One in eight women will be diagnosed with breast cancer in their lifetime, and two-thirds of women diagnosed with breast cancer are aged 50 and older. Known risk factors include radiation exposure and never being pregnant or having a first child after age 35. Other risk factors include menopause after age 55, postmenopausal hormone therapy, obesity, and having dense breast tissue. Hereditary factors can also be a cause. BRCA1 and BRCA2 gene mutations account for about 20% to 25% of hereditary breast cancers and about 5% to 10% of all breast cancers. A woman whose mother, sister, or daughter had breast cancer—especially if the cancer was bilateral, pre-menopausal, or occurred in more than one first-degree relative—is two or three times more likely to develop breast cancer. Genetic counseling should be considered for women with this history.
Reviewing Recent Data on Breast Cancer Diagnosis-Related Failure
A recent review of claims data from The Doctors Company revealed that 92% of breast cancer cases involved a diagnosis-related failure, and about 30% of these cases included misinterpreting a diagnostic test, such as a mammogram or breast biopsy. Research suggests that screening mammograms miss 10% to 20% of breast cancers. A study in the New England Journal of Medicine compared traditional mammograms to digital mammograms and found that the digital screenings were superior for women younger than 50, those with dense breast tissue, and women who were premenopausal or in their first year of menopause.
Getting on the Same Page: Beginning Screening Mammography
There may be some confusion about when screening mammography should begin because recommendations vary. The American Cancer Society recommends that women older than 40 get annual mammograms, whereas the United States Preventative Task Force recommends screening mammograms begin at 50 and encourages younger patients to discuss if earlier screenings are appropriate with their physician. It’s essential that all physicians practicing in the same group or integrated delivery system follow the same guidelines. This is important because if screening recommendations are not followed and a patient is subsequently diagnosed with breast cancer, a delay in diagnosis will be the basis for a claim.
Another issue seen in almost 30% of breast cancer claims is a delay in ordering a diagnostic test. A physician may think a palpable breast mass in a 38-year-old woman is a cyst, based on physical and mammographic findings, and recommend “watchful waiting” rather than ordering a directed needle biopsy. However, if she is lost to follow-up and the mass is later diagnosed as cancer with sentinel lymph node involvement, a claim may be filed based on a delay in diagnosis. The key is to make every effort to ensure that group practices and integrated delivery systems are on the same page with adhering to guideline recommendations.
Readings & Resources (click to view)
Pisano E. Diagnostic performance of digital versus film mammography for breast cancer. N Eng J Med. 2006;355:1773-1783.
Baum JK, Hanna LG, Acharyya S, et al. Use of BI-RADS 3–Probably Benign Category in the American College of Radiology Imaging Network Digital Mammographic Imaging Screening Trial. Radiology. 2011;260:61-67.
Saslow D, Boetes C, Burke W, et al for the American Cancer Society Breast Cancer
Advisory Group. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57:75-89.
Smith RA, Saslow D, Sawyer KA, et al. American Cancer Society guidelines for breast cancer screening: Update 2003. CA Cancer J Clin. 2003;53:141-169.
American Cancer Society. Detailed Guide: Breast Cancer. 2012. Available at http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/index.