WASHINGTONWhen women with breast cancer sue their doctors for
malpractice, it is most often because of missed or delayed diagnosis,
and the most common reasons are mistakes in the evaluation and workup
of breast cancer screening procedures, Vara Samudrala, MD, said at
the 100th annual meeting of the American Roentgen Ray Society.
Other frequently cited problems are clinicians who fail to take
seriously what their patients tell them and who fail to notify
patients of the need for follow-up testing, said Dr. Samudrala, a
fellow in radiology at the Henry Ford Hospital, Detroit. Dr.
Samudrala and her colleagues drew their conclusions from their review
of 150 cases involving missed or delayed diagnosis of breast cancer.
More and more women are undergoing mammographic screening, with the
result that breast cancer litigation is increasing in both the number
of cases and the amount of settlement claims, Dr. Samudrala said.
1995 Physicians Insurers Association of America study showed an
average settlement of $183,000 for breast cancer claims. There
is every indication that this number is rising, she said.
In their survey of claims, the Henry Ford Hospital team found 10
patterns accounting for most of the lawsuits. At the top of the list
were clinician mistakes in evaluation of palpable findings, improper
workup of mammographic abnormalities, and failure to follow American
College of Radiology (ACR) guidelines.
In the majority of such cases, a palpable lesion was present that the
patient herself had detected, Dr. Samudrala said. In many cases, the
patient was experiencing pain and tenderness in the area in question.
The Michigan team had a number of recommendations to prevent errors
leading to litigation.
Mammography alone is not reliable as the only tool to evaluate
a massfollow-up with ultrasound may be needed. Do not
place a lesion in 6-month follow-up until after proper diagnostic
workup, Dr. Samudrala said. Sometimes the lesion looks benign,
and a clinician may be tempted simply to use a
watch-and-wait approach. However, the Henry Ford
teams position is that additional workup is essential for each
Know the ACR standards for screening and diagnostic
mammograms. Follow protocols to avoid mistakes.
Always communicate the results to patients. Dr. Samudrala
cited a case in which a woman with a negative screening
mammogram was recommended for 6-month follow-up. The patient was not
informed of the need for follow-up, and she was diagnosed a year
later with breast cancer.
Dont stop searching for abnormalities after the first
one has been seen.
Avoid making false assumptions. The team mentioned, in
particular, mistaken assumptions about markers such as
BBs, used to signal the presence of known lesions. Many
times, these are used for benign skin lesions, Dr. Samudrala said,
but no one should assume that is what they represent unless it is
Know whats going on in your own institution, she
said, warning clinicians to assume nothing, trust no one.
Use standard language (BIRADS) in describing anomalies.
Without the standard language, the nature of what the clinician is
describing may be unclear, Dr. Samudrala said.
Dont ignore patients complaints. A common theme of
the malpractice claims analysis was women with palpable masses who
felt they had not been taken seriously. After examination of
the mass, the physician may have said its nothing,
its a thickening of the breasts, its fibrocystic
breasts, Dr. Samudrala said. When we, as
radiologists, hear that, bells start ringing.
In a few such cases, she said, the women were in their 20sa
factor that may lead a clinician to dismiss an abnormal finding with
the assumption that the patient is too young for breast
The Ford Team also recommends including the patients comments
on intake formsbecause they might provide information that will
be useful later on.
Use good technique. The researchers gave the example of a
patient whose breast increased in size from 1994 to 1996. Ultrasound
was performed with poor technique, leading to a mistaken diagnosis of
Be sure the radiation technologists are property trained. The
malpractice claims analysis showed that technologists are not always
properly trained and do not always know why the patient is having a
mammogram, Dr. Samudrala said.
The Michigan team plans to publish its findings, Dr. Samudrala said,
but in the meantime, she hopes that spreading the word will help the
breast cancer radiology community do a better job.
Understanding some of the factors that may lead to a
malpractice claim can help the radiologist minimize liability
exposure, while providing improved care, the team said in a
summary of the findings.