Yes. 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.

Discuss options with your patient and include her in management decisions. Elicit and heed all complaints and investigate abnormal symptoms aggressively. Develop a clear and effective plan and insure 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 versus your own findings.
• Use a diagram or descriptive notes to record the exact location of all lumps or lesions. 

• 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 with the patient in a way that helps them appreciate the importance of follow-up appointments.
• 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.
• Communicate all abnormal findings to the patient and document that act.  

• Make follow-up or test appointments before the patient leaves your office.
• Create a system to recall and track patients who need follow-up. Without a tracking system to ensure that the patient actually returns to the office or for additional testing, a note in the record that a patient needs to be followed is insufficient.
• Contact patients a day or two before their appointments to reduce noncompliance.
• Ask the radiology department or specialist to notify your office of patients who do not keep scheduled appointments.
• Document all patient no-shows or cancellations in the medical record, including for time-sensitive tests.
• Note patient refusals in the record with an explanation that the risks of not having a recommended diagnostic test or procedure were explained. Consider using an informed refusal form signed by the patient.
• Track all surgical referrals to ensure that you are receiving a timely report from the surgeon. 

• Provide pertinent clinical information for the radiologist on the mammography request form.
• Request that all abnormal findings be communicated directly by the radiologist or pathologist to the clinician of record.
• Document telephone conversations regarding the reported results.
• Review and sign all test results before they are filed in the record.
• Create a system to track ordered tests and outside referrals to ensure notification of test results and referral outcomes.
• Request written copies of all results, including those conveyed orally. 

• Document a thorough breast examination in the history and physical examination; enter, in quotes, the patients breast complaints and what she says.
• Use a diagram (or descriptive notes) to record the exact location of all lesions.
• In the event that a patient's breast care is being managed by another clinician, document the date of the patient’s last exam 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 their current risk for developing breast cancer.
• Consider using a problem list to highlight patients with a positive family history of breast cancer.

• All patients share similar risk.
• Younger women with breast complaints are not at potential risk for developing breast cancer.
• Patients will volunteer to update personal and family histories without prompting.
• All tests will be performed as requested.
• All tests will be adequately interpreted.
• Laboratory personnel and specialists will always relay relevant findings directly to the primary care provider (PCP) or patients.
• Negative imaging in the picture of a breast mass, lump, or thickening is the end of a workup.
• Visits to specialists are always conducted as requested.
• Patients always understand the varying roles of the PCP, the Radiology staff, and breast specialists.
• The specialist will adequately coordinate the diagnostic care and communication with the patient around need for follow-up. 

Not all patients with dense breasts necessarily need an MRI. Patients with dense breast tissue and no other risk factors may not meet criteria for breast MRI. Studies indicate that low-risk patients with dense breast tissue may benefit from digital 3D tomosynthesis mammography. More information on risk stratification can be found at breast.massrad.org

Yes, about three percent of colon cancer cases occur in patients younger than 40. The risk is increased for individuals under age 40 with a positive family history of colon cancer or polyposis syndromes. Regardless of the patient's age, low risk does not mean no risk. Do not simply dismiss complaints or symptoms because of a patient's age, lack of family history, or other non-clinical factors.

Yes. A patient of any age who presents with rectal bleeding requires a discussion of his or her risk factors including a family or personal history of colon cancer or polyps or a personal history of inflammatory bowel disease (Crohn's disease or ulcerative colitis). In addition, some form of visualization of the colon such as flexible sigmoidoscopy should be performed for those less than 40 years of age with no family history of colon cancer or polyps to look for a source of bleeding. A colonoscopy should be recommended to patients less than 40 years of age with rectal bleeding and a family history or personal history of colon cancer or polyps to exclude a colon cancer or polyp as the cause.

No. Screening for colorectal cancer can detect cancer in its early stages, as well as pre-cancerous growths. Treatment of colorectal cancer at an early stage has a high success rate, but detection and treatment do not guarantee a cure.

