning-based prediction of breast cancer growth rate in vivo. Br J Cancer 2019; 121:497-504. [PMID: 31395950 PMCID: PMC6738119 DOI: 10.1038/s41416-019-0539-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 07/07/2019] [Accepted: 07/11/2019] [Indexed: 01/04/2023] Open
Abstract
Background Determining the rate of breast cancer (BC) growth in vivo, which can predict prognosis, has remained elusive despite its relevance for treatment, screening recommendations and medicolegal practice. We developed a model that predicts the rate of in vivo tumour growth using a unique study cohort of BC patients who had two serial mammograms wherein the tumour, visible in the diagnostic mammogram, was missed in the first screen. Methods A serial mammography-derived in vivo growth rate (SM-INVIGOR) index was developed using tumour volumes from two serial mammograms and time interval between measurements. We then developed a machine learning-based surrogate model called Surr-INVIGOR using routinely assessed biomarkers to predict in vivo rate of tumour growth and extend the utility of this approach to a larger patient population. Surr-INVIGOR was validated using an independent cohort. Results SM-INVIGOR stratified discovery cohort patients into fast-growing versus slow-growing tumour subgroups, wherein patients with fast-growing tumours experienced poorer BC-specific survival. Our clinically relevant Surr-INVIGOR stratified tumours in the discovery cohort and was concordant with SM-INVIGOR. In the validation cohort, Surr-INVIGOR uncovered significant survival differences between patients with fast-growing and slow-growing tumours. Conclusion Our Surr-INVIGOR model predicts in vivo BC growth rate during the pre-diagnostic stage and offers several useful applications.
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Affiliation(s)
- Shristi Bhattarai
- Department of Biology, Georgia State University, Atlanta, GA, 30303, USA
| | - Sergey Klimov
- Department of Biology, Georgia State University, Atlanta, GA, 30303, USA
| | - Mohammed A Aleskandarany
- Nottingham Breast Cancer Research Centre, Division of Cancer and Stem Cells, School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, NG5 1PB, UK
| | - Helen Burrell
- Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, Nottingham City hospital, Nottingham, NG5 1PB, UK
| | - Anthony Wormall
- Nottingham Breast Cancer Research Centre, Division of Cancer and Stem Cells, School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, NG5 1PB, UK
| | - Andrew R Green
- Nottingham Breast Cancer Research Centre, Division of Cancer and Stem Cells, School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, NG5 1PB, UK
| | - Padmashree Rida
- Department of Biology, Georgia State University, Atlanta, GA, 30303, USA
| | - Ian O Ellis
- Nottingham Breast Cancer Research Centre, Division of Cancer and Stem Cells, School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, NG5 1PB, UK
| | - Remus M Osan
- Mathematics and Statistics, Georgia State University, Atlanta, GA, 30303, USA
| | - Emad A Rakha
- Nottingham Breast Cancer Research Centre, Division of Cancer and Stem Cells, School of Medicine, University of Nottingham and Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, NG5 1PB, UK.
| | - Ritu Aneja
- Department of Biology, Georgia State University, Atlanta, GA, 30303, USA.
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Zarcos-Pedrinaci I, Fernández-López A, Téllez T, Rivas-Ruiz F, Rueda A A, Suarez-Varela MMM, Briones E, Baré M, Escobar A, Sarasqueta C, de Larrea NF, Aguirre U, Quintana JM, Redondo M. Factors that influence treatment delay in patients with colorectal cancer. Oncotarget 2017; 8:36728-36742. [PMID: 27888636 PMCID: PMC5482692 DOI: 10.18632/oncotarget.13574] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 11/12/2016] [Indexed: 01/07/2023] Open
Abstract
A prospective study was performed of patients diagnosed with colorectal cancer (CRC), distinguishing between colonic and rectal location, to determine the factors that may provoke a delay in the first treatment (DFT) provided.2749 patients diagnosed with CRC were studied. The study population was recruited between June 2010 and December 2012. DFT is defined as time elapsed between diagnosis and first treatment exceeding 30 days.Excessive treatment delay was recorded in 65.5% of the cases, and was more prevalent among rectal cancer patients. Independent predictor variables of DFT in colon cancer patients were a low level of education, small tumour, ex-smoker, asymptomatic at diagnosis and following the application of screening. Among rectal cancer patients, the corresponding factors were primary school education and being asymptomatic.We conclude that treatment delay in CRC patients is affected not only by clinicopathological factors, but also by sociocultural ones. Greater attention should be paid by the healthcare provider to social groups with less formal education, in order to optimise treatment attention.
