Physician-Patient Discussion and Take Home Points Related to Breast Patient Safety

Presentation and Screening

Patient-detected Lump/Mass

A self-discovered lump should be followed to resolution even if there is provider-patient discordance on the presence of the lump. Follow every mass to conclusion.

Patient Unsatisfied with a Negative Finding

Engage the patient in a discussion about her breast care management subsequent to negative test/imaging results. Develop a clear and effective plan, and ensure the patient’s understanding and agreement of that plan.

Document all interactions as they occur to support future care and to clarify any disputes that may arise later. This includes:

• in the history and physicals section of the record, include the findings of the breast examination (note—in quotes—what the patient said, as well as your own findings);
• for a confirmed lump or lesion, use a diagram or description to record the exact location and size (if known); and
• for an unconfirmed mass, record—in the patient’s words—the location and nature of the complaint.

Significance of Early Detection of Breast Cancer

Without reliable evidence that early detection of breast cancer can significantly reduce the risk of mortality, health care providers cannot guarantee a cure based on the timing of the diagnosis. Patients may need to be educated as to the rigors and subtleties of research data, and discrepancies in findings among various studies.

Risk of Breast Cancer for Women Younger than Age 30

Be careful not to dismiss patients under age 30, who have an approximately 1 in 2,000 chance of being diagnosed with breast cancer at an early age).¹ Women with multiple risk factors—especially those that indicate a high level of risk and possible BRCA1/BRCA2 gene mutation—should be concerned about the possibility of early breast cancer.

Care Management

Patient Identified as Having Dense Breasts

Offer patients access to information explaining the impact of breast density on their overall breast cancer risk (and on the ability to detect cancer), and the risks and benefits of any follow-up screening options.

• Provide all patients the opportunity for a follow-up discussion (with you or a designee) to ensure that they comprehend their overall breast cancer risk, and the risks and benefits of any follow-up screening options. For some patients, printed/online information may be sufficient.
• Document any decisions reached regarding additional cancer screening due to breast density.

Communication

• Communicate all abnormal findings to the patient and document that act.
• Avoid sending the wrong message to a patient by only telling her that a palpable lump is probably benign. Stress that additional studies may be needed to look for evidence of malignancy.
• Share any uncertainty on your part in a way that helps your patient appreciate the importance of adherence to follow up.
• Confirm and document with other providers which of you will be the clinician of record and responsible for ordering tests and following up with the patient.

Test Results

• Explain to the patient how test results will be communicated to her and (if appropriate) other clinicians.
• Document any telephone conversations with patients regarding the reported results.
• To ensure notification of test results, employ a system to track ordered tests through the receipt and communication to the patient.

Follow Up

• Make follow-up or test appointments before the patient leaves your office.
• Physicians and patients share responsibility for follow up; explain to your patients your tracking and compliance system (contacting patients a day or two before their follow-up appointments can reduce non-adherence).
• Track all surgical referrals to ensure that you are receiving a timely report from the surgeon.
• Ask the Radiology department, breast care center, or specialist to notify your office of patients who do not keep scheduled appointments. Document all patient no-shows or cancellations, including for time-sensitive testing.
• If a patient refuses follow up, explain the risks of not having a recommended diagnostic test or procedure. Note the patient’s refusal for follow up in the record; consider using an informed refusal form signed by the patient.

Documentation

• Document a thorough breast examination in the history and physical examination; enter, in quotes, the patient’s breast complaints and what she says.
• Use a diagram or description to record the exact location and size (if known) of all confirmed lumps or lesions.
• For an unconfirmed mass, record—in the patient’s words—the location and nature of the complaint.
• In the event that a patient’s breast care is being managed by another clinician, document any available information from those visits needed to ensure that subsequent exams are performed when appropriate.
• Update any known changes to the patient’s risk factor assessment and your recommendations for screening based on that patient’s current risk for developing breast cancer.
• Consider using a problem list to highlight patients with a positive family history of breast cancer.

Reference

1 Siegal R, Naishadham D, Jemal A. Cancer statistics, 2012. CA: A Cancer Journal for Clinicians. 2012;62:10–29.