Breast Cancer Missed as Physician Fails to Examine Patient

This case involves a forty-five-year-old female who presented to her primary care physician’s office with complaints of a nodular lump on her breast. At the initial visit, the patient was only seen by a medical student, the physician did not interview or examine the patient. The student reported the lump as a small fixed mass that appeared to have some dimpling of the surrounding tissue. The patient was scheduled and sent for a mammogram. The test was reported as having no abnormalities other than fibrocystic breast disease. Six months later the lump grew to 5cm x 5cm and, at this point, an additional mammogram follow-up was ordered. Further imaging studies reported that the patient now had a severe metastatic disease.

Question(s) For Expert Witness

1. How often is breast cancer first identified by the physical exam?

Expert Witness Response

First, a physician must always examine the patient, as one cannot necessarily depend on the medical student to justify the physical exam findings. Breast cancer is often detected radiographically but is the physical exam findings that initiate the workup for breast cancer. Some physical exam findings include induration/skin dimpling of the breast, bloody nipple discharge, and an immovable mass. If the physical exam is abnormal then a mammogram would be performed next. Mammographic features suggestive of malignancy include asymmetry or microcalcifications. If any of these features are identified, diagnostic mammography along with breast ultrasonography should be performed before a biopsy is obtained. In certain cases, breast magnetic resonance imaging (MRI) may be warranted. Consult with a breast surgeon and oncologist is always warranted in cases where the mammogram is abnormal, as further workup would be needed to assess for metastasis.