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Affiliation(s)
- Irene Zarcos-Pedrinaci
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | | | - Teresa Téllez
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Francisco Rivas-Ruiz
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Antonio Rueda A
- Servicio de Oncología Médica, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - María Manuela Morales Suarez-Varela
- Unit of Public Health, Hygiene and Environmental Health, Department of Preventive Medicine and Public Health, Food Science, Toxicology and Legal Medicine, University of Valencia, CIBER-Epidemiology and Public Health (CIBERESP), Valencia, Spain
| | - Eduardo Briones
- Public Health Unit, Distrito Sanitario Sevilla, Consorcio de Investigación Biomédica de Epidemiología y Salud Pública, Madrid, Spain
| | - Marisa Baré
- Clinical Epidemiology and Cancer Screening, Corporació Sanitària Parc Taulí, Sabadell, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Antonio Escobar
- Research Unit, Hospital Universitario Basurto, Bilbao, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Cristina Sarasqueta
- Research Unit, Donostia University Hospital, San Sebastián, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Nerea Fernández de Larrea
- Area of Environmental Epidemiology and Cancer, National Epidemiology Centre, Instituto de Salud Carlos III, Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiología y Salud Pública, CIBERESP), Madrid, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Urko Aguirre
- Research Unit, Hospital Galdakao-Usansolo, Galdakao, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - José María Quintana
- Research Unit, Hospital Galdakao-Usansolo, Galdakao, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Maximino Redondo
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
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Müller CSL, Pföhler C, Kohn D, Vogt T. Huge undifferentiated fibroblastic sarcoma of the foot and lower leg: impact of diagnostic delay and discussion of an entity. BMJ Case Rep 2013; 2013:bcr-2013-200192. [PMID: 24121812 DOI: 10.1136/bcr-2013-200192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a case of a 40-year-old female patient with a huge fibroblastic differentiated sarcoma of the left foot. After sampling all clinical, pathological and imaging information, the case was presented to the interdisciplinary tumour conference. Further treatment and medical care took place in the department of orthopaedics and orthopaedic surgery of our university hospital. Treatment consisted of amputation of the left foot and lower leg as an extremity-preserving surgical procedure was not possible because clear surgical margins could not be achieved with preservation of a functional rest of ankle and foot. Till date, no metastases have occurred.
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Norsa'adah B, Rahmah MA, Rampal KG, Knight A. Understanding barriers to Malaysian women with breast cancer seeking help. Asian Pac J Cancer Prev 2013; 13:3723-30. [PMID: 23098462 DOI: 10.7314/apjcp.2012.13.8.3723] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Delay in help-seeking behaviour which is potentially preventable has a major effect on the prognosis and survival of patients with breast cancer. The objective of this study was to explore reasons for delay in seeking help among patients with breast cancer from the East Coast of peninsular Malaysia. A qualitative study using face- to-face in-depth interview was carried out involving 12 breast cancer patients who had been histo-pathologically confirmed and were symptomatic on presentation. Respondents were selected purposely based on their history of delayed consultation, diagnosis or treatment. All were of Malay ethnicity and the age range was 26-67 years. Three were in stage ll, seven in stage lll and two in stage lV. At the time of interview, all except one respondent had accepted treatment. The range of consultation time was 0.2-72.2 months with a median of 1.7 months, diagnosis time was 1.4-95.8 months( median 5.4 months )and treatment time was 0-33.3 months (median 1.2 months). The themes derived from the study were poor knowledge or awareness of breast cancer, fear of cancer consequences, beliefs in complementary alternative medicine, sanction by others, other priorities, denial of disease, attitude of wait and see and health care system weakness. Help-seeking behaviour was influenced by a complex interaction of cognitive, environmental, beliefs, culture and psycho-social factors. Breast cancer awareness and psychological counselling are recommended for all patients with breast symptoms to prevent delay in seeking clinical help.
