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The Nurse Navigator's Role in Preventing Medical Legal Issues Associated with Breast Cancer Diagnosis and Treatment: Part 1

November 19, 2010 | AONN+ Blog | Breast Cancer
Featuring:
Lillie D. Shockney, RN, BS, MAS, HON-ONN-CG
Lillie D. Shockney, RN, BS, MAS, HON-ONN-CG
Editor-in-Chief, JONS; Co-Founder, AONN+; University Distinguished Service Professor of Breast Cancer, Administrative Director, The Johns Hopkins Breast Center; Director, Johns Hopkins Cancer Survivorship Programs; Professor of Surgery and Oncology, JHU School of Medicine; Co-Creator, Work Stride-Managing Cancer at Work

In case you are not aware, the most common medical malpractice issue medical providers deal with today relates to breast cancer care—specifically, misdiagnosis, delay in diagnosis, and/or failure to follow standard of care. So it is probably not a surprise that the nation has a shortage of breast imaging radiologists and soon will be facing a shortage of breast oncologic specialists as well. To aggravate this issue further, reimbursement for treatment rendered isn’t matching up with expenses incurred, driving even more medical professionals from wanting to stay in this oncologic specialty. 

This can result in an increase in medical malpractice issues due to the healthcare delivery system having to “default” to having generalists taking care of breast cancer patients. Below is a summary of some of the issues that arise that can lead to a lawsuit, which nurse navigators can “head off at the pass” by being knowledgeable about them and taking proactive steps in preventing them from happening. As you review the summary, think about your role as a navigator in helping your team member reduce their malpractice risk.

1. Still using analog film mammography—With the advent of digital mammography, dramatic improvements in the accuracy of breast imaging studies have been achieved. Digital mammography will find 28% more early stage breast cancers than the (old) analog film. So if your facility hasn’t converted yet, be a champion for making that happen. If you are seeing patients whose mammograms were done at an outside facility and they were not digital, make sure that a breast imaging radiologist on your team re-reads them to ensure that density is not a blockade for identifying what may be a stage 0 or stage 1 breast cancer.

2. General radiologists reading mammograms—Not all radiologists are skilled at reading mammograms. Remember, mammograms contain no skeletal structures. Most radiologists are all about looking at bones. A study published several years ago confirmed that if a general radiologist is reading a mammogram and cancer is in fact present on the film, though subtle, it will be missed 41% of the time. This can and does result in a delay in diagnosis for many women.

3. General pathologists reading unusual breast biopsies—Although most general pathologists are familiar with invasive ductal carcinoma when looking at it under a microscope, there are other types of breast cancer that can be a little trickier and require an experienced, skilled pathologist who specializes in breast cancer. Ductal carcinoma in situ has been underdiagnosed and overdiagnosed. Phyllodes tumors (both benign and malignant) also have been met with confusion. Invasive lobular tumors are even a little tricky. Then there are breast cancer types like inflammatory breast cancer, metaplastic breast cancer, and sarcomas of the breast that require an experienced eye. Today, the hormone receptors commonly will be evaluated on breast biopsy tissue. What isn’t well known, though, is that if the results are negative they are to be repeated again on the surgical pathology specimen. This is because breast cancer cells may not be uniformly positive for estrogen. The biopsy might have hit a negative cell(s) when a portion of the tumor is in fact positive and the patient would benefit from hormonal therapy.

4. Inadequate or inappropriate sampling for a biopsy to make the diagnosis—Fine needle aspirate biopsies are considered substandard when trying to make a diagnosis of a mass within the breast. On the flip side, doing an open excisional biopsy without determining if the patient is a candidate for a core biopsy can result in problems as well. After an incision is made the breast will form scar tissue. Scar tissue on a mammogram appears as an abnormality, which can result in a cycle of biopsies being done in the future. It also exposes the patient to higher risk of infection and the complications that can accompany general anesthesia. Today more than 90% of biopsies can be done as a core biopsy in the breast-imaging setting.

5. Specialists vs generalists for providing the actual breast cancer treatment—A study was conducted and published by the Advisory Board’s Oncology Roundtable last year. The results were as follows:

  1. Patients receiving inadequate treatment—24% for specialists; 47% for generalists
  2. Inadequate axillary node dissections—8% for specialists; 40% for generalists
  3. Inadequate definitive axillary treatment—4% for specialists; 38% for generalists
  4. Local recurrence rate—13% for specialists; 23% for generalists

6. Delays in diagnosis—These delays can result from not referring a patient for diagnostic evaluation in the presence of a breast symptom (found by a provider or by the patient). These include: not pursuing further diagnostic evaluation when symptoms are present and mammography and ultrasound are “normal;” informing a patient she is too young to get breast cancer; failing to follow-up on BI-RADS 4 mammogram; or failing to call a patient back in the presence of an abnormal finding on screening mammography. Inflammatory breast cancer is a specific type of breast cancer that has an unusual presentation and has been misdiagnosed as being mastitis, resulting in a delay in diagnosis and treatment that can cost a patient her life. This is considered one of the most aggressive forms of breast cancer and its initial presentation can be subtle—a redness and swelling of the breast with a normal mammogram and ultrasound. Diagnosis is made by performing a skin-punch biopsy, which will show the presence of breast cancer in the dermal lymphatics of the breast tissue. It is the one type of breast cancer that warrants urgency in getting systemic treatment underway. The disease is already stage III by definition of the type of breast cancer.

Part 2 will detail additional medical malpractice issues related to the diagnosis and treatment of patients with breast cancer.

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