Tracking for breast cancer.

Abstract

cations, concludes that the findings are somewhat suggestive of malignancy, and recommends a percutaneous core biopsy. On approval of the woman’s primary care physician, the radiologist performs a stereotaxic biopsy. The pathologist reports that the specimen is normal but, because the mammographic appearance of the lesion remains worrisome to the radiologist, the radiologist recommends surveillance mammography every 6 months. The patient does not return for her first 6-month mammogram, in spite of a postcard reminder mailed to her address. At the end of 1 year, another reminder notice is mailed, followed by a telephone call to the patient, but she still does not appear for follow-up mammography. Eighteen months after the original biopsy, the patient does return for mammography because her physician feels a lump in her breast in the area in which the biopsy had been performed. This time mammograms are interpreted as highly suggestive of malignancy, and an open biopsy confirms the presence of carcinoma. Lymph nodes are positive and additional radiologic tests reveal bone metastases. While undergoing chemotherapy, the patient files a malpractice lawsuit against the radiologist, alleging that the radiologist’s failure to adequately monitor her and remind her “convincingly” to return for the 6-month and 12-month mammograms led to a delay in the diagnosis of breast cancer such that she now harbored metastatic disease and was deemed to have a dismal prognosis. This hypothetic scenario is not far-fetched, for as Goodman et al. [I] point out in their article, “Compliance with recommended follow-up after percutaneous breast core biopsy,” radiologists who perform percutaneous biopsies expose themselves to ever-expanding medical-legal consequences. An analysis of their article shows us why. Referring physicians of patients for whom radiologists recommended (after percutaneous biopsy) that open surgical biopsy be performed were mailed a letter in 4 weeks if the patients did not appear for biopsy and were telephoned in 8 weeks if the patients still did not appear. Patients for whom radiologists recommended (after percutaneous biopsy) that surveillance mammography be performed were mailed reminder notices in 7 months if they did not return for followup mammography and were telephoned in 9 months if they still had not come in. Even with these ambitious and, indeed, rigorous tracking procedures, the radiologists were able to achieve full compliance in only 74% of the patients for whom surgical biopsy was recommended and in only 54% of the patients for whom surveillance mammography was recommended. Think about this: 46% of the women who received reminders by both mail and telephone that follow-up mammography should be performed nonetheless never came in for their examinations. The plaintiff described in the hypothetic scenario could have been one of these women. The foregoing brings into focus the question of the degree to which radiologists are responsible for tracking, for potential development of breast cancer, patients on whom they have performed percutaneous breast core biopsies with negative findings. To answer this question. let us first review pertinent existing written standards and guidelines. We begin with the American College of Radiology standard for performance of stereotaxically guided breast interventional procedures, which states, in part, “The rate of compliance with the recommended follow-up in women with benign results following stereotaxically guided FNA (fine-needle aspiration) or CNB (core needle biopsy) should be tracked. Follow-up of all biopsies should be pursued to detect and record any false-negative or false-positive results” [2]. This standard is silent as to how the tracking and pursuing should be implemented. Another source of written guidelines relating to percutaneous breast biopsies is the Agency for Health Care Policy and Research, a division of the United States Department of Health and Human Services. In 1994 the agency published two booklets on mammography, one targeted at physicians [3] and the other at patients [4]. Although neither deals specifically with breast core biopsies, specific language sets forth the duties of radiologists relative to tracking patients who have had abnormal findings on mammography. Radiologists should be aware of these duties because