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Affiliation(s)
- Bachok Norsa'adah
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia.
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Rougraff BT, Lawrence J, Davis K. Length of symptoms before referral: prognostic variable for high-grade soft tissue sarcoma? Clin Orthop Relat Res 2012; 470:706-11. [PMID: 22183474 PMCID: PMC3270193 DOI: 10.1007/s11999-011-2192-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It is commonly assumed patients with high-grade soft tissue sarcomas who are diagnosed and treated quickly after the first onset of symptoms fare better than those with longer symptoms before treatment. The literature contains no substantive data to support this assumption for soft tissue sarcomas, particularly for high-grade lesions. QUESTIONS/PURPOSES We examined selected potential prognostic factors for high-grade soft tissue sarcoma and determined whether the time from first symptom to diagnosis has an impact on survival or disease-free survival and whether subcutaneous sarcomas are diagnosed more quickly than deep sarcomas. METHODS We retrospectively reviewed 381 consecutive patients treated for high-grade soft tissue sarcoma between 1992 and 2007. Each patient's time from first symptom (pain and/or palpable mass) was prospectively entered into a surgical oncology database. The patients were followed for disease recurrence and survival. We compared length of symptoms with disease-free survival, overall survival, metastases at diagnosis, tumor size, and patient age. Minimum followup was 1 month (mean, 57 months; range, 1-201 months). RESULTS The overall 5-year survival was 64.7% and disease-free survival was 54.5%. Tumor size and metastatic disease correlated with overall survival and disease-free survival but not length of symptoms. Length of symptoms did not correlate with overall survival or disease-free survival. CONCLUSIONS Our data do not support the assumption that longer length of symptoms before diagnosis predicts worse overall survival, disease-free survival, or metastatic disease at diagnosis. LEVEL OF EVIDENCE Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | - Kenneth Davis
- OrthoIndy, 8450 Northwest Blvd, Indianapolis, IN 46278 USA
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Hafström L, Johansson H, Ahlberg J. Diagnostic delay of breast cancer - an analysis of claims to Swedish Board of Malpractice (LÖF). Breast 2011; 20:539-42. [PMID: 21764312 DOI: 10.1016/j.breast.2011.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 06/09/2011] [Accepted: 06/26/2011] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Larsolof Hafström
- Department of Surgery, Sahlgrenska University Hospital, Göteborg, Sweden.
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8
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Breast cancer mimicking fibroadenomas in postmenopausal women. Int J Surg 2011; 9:2-4. [DOI: 10.1016/j.ijsu.2010.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 08/23/2010] [Indexed: 11/18/2022]
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Pérez G, Porta M, Borrell C, Casamitjana M, Bonfill X, Bolibar I, Fernández E. Interval from diagnosis to treatment onset for six major cancers in Catalonia, Spain. ACTA ACUST UNITED AC 2008; 32:267-75. [PMID: 18789609 DOI: 10.1016/j.cdp.2008.05.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Targets set by health care organizations on time intervals between cancer diagnosis and treatment often go unmet. The objective of the study was to analyse the interval from diagnosis to treatment onset, and related factors, in the six most incident cancers in Catalonia (Spain), a developed European region with universal free access to health care. METHODS Twenty-two hospitals contributed 1023 incident cancer patients (198 lung, 253 colorectal, 95 prostate, 109 urinary bladder, 266 breast, 102 endometrial). Information was gathered from hospital medical records. The dependent variable was the length of the diagnosis to treatment interval (DTI). Independent variables were age, sex, disease stage, hospital level, mode of admission to hospital, and type of physician seen before admission. Multivariate-adjusted odds ratios were calculated by unconditional logistic regression for each cancer site. RESULTS The median DTI (in days) was 39 for lung cancer, 25 for colorectal, 108 for prostate, 69 for bladder, 35 for breast and 40 for endometrial cancer. In prostate and bladder cancers, over 78% of patients showed a DTI >30 days, while in colorectal the figure was 42%. Disseminated stage (distant metastases) was associated with a lower DTI in all sites. Patients admitted to third-level hospitals and with an elective admission were more likely to have a DTI >30 days. CONCLUSIONS In Catalonia, a substantial proportion of cancer patients experience treatment delays that may impact negatively on psychological well-being, quality of life, and probably survival as well.
