Defense of breast cancer malpractice claims

HER2 fluorescent in situ hybridization signal degradation: a 10-year retrospective study

CONTEXT

Fluorescence in situ hybridization (FISH) analysis is recommended for invasive breast carcinomas with equivocal (2+) immunohistochemical expression of human epidermal growth factor receptor 2 (HER2). However, existing guidelines for the retention and storage requirements for HER2 FISH slides vary widely among countries and laboratories.

OBJECTIVE

To determine the degradation rate of HER2 FISH signals, and the optimal retention time and storage conditions for HER2 FISH slides.

DESIGN

Dual-probe HER2 FISH slides from March 2009 to June 2019 were retrieved from the archive to assess the presence, intensity and quantity of the green chromosome enumeration probe 17 (CEP 17) and orange HER2 signals. Per the institutional policy, FISH slides are placed in slide boxes and stored in - 80 °C freezers for up to 4 years, whereas older slides are stored at room temperature.

RESULTS

After excluding HER2 FISH slides that were deemed uninterpretable due to technical issues, a total of 6255 slides were assessed. Slides from 2009 to 2014 were stored at room temperature, while slides from 2015 to 2019 were stored in - 80 °C freezers. Slides stored in freezers showed retention of both the green and the orange signals. Slide stored at room temperature demonstrated significant decrease in the signal retention rate and the loss of signal did not progress in a linear fashion. The CEP17 signal was quenched much faster than the HER2 signal.

CONCLUSION

Our study is the first to demonstrate HER2 FISH signal degradation with time and slide storage conditions. Storing HER2 FISH slides in a -80 °C freezer allows for retention of both HER2 and CEP17 signals. At room temperature, the signals start to degrade with CEP17 signals lost at a faster rate. The results of the study may be used in official guidelines for storage conditions and retention time for HER2 FISH slides.

Timing and Delays in Breast Cancer Evaluation and Treatment

BACKGROUND

Even small delays in the treatment of breast cancer are a frequently expressed concern of patients. Knowledge about this subject is important for clinicians to counsel patients appropriately and realistically, while also optimizing care. Although data and quality measures regarding time to chemotherapy and radiotherapy have been present for some time, data regarding surgical care are more recent and no standard exists. This review was written to discuss our current knowledge about the relationship of treatment times to outcomes.

METHODS

The published medical literature addressing delays and optimal times to treatment was reviewed in the context of our current time-dependent standards for chemotherapy and radiotherapy. The surgical literature and the lack of a time-dependent surgical standard also were discussed, suggesting a possible standard.

RESULTS

Risk factors for delay are numerous, and tumor doubling times are both difficult to determine and unhelpful to assess the impact of longer treatment times on outcomes. Evaluation components also have a time cost and are inextricable from the patient's workup. Although the published literature has lack of uniformity, optimal times to each modality are strongly suggested by emerging data, supporting the current quality measures. Times to surgery, chemotherapy, and radiotherapy all have a measurable impact on outcomes, including disease-free survival, disease-specific survival, and overall survival.

CONCLUSIONS

Delays have less of an impact than often thought but have a measurable impact on outcomes. Optimal times from diagnosis are < 90 days for surgery, < 120 days for chemotherapy, and, where chemotherapy is administered, < 365 days for radiotherapy.

Advanced imaging modalities in early stage breast cancer: preoperative use in the United States Medicare population

BACKGROUND

Guidelines for breast cancer staging exist, but adherence remains unknown. This study evaluates patterns of imaging in early stage breast cancer usually reserved for advanced disease.

METHODS

Surveillance Epidemiology, and End Results data linked to Medicare claims from 1992-2005 were reviewed for stage I/II breast cancer patients. Claims were searched for preoperative performance of computed tomography (CT), positron emission tomography (PET), bone scans, and brain magnetic resonance imaging (MRI) ("advanced imaging").

RESULTS

There were 67,874 stage I/II breast cancer patients; 18.8% (n=12,740) had preoperative advanced imaging. The proportion of patients having CT scans, PET scans, and brain MRI increased from 5.7% to 12.4% (P<0.0001), 0.8% to 3.4% (P<0.0001) and 0.2% to 1.1% (P=0.008), respectively, from 1992 to 2005. Bone scans declined from 20.1% to 10.7% (P<0.0001). "Breast cancer" (174.x) was the only diagnosis code associated with 62.1% of PET scans, 37.7% of bone scans, 24.2% of CT, and 5.1% of brain MRI. One or more symptoms or metastatic site was suggested for 19.6% of bone scans, 13.0% of CT, 13.0% of PET, and 6.2% of brain MRI. Factors associated (P<0.05) with use of all modalities were urban setting, breast MRI and ultrasound. Breast MRI was the strongest predictor (P<0.0001) of bone scan (odds ratio [OR] 1.63, 95% confidence interval [CI] 1.44-1.86), Brain MRI (OR 1.74, 95% CI 1.15-2.63), CT (OR 2.42, 95% CI 2.12-2.76), and PET (OR 5.71, 95% CI 4.52-7.22).

