Breast cancer cases typically involve a radiologist and then an oncologist. The radiological expert is necessary to determine whether or not a mammogram was misinterpreted. The oncologist then reviews the materials to determine whether the delay in diagnosis made a significant difference in terms of the patient’s ultimate condition.These are all important players in a breast cancer medical malpractice claim.
Breast cancer failure to diagnose claims require a detailed knowledge of the physiology of breast cancer. In these type of medical malpractice claims it is the initial consultation with the doctor coupled with some delay in diagnosing and treating the cancer that forms the basis for a claim. The average delay in diagnoses is 14 months across the board. In evaluating the case the principal inquiry is when could the cancer have been diagnosed and what the probable outcome would have been if diagnosed in a timely fashion.
Patients who present with a breast mass that is approximately 2 centimeters or smaller (about the size of a dime) and no other symptoms are generally categorized into Stage I. It is essential that these patients undergo an aspiration of the breast mass if it does not resolve within 30 days.
In evaluating these medical malpractice cases it is important to know the patient’s history, that is:
A common defense in these cases is that even if the cancer had been timely diagnosed the outcome would not have been any different. The best comeback to this defense is an interpretation of the client’s blood chemistry levels after treatment such as chemotherapy. If the blood chemistry levels improved, then this may be evidence that the cancer did in fact respond to treatment. Likewise, it can be argued that even if there was no improvement that may be due to the increased size of the tumor.
Mammograms can come in the form of plain film or what is called computer assisted detection film, i.e. digitalized film. Plain film is typically read either by one or two radiologists. The digitalized film is interpreted by a radiologist who is assisted by the computer which flags any problems portrayed on the mammogram.
The key principle in interpreting the mammogram is to look for changes in suspicious areas from earlier films. These changes or calcifications may come in a number of different forms. They may come in the form of circles, lines or tight clusters. If the calcifications are round or oval or are scattered and not in tight clusters, then typically they are benign. Even though the calcification may not fit a suspicious pattern if it looks questionable the radiologist should recommend a follow-up mammogram in six months. If the calcification is suspicious, then further study needs to be done either in the form of a diagnostic mammogram, a spot compression, a magnification view, an ultrasound or a biopsy.
3-D mammograms have now been approved by the Food and Drug Administration. These mammograms are technically called tomosynthesis. The traditional mammogram is 2-D, i.e. two dimensional. Those 2-D mammograms remain the standard of care and are felt to provide unique benefits in that most physicians are familiar with that technology where as they may not be familiar with the 3-D technology.
The 3-D technology does involve slightly more radiation but the increase is felt to be minimal.
Two studies from the FDA, according to the Washington Post, report that when combined 2-D and 3-D images are reviewed by physicians there is a 7 percent improvement in the ability to distinguish between cancer and non-cancer cases. In particular, the 3-D technology has been found to be helpful in detecting small cancers.From a medical malpractice perspective that may be of some significance.
The National Cancer Institute has recommended that women over 40 have a mammogram every one to two years. On the other hand the U.S. Task Force assigned to make recommendations to policy makers on such issues has recommended that standard apply to only women over 50.
Patients who have been diagnosed with early stage breast cancer need to have follow-up. The frequency of follow-up for most patients is an annual mammogram and a breast exam by an experienced physician every six months. Those patients who had early breast cancer and who are now symptom free should probably not be exposed to tumor marking tests and imaging tests of any part of the body other than the breast.
If there appears to be negligence in terms of the diagnosis of the cancer, then the next step is to look at the causation issue. Tumors tend to be looked at in terms of size, lymph node involvement and metastasis. The greater the size, the more the lymph node involvement and the existence of metastasis then the more dire the outcome. In evaluating this issue of causation the staging of the cancer can frequently be important. Staging falls into four different levels with stage 1 involving a survival rate of five years at 100% and stage 4 meaning that the survival rate for five years is 20%. If the failure to properly diagnose has resulted in the patient going from stage 1 to stage 4, then the causation element has probably been met. In general, however, it must be established that the improper diagnosis has at the very least destroyed a substantial possibility of the patient surviving. If survival is not the issue, then it typically needs to be established by a preponderance of the evidence (the greater weight of the evidence) that the patient’s condition would have been substantially better than it is now if there had been a prompt diagnosis.
Breast cancer treatment options from a surgical point of view consist of either mastectomy or lumpectomy. Lumpectomy is not a good option if the tumor is too large or diffuse or if the patient can’t tolerate radiation. The lumpectomy spares most of the breast, leaves a smaller scar and eliminates the need to wear a false breast or have reconstructive surgery. It does involve typically two to six weeks of daily radiation which can result in some permanent shrinking and hardening of tissue and itchy, tender skin.
Mastectomy, on the other hand, typically only requires radiation when the tumor is very large or the cancer cells have spread to lymph nodes. Some women elect to have a prophylactic mastectomy, i.e. having the healthy breast removed along with the diseased one. Although that obviously reduces the risk of developing future breast cancer it is rarely necessary since the chance of that in the unaffected breast is typically quite low.
In terms of drugs to reduce the risk of cancer returning after surgery there are several options. Their usage depends on age and type of cancer. Tamoxifen does cut the risk of recurrence when taken for up to five years after surgery but only if the cancer is associated with the female hormone estrogen. In addition, this drug can bring on early symptoms of menopause.
Another option are the aromatase inhibitors which tend to cause fewer problems than tamoxifen. They can, however, cause bone loss and only post-menopausal women should take this medication since it shuts down estrogen production entirely. A third type of drug is trastuzumab which only helps women who have a protein called human epidermal growth factor receptor 2.
Breast cancer lymph node removal recommendations have undergone some further revisions recently as a result of a study reported in the Journal of the American Medical Association in February 2011. The study that is discussed in the article involved 900 women who were treated across the country, approximately half of whom had their lymph nodes removed and the other half did not. The conclusion of the study was that the five year survival rate was no greater for those women who had the lymph nodes removed than those who did not. Medical malpractice attorneys need to be sensitive to the changing landscape in terms of recommended treatment for breast cancer.
Breast cancer is diagnosed in approximately 200,000 women each year in the United States and as to those women the cancer reaches the lymph nodes in approximately one-third of the cases. The traditional recommendation of doctors has been that when the cancer has spread to any lymph nodes that the lymph nodes in the armpit be surgically removed along with the tumor in the breast in order to reduce the likelihood of recurrence. The lymph node removal, however, frequently produces disabling swelling in the arms known as lymphodema.
The particular study that is reported in JAMA was limited to women with tumors known as T1or T2, which are relatively small tumors and had no enlarged lymph nodes that could be felt and the cancer had not spread elsewhere in the body.
If you have been the victim of medical malpractice in regards to breast cancer diagnosis or treatment contact Brien Roche in Fairfax,Virginia and Washington,DC. For more information on breast cancer see the pages on Wikipedia.