Delay in diagnosis of breast cancer: Fact, fiction, or lawyer's folly?

National Cumulative Data Sharing Reports¹ during the time period January 1, 1985 to June 30, 1998 from the Physician Insurers Association of America, included information data on 157,892 malpractice claims. The data demonstrated that breast cancer ranks as the second most prevalent and second most expensive condition in malpractice claims against physicians. A total of 3,371 cases were reported, with payment being made on 1281 of these cases that were closed. The total indemnity for the breast cancer-related cases was over $265,000,000, with the average indemnity payment being $207,528. This data obviously establish that the diagnosis and treatment of breast cancer is an area of medicine in which a great potential for malpractice claims exists. This area has been explored somewhat in the medical literature of the 1990s.^2-6 However, the impact of delay and whether, and how, it affects outcome depends on a thorough knowledge and understanding of all phases of delay in the diagnosis of breast cancer and its associated biases. Many phases of delay in the treatment of breast cancer have been identified. The interval between the time of first symptoms to the first issued medical consultation is classified as "delay by the patient." The period from the first presentation to definitive treatment is classified as "provider delay." Provider delay may also be further divided into the period from first consultation to referral and the period from referral to treatment. Lead-time bias may affect all phases of delay and occurs when the survival period is measured from the date of diagnosis rather than from the presentation of the first symptom. It may be a source of confusion when one is trying to relate delay as it affects outcome or survival. Two of the three reviewed studies show marked contrast in their findings. Sainsbury et al found that increasing delay by provider did not impact negatively on outcome. In their article, patients treated with the shortest delay seemed to do worse. These findings conflict with Richards et al, who conclude that longer patient and provider delay produce worse survival. The contrast in these reports may be caused by several factors, including lead-time bias, under-reporting of delay by patients, rapid progression of disease leading to earlier presentation of the patient to the physician, and subsequent earlier, perhaps, diagnosis and aggressive treatment.⁷ Although most reports that investigate diagnostic delay and its impact on clinical outcome seem to be contradictory, the inconsistency of these studies may be because of the lack of considering all phases of delay and its accompanying bias when trying to determine the cause and effect of the situation. It is also possible that one needs to take into account, in addition to delay and bias, tumor biology, growth patterns, and the possibility of micrometastatic disease. However, common sense and good medical practice probably dictate that the public should be educated as much as possible about the symptoms and signs of breast cancer, the need for self-breast examination and screening mammography, and to seek physician consultation at the earliest possible moment. It is then important for the physician to assess the patient's signs, symptoms, test evidence, and as quickly as possible diagnose the condition of the patient and begin treatment.