Delay in Diagnosing Breast Cancer: A Case Summary and Tips to Reduce Risk

According to the American Cancer Society, breast cancer is second only to lung cancer as the leading cause of cancer deaths in women. During the pandemic (especially throughout the early months), the number of screening and diagnostic tests for breast cancer was dramatically reduced due to measures barring elective procedures, capacity issues, limited PPE equipment, and patient fear of potential exposure to COVID-19. A recent study found a decline of more than 80 percent in screening and diagnostic mammograms.¹ The impact this decline will have is still unclear. With additional virus surges occurring throughout the pandemic, it is likely that more declines in preventive care have occurred.

It is crucial for practices that act as primary care providers to monitor preventive breast healthcare. Using EHR reporting tools can help practices proactively remind patients to schedule their annual screening mammograms. Document patient notification of needed tests and follow up on adherence to testing to help prevent missed opportunities for an early breast cancer diagnosis.

When symptoms are present, include breast cancer as part of the differential diagnosis, with documentation of why the diagnosis was either correct or ruled out. As illustrated in the case example below, a delay in diagnosing breast cancer may result when a patient doesn’t follow through with diagnostic recommendations.

Case Example

A 36-year-old woman presented to her gynecologist with a primary complaint of right breast pain. After examining the patient, the gynecologist scheduled an ultrasound exam of the breast and a mammogram. The mammogram was completed five days after the patient’s appointment with the gynecologist. The results of the mammogram were normal, and the outcome was reported to the patient.

Subsequently, the patient canceled several appointments for the ultrasound. The gynecologist’s office made multiple attempts to contact the patient to schedule the ultrasound—including several phone calls to discuss the importance of having the ultrasound. The staff also followed up with a certified letter that the patient never claimed. All attempts to schedule the ultrasound were documented in the patient’s medical record.

The patient presented to her primary care practitioner several times after the mammogram for symptoms that were unrelated to gynecological treatments. Her complaints to the primary care physician included weight gain and bloating, anxiety, and sore throat. She did not contact the gynecologist’s office or keep any scheduled gynecological appointments during this time.

The patient returned to the gynecologist’s practice nine months after the initial visit with a new complaint of a lump in her right breast. A mammogram revealed a 2 cm nodule in the breast, with ultrasound findings consistent with fibroadenoma. A surgical biopsy revealed an infiltrating ductal carcinoma. The patient alleged a delay in the diagnosis of breast cancer.

Following Diagnostic Recommendations

Patients may not comply with diagnostic testing recommendations for a number of reasons. Many fear a cancer diagnosis—especially breast cancer—or their prior experience with a cancer patient (such as a parent, sibling, or close friend) may cause them to delay seeking diagnosis and treatment. Though early detection has led to an increased survival rate for those diagnosed with breast cancer, perceptions of cancer treatment (including surgery, radiation, and chemotherapy) and its side effects may prevent a patient from undergoing recommended further diagnostic testing.

Health literacy—the patient’s ability to obtain, process, and understand health information and services to make appropriate health decisions²—may also contribute to this problem. Patients with low health literacy may not understand healthcare discussions and the implications of recommendations. Factors that increase the risk of low health literacy include advanced age, poor English proficiency, lack of education, and low socioeconomic levels. Even highly educated patients may, however, have difficulty understanding healthcare-specific communications.

The Agency for Healthcare Research and Quality (AHRQ) funded the development and validation testing of a short assessment of health literacy in both English and Spanish.² This simple test, which can be administered in only two or three minutes and can identify patients who may require greater assistance and time for explanations and instructions.

Techniques such as AHRQ’s Teach-Back Technique are beneficial in evaluating the patient’s understanding of follow-up care, testing recommendations, medication administration, and other healthcare instructions. The teach-back method involves asking the patient to repeat instructions in his or her own words.

Another technique to promote clear communication and assess the patient’s understanding of the need for testing is the Institute for Healthcare Improvement’s Ask Me 3® program. Educational materials to implement the Ask Me 3 program may be downloaded free on the website. The Ask Me 3 program encourages patients to better understand their health conditions and participate in their own healthcare by writing in their own words a response to these three questions:

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?

The answers allow the provider to assess the patient’s understanding of the treatment plan.

Clinician-Patient Communication: Clarity Is Key

Thorough communication with patients about the plan for treatment is important to help them achieve optimal outcomes. In the case example above, it appears the patient did not understand that each test provided different information and that the results of both tests are necessary for a complete diagnosis. Providing a thorough explanation can help prevent patients from stopping before the treatment plan is complete.

If a patient becomes distant, difficult to treat, or does not comply with treatment plans, examine the source of the behavior. Many patients are hesitant to admit their fears or lack of understanding. Emotional status and level of health literacy may lead to lapses in care that negatively affect a patient’s health status. Information and encouragement from clinicians with validation of patient understanding may make the difference in achieving desired outcomes of care.

For guidance and assistance in addressing any patient safety or risk management concerns, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.