Optimal Management of Primary Breast Cancer

▪  Abstract: The diagnosis and treatment of breast cancer have changed in response to not only new technologies but also cultural and social aspects of the disease. While breast-conserving surgery and adjuvant therapy are the preferred treatments for many breast cancers, neoadjuvant therapy is often used in advanced disease. In this review we examine the treatment options that are influenced by pathologic and clinical factors. Invasive breast cancer is a potentially curable disease if it is regarded and managed by a multidisciplinary approach from the outset.  ▪     

MCF-10AT: A Model for Human Breast Cancer Development

▪   Abstract: A number of lesions, collectively termed Proliferative Breast Disease (PBD), have been associated with high risk of developing breast cancer. Understanding of the natural history of PBD and its relationship to breast cancer progression has been hampered by the lack of an experimental model. MCF-10AT cells are of human, breast epithelial cell origin. They grow as xenografts in immune-incompetent mice where they produce normal-appearing ducts, atypical hyperplasia, carcinoma-in-situ, and invasive carcinoma. Estrogen supplementation of the mice accelerates development of cancer. The MCF-10AT model of PBD offers a new approach to the study of early breast cancer progression and its prevention.  ▪     

The Value of Fine Needle Aspiration Cytology in Breast Fibromatosis: Study of Two New Cases and Review of the Literature

▪ Abstract: We report two new cases of breast fibromatosis studied by needle aspiration cytology observed in a 32-year-old man and a 49-year-old woman. The lesions manifested as palpable, painless, and firm masses of the para-areolar breast soft tissues. Preoperative fine needle cytology revealed scant cellularity, featuring oval and spindle cells with bland nuclei and occasional larger polygonal cells with high nuclear:cytoplasmic ratio. Histologically, interwoven fascicles of spindle cells with bland nuclei, infiltrating the adjacent breast fat, were recognized. Based on available reports in the literature, we concluded that needle aspiration cytology, although not entirely specific, may be a source of important information in patients with breast fibromatosis. In particular, it confidently allows the exclusion of breast cancer and other more common diseases and is useful in planning a surgical approach to the lesion. ▪     

Imaging and Management of Breast Masses During Pregnancy and Lactation

▪ Abstract: Detection and management of breast abnormalities that develop during pregnancy and lactation is difficult for both the clinician and the radiologist. This article reviews the hormonal and physiologic effects on the breast during pregnancy and lactation. Breast masses that occur in pregnant or lactating patients, including pregnancy-associated breast cancer, are discussed and the corresponding ultrasound and mammographic findings are presented. Finally, a rationale for the imaging evaluation and management of the pregnant or lactating patient with a breast mass are presented. ▪     

Clear Cell Ovarian Carcinoma Following Long-Term Tamoxifen Use

▪ Abstract: A case of clear cell ovarian cancer and endometriosis in a postmenopausal patient following adjuvant tamoxifen for breast cancer is presented. Immunohistochemistry demonstrated the tumor to be positive for progesterone receptor protein but not estrogen receptor protein; the endometriosis was positive for both proteins. Literature review reveals this to be the first report of both clear cell ovarian cancer and endometriosis following tamoxifen use, and the third report of epithelial ovarian cancer associated with tamoxifen.  ▪     

The Use of Argon Beam Coagulation in the Management of Bleeding from an Ulcerated Breast Lesion

▪ Abstract: Skin ulceration is an uncommon, but serious manifestation of locally advanced breast cancer. When the ulcerations present with bleeding, they can be particularly difficult to treat. Cautery often fails because the electrode adheres to the skin and rebleeding begins when the instrument is pulled away. We present a case in which argon beam coagulation was used to achieve hemostasis in a bleeding breast ulceration. ▪     

Multidisciplinary Management of Locally Advanced Breast Cancer

▪ Abstract: The treatment of locally advanced breast cancer is aimed at achieving long-term local control with local surgery and/or radiation therapy and at improving disease-free and overall survival through the application of systemic cytotoxic chemotherapy and hormonal therapy. Studies of local therapy alone with surgery or radiotherapy have demonstrated high rates of local recurrence and low rates of long-term survival. The application of anthracycline-based neoadjuvant chemotherapy has resulted in rates of response ranging from 72% to 97%, clinical complete responses of 12–52%, and pathologic complete responses of 4–33%. Multidisciplinary treatment with neoadjuvant therapy, followed by local surgery and/or radiation therapy, followed by additional chemotherapy, has resulted in rates of local control that exceed 80%, and 5-year survival rates exceeding 50% are not unusual. The use of anthracycline-based neoadjuvant chemotherapy in the treatment of locally advanced breast cancer is thus now firmly established. Research in the treatment of locally advanced breast cancer is needed to further define the optimal method of local therapy and the role of new agents such as the taxanes. ▪     

