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Docs Quick to Dismiss Breast Cancer Without Biopsy

Mon Jun 24, 2002

NEW YORK (Reuters Health) - Too many breast cancer patients are initially told they are cancer-free, most often because their physicians said they believed the suspicious mass was harmless and didn't perform a biopsy to check, according to researchers.

"Despite widespread screening mammography, inappropriate reassurance that a palpable mass is benign, without biopsy, remains the leading cause of physician-delayed diagnosis of breast cancer, affecting 5% of patients in our series," Dr. William H. Goodson of the University of California, San Francisco, and his co-author Dr. Dan H. Moore write.

"Combining all causes, 9% of patients experienced delay," Goodson and Moore added.

Although most patients with breast cancer do not experience a delay in diagnosis, previous studies have found that between 6% and 16% of patients are initially, and mistakenly, told by their doctors that they do not have the disease. If 180,000 women develop breast cancer each year, the authors reason, at least 10,000 patients may be initially misdiagnosed as cancer-free.

Goodson and Moore set out to determine the most common causes of delay in physicians' ability to diagnose breast cancer by examining the time taken to correctly diagnose 435 patients who underwent surgery to remove 454 breast cancers.

Goodson and Moore found that a total of 42 cancers, or 9% of all diagnosed, belonged to patients who were initially told they were cancer-free. Half of the delays in diagnosis lasted 9 months or longer, and the longest delay lasted 3 years.

Most of the patients given an initially incorrect diagnosis were told by their doctors that a suspicious lump was benign without performing a biopsy, during which doctors remove cells from the lump to test for the presence of disease. Another 14 patients did not receive a prompt diagnosis because their mammograms had been misread, and 9 others were mistakenly diagnosed as cancer-free because of botched biopsies, either a misreading of the results or from mistakes in performing the procedure.

One aspect that might influence delays in diagnosis, the authors report, is whether or not patients found the suspicious mass themselves or the lump was detected by a woman's doctor. Although 35% of cancers in this study group were first discovered by the patient herself, patient-found tumors represented almost two-thirds of all cases in which a delay in diagnosis occurred.

"Physicians seem to intuit lower cancer risk for self-discovered masses and seek to reassure patients using CBE (clinical breast examination) or mammography, without performing biopsy," Goodman and Moore write in the June 24 Archives of Internal Medicine.

In order to reduce the risk of delays in diagnosis, the authors recommend that doctors not rely on clinical breast exams to indicate whether a suspicious lump is cancerous. Furthermore, Goodman and Moore write that biopsies should be conducted by trained professionals, who are less prone to mistakes.

"Reducing delay in diagnosis will require less willingness to rely on clinical examination to decide that a mass is benign, less reliance on benign mammography reports to decide not to biopsy a mass, and a requirement that fine-needle aspiration biopsy be done by persons with demonstrated competence for the procedure," Goodman and Moore conclude.

SOURCE: Archives of Internal Medicine 2002;164:1343-1348.

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