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Affiliation(s)
- Glòria Pérez
- Agència de Salut Pública de Barcelona, Barcelona, Spain; Universitat Pompeu Fabra, Catalonia, Spain.
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10
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Principles of Evidence-Based Medicine as Applied to Sentinel Lymph Node Biopsies. AJSP-REVIEWS AND REPORTS 2008. [DOI: 10.1097/pcr.0b013e31817a79d5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rougraff BT, Davis K, Lawrence J. Does length of symptoms before diagnosis of sarcoma affect patient survival? Clin Orthop Relat Res 2007; 462:181-9. [PMID: 17534186 DOI: 10.1097/blo.0b013e3180f62608] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
It generally is accepted that earlier diagnosis of sarcoma is associated with a better disease-free survival. Because the legal community is convinced this is true, a delay in cancer diagnosis is a frequent source of medical malpractice lawsuits. We asked whether symptom duration before diagnosis affected sarcoma outcome. We compiled prospective data from 624 consecutive patients with sarcoma treated from 1992 to 2003. The data included length of symptoms before diagnosis, tumor size and grade, presence of metastatic disease at diagnosis, anatomic location, disease-free survival, overall survival, and local recurrence. Length of symptoms did not predict presence of metastatic disease at diagnosis, survival, or disease-free survival. We found no correlation between the length of a patient's symptoms and the tumor size or anatomic site of disease (axial, proximal, and distal). Tumors were larger at diagnosis in axial and proximal locations than in more peripheral locations, despite no difference in length of symptoms before diagnosis. Patients with sarcoma with long-standing symptoms did not have a worse prognosis than those with a shorter length of symptoms before diagnosis in terms of disease-free survival, overall survival, and presence of metastatic disease at diagnosis.
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Affiliation(s)
- Bruce T Rougraff
- Orthopaedic Department, St Vincent Hospital, Indianapolis, IN, USA.
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Pinkney TD, Raman S, Piramanayagam B, Corder AP. The results of a structured diagnostic pathway designed to minimise the chance of breast cancer misdiagnosis. Eur J Surg Oncol 2007; 33:551-5. [PMID: 17336481 DOI: 10.1016/j.ejso.2007.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2006] [Accepted: 01/17/2007] [Indexed: 11/15/2022] Open
Abstract
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%.
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Affiliation(s)
- T D Pinkney
- Department of Surgery, The County Hospital, Union Walk, Hereford, HR1 2ER, UK
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Wick MR. Medicolegal liability in surgical pathology: a consideration of underlying causes and selected pertinent concepts. Semin Diagn Pathol 2007; 24:89-97. [PMID: 17633350 DOI: 10.1053/j.semdp.2007.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Malpractice actions against surgical pathologists are still relatively uncommon, but they have increased in frequency over time and are associated with sizable indemnity figures. This discussion categorizes areas of liability in surgical pathology into three groups: those that represent health system flaws (problems with specimen identification, or transportation, or both; lack of clinical information or erroneous information; sampling effects and defects; and poorly reproducible or poorly defined diagnostic or prognostic criteria), others that exist at the interface between the system and individuals (allowing clinicians to bypass pathologic review of referred specimens; acceding to clinical demands for inadvisable procedures; and working in a disruptive environment), and truly individual errors by pathologists (lapses in reasoning; deficiencies concerning continuity in the laboratory; invalid assumptions regarding recipients of surgical pathology reports; over-reliance on the results of "special" tests; and problems with peer consultation). Finally, two important topic areas are discussed that commonly enter into lawsuits filed against surgical pathologists; namely, "delay in diagnosis" of malignant neoplasms and "failure to provide adequate prognostic information." Based on a review of the pertinent literature, we conclude that the clinical courses of most common malignancies are not affected in a significant manner by delays in diagnosis. Moreover, the practice of using "personalized external validity" for supposedly prognostic tests is examined, with the resulting opinion that prognostication of tumor behavior in individual patients is not reliable using anything but anatomic staging systems.
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Affiliation(s)
- Mark R Wick
- Department of Pathology, University of Virginia Health System, Charlottesville, USA.