Depending on the mode of colon visualization, whether colonoscopy, virtual colonoscopy, barium enema, or flexible sigmoidoscopy, patients being screened for colorectal cancer are exposed to some risks from the oral cathartic preparations, including: nausea, vomiting, weakness, dizziness, severe diarrhea, acute renal failure (secondary to the dehydration and/or acute phosphate nephropathy). For colonoscopy, there are additional risks, including adverse reactions to the sedative and/or analgesia , perforation of the bowel (approximately 1 patient in 1000 procedures), and excessive bleeding from any polypectomy site (1–2 patients per 100 procedures). Risk factors for immediate post-polypectomy bleeding include age over 65 years, anticoagulant use, co-morbid cardiovascular and chronic renal disease, polyp size larger than 1 centimeter, and poor bowel preparation.

First, confirm that the bowel cleanout was adequate and that the visualization procedure was successfully completed by noting that the colonoscopist reached the cecum and documented this fact. If the preparation was poor and/or the cecum was not completely visualized, recommend a repeat colonoscopy within a short interval of time (several weeks).

Even if the preparation was excellent and the base of the cecum was reached, the recognized miss rate in the recent colonoscopy literature is four percent for right-sided cancers, and up to 10 percent for adenomas larger than 1 centimeter. Therefore, for patients dissatisfied with an adequate colonoscopy (by report), a reasonable course of action is to recommend a repeat colonoscopy within a relatively short interval (1–6 months) to view the colon again. Alternatively, a virtual colonoscopy or barium enema with no sedation could be done to view the colon and try to find a possible missed lesion. Discuss the risks and benefits of these options to further exclude colon cancer or polyps as a cause of the patient's symptoms or signs.

Develop a clear and effective plan and insure 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 physical section of the record, include the findings of the examination. Note—in quotes—what the patient said versus your own findings.
• Use descriptive notes to record the exact details of the complaints.
• Record rationale when deviating from any of the suggested guidelines and state the alternative approach to be taken and why. Communicate that to the patient.

Avoid sending the wrong message to patients by just telling them that their symptoms are probably benign. Stress that additional studies may be needed to rule out malignancy.

• Share any uncertainty with the patient in a way that helps them appreciate the importance of compliance with follow-up recommendations.
• Confirm and document with other providers which of you will be the clinician of record and responsible for coordinating the patient's care.
• Make sure that the patient has been fully informed as to which provider will be coordinating his/her care going forward.
• Communicate all abnormal findings to the patient and document that act.

Make an effort to schedule follow-up or test appointments before the patient leaves your office.

• Create a system to recall and track patients who need follow-up. Without a tracking system to ensure that the patient actually returns to the office or for the ordered testing, a note in the record that a patient needs to be followed is insufficient.
• Contact patients a day or two before the appointment to reduce noncompliance.
• Ask the specialist to notify your office of patients who do not keep scheduled appointments.
• Document all patient no-shows or cancellations in the medical record and consider additional efforts if a missed appointment would jeopardize patient care.
• Note patient refusals in the record with an explanation that the risks of not having a recommended diagnostic test or procedure were explained. Consider using an informed refusal form signed by the patient.
• Track all referrals to ensure that you are receiving a timely report from the specialist.

Provide pertinent clinical information for the gastroenterologist/specialist request form.

• Request that all abnormal findings be communicated directly by the specialist to the clinician of record.
• Document telephone conversations regarding the reported results.
• Review and sign all test results before they are filed in the record.
• Create a system to track ordered tests and outside referrals to ensure notification of test results and referral outcomes.
• Request written copies of all results, including those conveyed orally.

Document a thorough history and physical examination; enter—in quotes—the patient's complaints and what you understand was being reported.

All patients share similar risk.