CONCLUSIONS

Aside from bone scans, performance of advanced imaging is increasing in early stage Medicare breast cancer patients, with limited rationale provided by coded diagnoses. In light of existing guidelines and increasing scrutiny about health care costs, greater reinforcement of current indications is warranted.

Physician over-recommendation of mammography for terminally ill women

BACKGROUND

There has been recent, sometimes intense, debate about when to begin screening and how often to screen women for breast cancer with mammography. However, there should be no controversy regarding screening women who are unlikely to benefit from the procedure, such as those with a serious, life-limiting illness who would not live long enough to benefit from the potential detection and treatment of breast cancer. Identifying characteristics of physicians who recommend mammography for terminally ill women can help guide efforts to minimize patient risks and make better use of health care resources.

METHODS

The authors used data from a nationally representative survey of primary care physicians (PCPs) (N = 1196; response rate, 67.5%) conducted in 2006 and 2007 to examine PCPs' breast cancer screening recommendations for hypothetical patients ages 50 years, 65 years, and 80 years who were healthy, had a moderate comorbidity, or had a terminal comorbidity.

RESULTS

Many PCPs (47.7%) reported that they would recommend mammography to a woman aged 50 years, 65 years, or 80 years with terminal lung cancer, indicating over-recommendation. Physician characteristics associated with over-recommending mammography included obstetrician/gynecologist (odds ratio [OR], 1.69) or internal medicine (OR, 0.45) specialty, being a woman (OR, 1.40), being a racial/ethnic minority (OR, 1.72), and working in a smaller practice (OR, 1.41).

CONCLUSIONS

The current results indicated that physician over-recommendation of screening mammography among terminally ill women is common. Certain physician and practice characteristics, including specialty, were associated with over-recommending mammography. The authors concluded that an informed and shared mammography decision-making process for terminally ill women may eliminate unnecessary patient risks and health care expenditures.

Malpractice litigation in patients in relation to delivery of breast care in the NHS

Malpractice litigation involving patients with carcinoma of the breast has been evaluated in United States of America (USA). The extent of litigation in breast cancer has not been published in UK and malpractice claims in relation to overall breast care have not been published before. We sought to study and evaluate all the litigation claims in relation to breast care with the National Health Service Litigation Authority (NHSLA) from May 1995 to September 2005. We also studied changes in litigation claims and outcomes in incidents reported before and after January 1, 2000.

Screening mammography, public perceptions, and medical liability

PURPOSE

To outline the most common sources of raising malpractice claims in screening mammography and to discuss the related medical litigation issues in the light of the evidence-based medicine.

METHODS AND MATERIAL

Electronic and manual search of the relevant literature.

RESULTS

The most common cause of malpractice is the delayed diagnosis of breast cancer. The plaintiff must establish that the radiologist was negligent and the delay in diagnosis caused injury to the patient. Literature shows that mammography does not always detect breast cancer, and even skilled radiologists may periodically miss malignant lesions. Also, delay in diagnosis does not always affect treatment and prognosis. Over-promotion of screening mammography has made disproportionately difficult for a defendant radiologist to prevail in a malpractice lawsuit. Thus, screening mammography is at stake, although it saves lives. The public and legal system should be educated about biological processes, medical practice, and the limitations of screening mammography.

CONCLUSION

If mammography is to survive medical litigation and continue to save lives a major reform in public perception, in the stance of the mass media, and in the ability of legal system to understand medicine is required. Physicians and medical associations have an important role to play.

Trouble in the office: liability issues in ambulatory care

Most clinicians are keenly aware of the liability risks associated with adverse birth outcomes for mother and/or infant. This level of awareness and concern also needs to extend to the day-to-day management of office practice. Clinicians who care for healthy women and their families may see abnormalities infrequently. The low yield of abnormal results means that close monitoring is essential to prevent overlooking the rare abnormal finding. This article focuses on three areas of liability risk for midwives and others who practice in the ambulatory setting: 1) inadequate tracking of test and referral results, 2) failure to diagnose, and 3) poor communication. Although none of these issues are limited to the ambulatory setting, only office practice is addressed in this article.