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Wick MR, Bourne TD, Patterson JW, Mills SE. Evidence-based principles and practices in pathology: selected problem areas. Semin Diagn Pathol 2005; 22:116-25. [PMID: 16639990 DOI: 10.1053/j.semdp.2006.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Contrary to the intuitive impression of most pathologists, there are still many areas in laboratory medicine where evidence-based medicine (EBM) principles are not applied. These include aspects of both anatomic and clinical pathology. Some non-EBM practices are perpetuated by clinical "consumers" of laboratory services, because of inadequate education, habit, or over-reliance on empirical factors. Other faulty procedures are pathologist-driven, with similar underpinnings. This overview considers several exemplary problem areas representing non-EBM practices in the hospital laboratory. Such examples include ideas and techniques centering on metastatic malignancies, "targeted" oncological therapy, analysis of surgical margins in the excision of neoplasms, general laboratory testing and data utilization, evaluation of selected coagulation defects, administration of blood products, and analysis of hepatic iron-overload syndromes. The concepts illustrating departures from EBM are discussed for each of those topics.
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Affiliation(s)
- Mark R Wick
- Department of Pathology, University of Virginia Health System, Charlottesville, Virginia 22908-0214, USA.
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Abstract
Screening for cancer has become extremely common. The evidence supporting screening for breast, colon, and cervix cancer is strong, but it is unclear for skin cancer, problematic for prostate cancer, and ineffective for lung cancer. Despite the problems associated with many screening approaches for cancer, enthusiasm by the medical profession and the public remains high. The objective analysis for the major tumor types is presented in this review, but the ultimate decision on whether to be screened lies in the personal and societal arena of values.
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Affiliation(s)
- Frank L Meyskens
- Department of Internal Medicine, Chao Family Comprehensive Cancer Center, University of California at Irvine, 101 The City Drive, Building 56, Room 215, Route 81, Orange, CA 92868, USA.
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16
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Love RR, Duc NB, Baumann LC, Anh PTH, To TV, Qian Z, Havighurst TC. Duration of signs and survival in premenopausal women with breast cancer. Breast Cancer Res Treat 2004; 86:117-24. [PMID: 15319564 DOI: 10.1023/b:brea.0000032980.55245.c3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
UNLABELLED CONDENSED: Among 550 women reporting a lump as the first sign of breast cancer, those with this sign for 6-29 months compared to those with 1-6 months, had bigger tumors and more frequent axillary node involvement. Overall survival, however, was not significantly different in these two groups. BACKGROUND The relationship of delay in diagnosis of breast cancer to survival is uncertain. METHODS We evaluated the relationship of patient-reported duration of signs of breast cancer to survival in participants in a clinical trial of adjuvant hormonal therapy in Vietnam and China. RESULTS Among 550 women reporting a lump as the first sign of breast cancer and information on when this appeared, the median duration of this sign before diagnosis was 6 months. Comparing two groups of patients with durations of lumps 1-6 months and 6-29 months, the group with longer duration of lumps had larger tumors clinically and pathologically (p = 0.0006, and p = 0.004), more frequent axillary node involvement (p = 0.008), and shorter but not statistically different disease-free and overall survival from the time of diagnosis (p = 0.09 and 0.35, respectively). CONCLUSIONS Breast cancer evolves slowly in the detectable period of its natural history. The impact of delays in diagnosis of less than 6 months is likely to be very limited; delays more than 6 months appear to have some, but marginal impact on survival.
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Affiliation(s)
- Richard R Love
- Department of Medicine, Section of Medical Oncology, University of Wisconsin School of Medicine, Madison, WI, USA.
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Abstract
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.