Medical malpractice and anesthesiology: literature review and role of the expert witness

PURPOSE: To provide a narrative review of the physician experience of medical malpractice litigation applied to an anesthesiology case with particular emphasis on the role played by medical expert witnesses. SOURCES: Literature searches were conducted of English-language medical publications published between 1996 - 2006 using both Medline and Pubmed databases. Key words included: "medical malpractice"; "medical malpractice litigation"; "medical expert witness"; "expert witness liability", "expert witness bias"; "hindsight bias"; and "outcome bias". PRINCIPAL FINDINGS: Patient injury resulting from medical care is common but most injured patients do not sue. Implicit review of medical files is biased to an important degree by the occurrence of severe injury; care is more often deemed substandard when the resulting injury is severe. Expert analysis of medical mal-occurrences is influenced by both hindsight and outcome bias. Compensation for those who do sue is influenced by the severity of injury and the degree of disability. The activity of experts is not commonly subject to review by peers, professional groups or licensing authorities. CONCLUSIONS: The legal process for resolving patient claims against physicians is well delineated and transparent; its operational features are complex and prejudiced by severe outcomes. Bias is pervasive in the analysis of medical occurrences and may result in findings against caregivers which are unfair.     

Delay in the clinical diagnosis of breast cancer: estimating its effect on prognosis, with particular reference to medical litigation

Medical malpractice litigation is increasing. Delay in diagnosis is the commonest basis for litigation involving the treatment of breast cancer. When delay in diagnosis has occurred, any losses for which a plaintiff seeks compensation require estimates to be made of any change in prognosis over the period of the delay relative to the extent of disease found when treatment is finally undertaken. We have examined the natural history of breast cancer and have attempted to provide evidence-based quantitative guidelines for the evaluation of the losses which may be claimed in malpractice cases.     

Delay in diagnosis of breast cancer.

OBJECTIVES: To assess the consequences of physician delay in the diagnosis of breast cancer by comparing stage, treatment, and outcome of patients with and without delay, and to identify patient characteristics that may make diagnosis more difficult. SUMMARY BACKGROUND INFORMATION: Delay in diagnosis of breast cancer is the most common clinical scenario resulting in malpractice litigation. METHODS: The records of 1014 patients were reviewed and the events preceding the diagnosis were reconstructed. Accurate assessment of the physician delay in diagnosis could be made for 606 patients, 51 (8%) with physician delay >3 months. Patients with delay were comparable to patients without delay in terms of age, height, weight, age at menarche, pregnancies, children, proportion in menopause, age at menopause, and family history of breast cancer. RESULTS: Thirty-six percent of patients who had a delay in diagnosis had normal mammograms versus 7% of patients without delay. Cancers in patients with delay were significantly larger on average than in those without delay, but there were no significant differences in pathology, differentiation, nodal status, TNM stage, treatment, or outcome. CONCLUSIONS: Physician delay in the diagnosis of breast cancer is common, and patients with delay are similar to patients without delay, although they are more likely to have normal mammograms. The consequences of physician delay in terms of stage at diagnosis, treatment, and outcome were not statistically significant.     

Uncovering Malpractice in Appendectomies: a Review of 234 Cases

Background

General surgery is a “high-risk specialty” with respect to medical malpractice rates, and appendicitis is one of the most common diagnoses encountered by practitioners. Our objectives were to detail issues affecting malpractice litigation regarding appendicitis and appendectomies, including outcomes, awards, alleged causes of malpractice, and other factors instrumental in determining legal responsibility and increasing patient safety.

Study Design

Publically available federal and state court records were examined for pertinent jury verdict and settlement reports. Information from 234 pertinent cases was collected, including alleged causes of malpractice and outcomes.

Results

Of the 234 cases included in this study, the most common factor noted was an alleged delay in diagnosis (67.1 %), followed by intraoperative negligence (16.2 %). Alleged deficits in informed consent, although only specifically cited as a cause of malpractice in 1.3 % of cases, were found to be an important aspect of many cases. In total, 59.8 % of cases were ruled in favor of the physician, 23.7 % in favor of the plaintiff, and 5.5 % reached a settlement. The average plaintiff award was US$794,152, and the average settlement award was US$1,434,286.