Non-alignment of expectations between provider and patient can complicate the care process and be a trigger for complaints following a poor outcome. To avoid this, clinicians should be careful to:

• Clarify for the patient what the role of the primary care provider (PCP) entails in order to calibrate patient expectations.
• Use probing style questions to elicit relevant patient information.
• Consider other mechanisms to elicit patient information in preparation for the office visit by providing self-administered questionnaires via mail or in the office while waiting to be seen. Review responses directly with the patient at beginning of the visit and clarify information as needed.
• Use diagrams and illustrations to highlight a patient's complaint or abnormal finding discovered by the PCP as part of the physical examination.
• Establish mechanisms (personal tickler system or office-wide systems) to track patients through the diagnostic process.
• Communicate all test results directly to the patient (both normal and abnormal) and outline the follow-up plan explicitly.
• Document all test results, communications with specialists, and follow-up plans as described to the patient.
• Record follow-up plans to be instituted and the expected timeline for completion.
• Communicate to the patient the follow-up plans to be instituted and the expected timeline for completion and by whom.
• Record rationale when deviating from any of the suggested guidelines and state the alternative approach to be taken and why. Communicate that to the patient.

Despite much publicity and education of the public in the United States as to the efficacy of colorectal cancer screening in decreasing mortality from colorectal cancer, only 40-50 percent of eligible, average risk patients (i.e., over age 50) have been screened for colorectal cancer at the present time. The reasons for the poor compliance with recommendations are unclear, but some of the lack of screening may relate to the uncertainty as to the best and most cost-effective screening modality. The question as to which modality is most effective in detecting cancers, and the most cost effective screening strategy, has been looked at by several groups via computer-generated models. Each of these studies has indicated that colonoscopy, flexible sigmoidoscopy, and annual fecal occult blood testing are all cost-effective in terms of cost per life (years saved from death by colon cancer compared with no screening). In terms of timing, computer modeling studies have suggested that a colonoscopy every 10 years, particularly at ages 50 and 60 years, is the most cost-effective strategy for primary screening for colorectal cancer.

An editorial by David Lieberman, MD, in the December 2005 American Journal of Gastroenterology added a new dimension of complexity to the timing of screening of asymptomatic, average-risk populations by pointing out differences in race (African American populations have a higher rate of colon cancers occurring at a younger age) and gender (women may have a lower risk in their 50s compared with men; they also appear to have fewer cancers picked up on sigmoidoscopy than men). These new data may indicate that PCPs should consider starting their colon cancer screening for average-risk African American patients at age 45 instead of age 50. In addition, PCPs may wish to recognize that flexible sigmoidoscopy may not be a good choice for screening women over age 50 who appear to have more proximal rather than distal neoplasia (i.e., within the reach of the flexible sigmoidoscope) compared to men of the same age.

* Lieberman D. Race, gender, and colorectal cancer screening American Journal of Gastroenterology. 2005;100:2756–58.

Elicit the patient's ideas about his/her refusal and any preferences for how your concerns should be approached. Consider asking the patient the following questions:

• Do you have an interest in being screened for any potential health risk?
• Is there something particular about colorectal cancer screening that concerns you?
• If indications of colorectal cancer were detected, would you want to be treated?
• Do you understand that, if you do contract colorectal cancer, your options for treatment—and your life expectancy—may be diminished by your refusal to undergo screening?
• Would you like to discuss this issue with another provider?
• Document any question you discuss with the patient and his/her responses.

Dr. Marc Garnick is the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and founder of the Hershey Family Foundation for Prostate Cancer Research at BIDMC. His recommendation is based on having performed thousands of DREs:

I prefer having patients assume a left lateral decubitus position. This allows excellent visualization of the perianal area and anal area and allows elevation of the right gluteal muscle to allow easier insertion of the gloved examining finger. For patients who have difficulty getting into this position (due to arthritis or other mobility issues), I have the patient assume a standing position over the edge of the examining table, have his hands placed on the table for stability, and perform the exam in that fashion. This is more uncomfortable for the clinician, however, and does not allow the same visualization of the anal and perianal area.