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Affiliation(s)
- M D Barber
- Edinburgh Breast Unit, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
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Are women who are taking Hormone Replacement Therapy doing so with informed consent? Radiography (Lond) 2003. [DOI: 10.1016/j.radi.2003.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Puckridge PJ, Saunders CM, Ives AD, Semmens JB. Breast cancer and pregnancy: a diagnostic and management dilemma. ANZ J Surg 2003; 73:500-3. [PMID: 12864824 DOI: 10.1046/j.1445-1433.2002.02566.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The purpose of the present paper was to review the current knowledge of pregnancy concurrent with a diagnosis of breast cancer, and how best to manage this group of women and those breast cancer survivors who may subsequently conceive. RESULTS Pregnancy-associated breast cancer or gestational breast cancer is defined as breast cancer diagnosed during pregnancy or in the 12 months post-partum. A review of the current literature on breast cancer-related pregnancy suggests an incidence of between 0.7 and 3.9%. The prognosis is thought not to be significantly different from non-pregnancy-associated breast cancer, except in cases where a delay in diagnosis is associated with more advanced disease. The treatment is similar to non-pregnant cases, with the exception of radiotherapy, which is contraindicated throughout pregnancy; and chemotherapy, which is contraindicated during the first trimester. Few breast cancer survivors go on to conceive, but those who do have no worse breast cancer or pregnancy outcomes. CONCLUSION Most of the research in this field has come from small, specialized institutions and may not reflect what occurs in the wider community. Further population-based research in this area is needed, and is currently being undertaken in Western Australia.
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Affiliation(s)
- Philip J Puckridge
- University Department of Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
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20
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Caballero Alcántara JE, Marchal Escalona C, García Penit J, Padilla León M. [Analysis of the delay in surgical treatment of adenocarcinoma of the prostate]. Actas Urol Esp 2003; 27:286-91. [PMID: 12830550 DOI: 10.1016/s0210-4806(03)72922-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The prostate cancer is an important cause of men's mortality in our society. PURPOSE To know the time of delay in to realise the surgical treatment of the prostate cancer. MATERIALS AND METHODS Analysis of 30 cases of patients treated with radical prostatectomy, cuantifying the time of delay in all the periods of the process. RESULTS Appointment in general practitioner-first appointment in urology: 21.7 days. First appointment in urology-biopsy: 22.8. Biopsy-diagnosis: 34.3. Diagnosis-appointment of anesthesiology: 28.5. Anesthesiology-radical prostatectomy: 25.7. CONCLUSIONS There are actions for to reduce the delay in to perform the diagnosis or treatment, where we can act how an improvement plan: to give poblational education in general and information to the patient in particular, to analyze the rules of medical action, to improve the coordination between level, to improve the flexibility in outpatients appointment and time waiting for diagnosis test and treatment, to correct the temporality, to create clinical units of many specialties and to improve the politics of health.
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Langlands AO, Gebski V, Hirsch D, Tattersall MHN. Delay in the clinical diagnosis of breast cancer: estimating its effect on prognosis, with particular reference to medical litigation. Breast 2002; 11:386-93. [PMID: 14965700 DOI: 10.1054/brst.2002.0456] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2002] [Revised: 06/05/2002] [Accepted: 06/13/2002] [Indexed: 02/06/2023] Open
Abstract
Medical malpractice litigation is increasing. Delay in diagnosis is the commonest basis for litigation involving the treatment of breast cancer. When delay in diagnosis has occurred, any losses for which a plaintiff seeks compensation require estimates to be made of any change in prognosis over the period of the delay relative to the extent of disease found when treatment is finally undertaken. We have examined the natural history of breast cancer and have attempted to provide evidence-based quantitative guidelines for the evaluation of the losses which may be claimed in malpractice cases.
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Affiliation(s)
- A O Langlands
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, NSW, Australia.
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22
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Abstract
Fibroadenoma of the breast is a common cause of a benign breast lump in premenopausal women. The consensus view is that women with fibroadenomas are not at significant increased risk of developing breast cancer. Diagnosis is based on the combination of clinical examination, imaging and non-surgical tissue biopsy (the triple test). A clinical diagnosis of fibroadenoma alone is unreliable and does not exclude malignancy even in younger women. The choice of imaging is mammography, combined with ultrasound in older women, and ultrasound alone in younger women. Tissue biopsy, by either fine-needle aspiration or core biopsy, is the most accurate means of establishing the diagnosis. Traditionally, symptomatic fibroadenomas were treated by surgical excision, and this option should always be offered. There is increasing evidence that a conservative approach is safe and acceptable, provided the result of an adequate triple test is both negative for cancer and consistent with a fibroadenoma. Patients who choose conservative management need to be informed of the limitation of the tests, and must be assessed promptly if there is symptomatic or clinical change.
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Affiliation(s)
- N Houssami
- Sydney Square Breast Clinic, NSW, Medical Benefits Fund of Australia.
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