Worrying lump

...Dr J undertakes an examination and finds a "2 cm non-tender subcut lump under right axilla". She prescribes antibiotics and asks the patient to return for review...

BACKGROUND: Mrs L is 58 years old and attends her GP surgery complaining of a sore back. Dr J offers a diagnosis of "non-specific" back pain and prescribes co-codamol. The patient is also worried about a small lump on her right breast. Mrs L said she had noticed a similar lump in her left breast over a year ago but there is no mention of this in her notes. Dr J conducts an examination and notes two small lumps (like "rice grains") on both breasts with no other obvious skin changes or lymph node involvement. She records: "Possible fibroadenoma".

Three months later Mrs L attends the surgery complaining of a lump in her right underarm. Dr J undertakes an examination and finds a "2 cm non-tender subcut lump under right axilla". The GP prescribes antibiotics and asks the patient to return for review in three weeks, or sooner if she notices any changes.

Two weeks later Mrs L re-attends the surgery. Another GP – Dr P – sees the patient and notes that the axilla lump has not responded to the antibiotics and the patient is worried it has grown larger. Given the history of breast lumps the GP refers her to the local breast clinic under the two-week rule. A consultant examines Mrs L and, in addition to the axillary lump, notes a small firm lump in the peri-areolar region of the right breast.

A mammogram is requested and Mrs L is later diagnosed with invasive ductal carcinoma with metastatic deposits in the right axilla. Three weeks later she undergoes a mastectomy with axillary clearance. Given further nodal involvement she undergoes chemotherapy and radiotherapy. A year later there is no sign of recurrence.

The surgery receives a letter of claim from solicitors acting on behalf of Mrs L alleging clinical negligence against Dr J for failing to obtain and document a clear history and refer her to the breast clinic. It is claimed an early referral would have resulted in the detection of the primary breast cancer and lymph node involvement – and the delay in diagnosis has reduced the patient’s predicted ten-year survival. The delay also resulted in additional stress and depression resulting in time off work.

ANALYSIS/OUTCOME: MDDUS reviews the case and instructs an expert in primary care. He notes that NICE provides clear guidance that the finding of a persisting breast lump in a woman over age 30 years mandates referral. In this case Dr J did find two small lumps but the expert believes referral was not merited at this stage but review of the patient after a period would be reasonable.

The expert also states subsequent findings do not support the contention that that the cancer was present (either in the breast or axilla) at the first consultation. The lump found in the breast clinic was not the same one identified by Dr J and she contends in subsequent statements that Mrs L was advised to re-attend if these lumps persisted or enlarged or if she noticed any other changes – however this advice is not recorded in the patient notes.

In regard to the second consultation for the lump under the right axilla, the expert is supportive of Dr J’s decision to treat with antibiotics and review. An additional report by an expert oncologist offers the opinion that an urgent referral at this stage would have advanced the diagnosis by no more than a few weeks and would have had little or no impact on the prognosis.

The primary care expert states that the main vulnerability in the case is to do with the poor contemporaneous notes. MDDUS decides in agreement with the member to settle the case for a modest sum with no admission of liability.

KEY POINTS

  • Record advice given to patients in regard to warning signs and review.
  • Persisting breast lumps in women over 50 merit urgent referral – check accepted guidelines.

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