Conclusion

An important strategy to decrease liability in a physician's practice is prompt evaluation of an appendicitis patient. An integral part of this is efficient communication between physicians practicing a wide variety of specialties, especially including practitioners in emergency medicine and general surgery. Additionally, completing a thorough informed consent explaining all aspects of the procedure including the factors we outline will not only increase patient awareness of potential risks but also protect the physician in the face of litigation.     

Detection and Significance of Occult Axillary Metastatic Disease in Breast Cancer Patients

▪ Abstract: After clinical staging, the single most important prognostic factor for patients with newly diagnosed primary breast cancer is the presence or absence of detectable metastases to axillary lymph nodes when examined by conventional light microscopy. More sensitive methods of determination of lymph node status, such as evaluation of serial sections, immunohistochemical staining, and use of molecular biological assays increase the rate of detection of micrometastases. Although the feasibility of enhanced detection of occult axillary metastatic disease is well established, the prognostic significance of such detection is only recently starting to emerge. Furthermore, the enormous recent interest in the application of sentinel lymph node biopsy as an alternative to the evaluation of the entire axilla in patients with breast cancer makes the first-time detailed evaluation for micrometastases practically feasible. In this review the different methods of detecting micrometastatic disease in the axilla and the significance of such findings are discussed. ▪     

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.     

Measuring Physicians' Performances and Marketing the RESULTS: A Breast Cancer Model

▪ Abstract: The recent transition to managed care has intensified the public's concerns about the quality of medical care. In response, payers, who until recently seemed preoccupied with costs, are demonstrating a renewed interest in value, which in turn could lead to an expansion of negotiations with physicians to include the tracking of such issues as physician performance, patient satisfaction, and patient outcomes. As a response to public concern and demand for accountability, the medical establishment must develop methods to assist payers in estimating relative value of competing medical services. In anticipation of a values transition in their specialty, breast care, the authors established a performance-oriented database which facilitated assessments of their performance in relation to community standards, and enhanced efforts to identify and correct performance deficiencies. Year-end results were summarized in a report-card format that improved marketability. The author's experiences should be of interest to physicians who are attempting to respond to changes in the rapidly evolving medical marketplace.  ▪     

Breast Cancer: Unique Communication Challenges and Strategies to Address them

Abstract:  Women with breast cancer have become increasingly more involved on a national and local level in advocating for resources to fight cancer. However, in the context of the relationship with their physicians and other cancer caregivers, much remains to be done in providing them with adequate support. In this paper, we highlight the difficulties in communication related to breast cancer and describe strategies and approaches that may be helpful in improving the communication throughout the cancer trajectory. Specifically, breast cancer patients have high unmet information needs relevant to health information and dissatisfaction with the actual information they receive from their providers. These needs seem even more pronounced when patients are older, of lower socio-economic class and from differing cultural backgrounds which may affect their ability to express their desires for information and desire to be involved in decision-making about their treatment. Other communication challenges can be envisioned as occurring at key points across the cancer trajectory: diagnosis disclosure, treatment failure, transition to palliative care, and end of life discussions. These involve techniques as basic as how to establish trust and rapport and determine a patient's information and decision-making preferences and as complex as giving bad news. These strategies are now viewed as essential skills in that they can affect patient distress and quality of life, satisfaction, and malpractice litigation as well as practitioner stress and burnout.     

Medicolegal analysis of 100 malpractice claims against bariatric surgeons.

BACKGROUND: Very few studies have addressed malpractice litigation specific to bariatric surgery. This study was designed to analyze litigation trends in bariatric surgery to prevent further lawsuits and improve patient care. METHODS: A total of 100 consecutive bariatric lawsuits were reviewed by a consortium of experienced bariatric surgeons and an attorney specializing in medical malpractice. RESULTS: Of the 100 lawsuits, 45% were reviewed for defense attorneys. The mean patient age was 40 years (range 18-65), 75% were women, 81% had a body mass index of <60, 31% were diabetic, and 38% had sleep apnea. Of the surgeons, 42% had <1 year of experience, and 26% had done <100 cases. Although 69% of the physicians were members of the American Society of Bariatric Surgery, only 22% had detailed consent forms. The surgical procedures were performed between 1997 and 2005 and included Roux-en-Y gastric bypass (78% total, 33% open, and 45% laparoscopic), vertical banded gastroplasty (3%), minigastric bypass (6%), biliopancreatic diversion/duodenal switch (4%), and revision (9%). Of the 100 cases, 32% involved an intraoperative complication and 72% required additional surgery. The most common adverse events initiating litigation were leaks (53%), intra-abdominal abscess (33%), bowel obstruction (18%), major airway events (10%), organ injury (10%), and pulmonary embolism (8%). From these injuries, 53 patients died, 28% had a full recovery, 12% had a minor disability, and 7% had major disabilities. Evidence of potential negligence was found in 28% of cases. Of these cases, 82% resulted from a delay in diagnosis and 64% from misinterpreted vital signs. CONCLUSIONS: This study found that leaks and delayed diagnosis were the most common cause of litigation. Even experienced bariatric surgeons should understand the most common errors made by others to prevent complications and avoid litigation.     

