Guideline for managing breast lumps
Can J Surg 1999;42:151
© 1999 Canadian Medical Association
In response to: J.F. Gately; E.B. Fish
I and my colleagues wish to reassure Dr. Gately that this guideline is consistent with those that already exist.1 We have adapted it to the perspective of a primary care physician and focused it to manage any medicolegal concerns related to a delayed diagnosis of breast cancer.2
Even if there are no clinical findings or the woman's breast cyst disappears on aspiration, our 45-year-old patient should have mammography as part of her complete assessment.1 If the mammogram is normal, as expected, it automatically becomes the baseline for a regular biannual mammographic screening program. For the purpose of simplicity, we chose to recommend it as such, rather than as part of the diagnostic evaluation. Whether the next mammogram should be obtained in 2 years, as recommended by the National Cancer Institute,3 or in 5 years, as recommended by most world authorities, including the National Cancer Institute of Canada,4 is debatable.
Our 45-year-old woman thought she had a palpable lump and was informed and concerned enough to report to her family physician for an examination. Like most Canadian women, she likely obtained her information from media sources originating in the United States, which promote mammographic screening beginning at 40 years of age. In view of her obvious concern about her personal breast health, in our view it was prudent to offer, for her consideration, access to biannual mammography at age 47 years instead of 50 years.
Dr. Fish refers to the fact that most consultant surgeons will aspirate cells from a solid breast lump and send them for cytologic examination. They are well aware of the delays and errors that sometimes occur in the process. At the same time they have the opportunity to arrange for excisional biopsy, which will be necessary to establish an unequivocal diagnosis.
From the standpoint of the family practitioner, however, for whom this guideline was prepared, I and my colleagues believe it is much simpler, easier and safer to refer the patient immediately and directly to a surgeon.
Delay in diagnosis of breast cancer has become a worrisome cause of medicolegal litigation for both surgeons and family practitioners.2 By immediate referral, as recommended in our guideline, the family physician can avoid any such stressful experience.
Leo Mahoney, BA, MD, MS
Department of Surgery
University of Toronto
Toronto, Ont.
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References
- Clinical practice guidelines for the care and treatment of breast cancer. CMAJ 1998;158(Suppl 3):S3-4.
- Osuch JR, Bonham VL. The timely diagnosis of breast cancer. Principles of risk management for primary care practitioners and surgeons. Cancer 1994;74(1 Suppl):271-8.
- National Institutes of Health Consensus Conference on Breast Cancer Screening for Women Ages 4049. Proceedings. Bethesda, Maryland. January 21-23, 1997 [review]. J Natl Cancer Inst Monogr 1997;(22):vii-xviii, 1-156.
- Morrison BJ. Screening for breast cancer. In: Canadian Task Force on the Periodic Health Examination. Canadian guide to clinical preventive health care. Ottawa: Health Canada; 1994. p. 788-95.