Lawsuits against plastic surgeons: Does locale affect incidence of claims?

BACKGROUND:

Physicians continue to practice in a very litigious environment. Some physicians try to mitigate their exposure to lawsuits by avoiding geographical locations known for their high incidence of medical malpractice claims. Not only are certain areas of the United States known to have a higher incidence of litigation, but it is also assumed that certain areas of the hospital incur a greater liability. There seems to be a medicolegal dogma suggesting a higher percentage of malpractice claims coming from patients seen in the emergency room (ER), as well as higher settlements for ER claims.

OBJECTIVE:

To determine if there is any validity to the dogma that a higher percentage of malpractice claims arise from the ER.

METHODS:

An analysis of common plastic surgery consults that result in malpractice claims was performed. The location where the basis for the lawsuit arose – the ER, office (clinic) or the operating room (OR) – was evaluated. The value of the indemnity paid and whether its value increased or decreased based on the location of the misadventure was evaluated.

RESULTS:

According to the data, which represented 60% of American physicians, there was a larger absolute number of malpractice claims arising from the OR, not the ER. However, the highest average indemnity was paid for cases involving amputations when the misadventure originated in the ER.

CONCLUSIONS:

The dogma that a greater percentage of lawsuits come from incidents arising in the ER is not supported. However, depending on the patient’s injury and diagnosis, a lawsuit from the ER can be more costly than one from the OR.     

Orthopedic medical malpractice: an attorney's perspective

Orthopedic surgeons are trained to manage problems involving the musculoskeletal system. It would be helpful to identify certain procedures, anatomic areas, or issues related to the physician-patient relationship that could potentially lead to a malpractice lawsuit. Once the problems are identified, steps toward continuing education and physician awareness could be initiated. In this study, we performed a randomized nationwide survey of medical malpractice attorneys to evoke their opinion on these issues. We found that the lumbar spine was the most common anatomic area involved in orthopedic medical malpractice cases, and a physician appearing rushed and uninterested is most likely to be the subject of a lawsuit where a poor physician-patient relationship was a contributing factor. Educational and professional programs are needed to increase the awareness and knowledge of orthopedic malpractice risks, and also to identify potentially preventable problems leading to malpractice litigation.     

An overview of medical malpractice litigation and the perceived crisis

In this overview of medical malpractice litigation in the United States, practical and philosophic aspects of the so-called malpractice litigation crisis are addressed. After reviewing the historical, legal rationale for compensating victims of negligent conduct by others, attention is focused on the plight of physicians who are charged with medical negligence and the oppressive insurance premiums that impose a heavy burden on all health care providers, particularly those in the surgical fields. A variety of political solutions advanced to "correct" the problem is reviewed. A historical prospective of malpractice litigation in the United States is presented together with an analysis of various legislative proposals--many of which have already been enacted in various states that will ostensibly "cure" the problems that concern clinicians. Consideration of the various legislative proposals includes: arbitrary limits on pain and suffering awards (caps); elimination of joint and several liability; regulation of attorneys fees; elimination of the collateral source rule; abrogation of punitive damages; proposals for periodic payments; and statutes of repose. Various procedural changes in the processing of malpractice claims are reviewed and analyzed from the perspective of both fairness and efficacy.     

Radiation and Local Control in Early Invasive Breast Cancer

▪ Abstract: Local control in the breast after breast-conserving surgery and radiation for the treatment of early invasive breast carcinoma has long been viewed as important to the patient to avoid later need for mastectomy. Now several studies support the hypothesis that local control is related to and impacts upon a patient's survival as well. The factors that predict for local control with this treatment are reviewed. The recent studies that support the link between local breast failure and distant disease are also discussed. ▪