Medical and legal implications of screening and follow-up procedures for breast cancer

Abstract

Grievances result from false expectations on the part of both practitioners and patients when a disease treatment problem is unsolved because of biological variations in the disease itself. Widely publicized screening and follow-up recommendations are often the source of the grievances. Even when recommendations are followed exactly, bad outcomes are still associated with incurable cancer even though a fatal outcome is inevitable. Patients must be told about treatment prospects including limitations of efficacy, so that patient expectations will be realistic. Otherwise, practitioners may find themselves involved in lawsuits alleging deviation from case standards for an adverse outcome actually attributable to the nature of the cancer. Because screening and follow-up techniques continue to control treatment of breast cancer, such lawsuits are common. When ineffective treatment exists, there often are adverse harm/benefit considerations and high costs, particularly when screening or follow-up are practiced defensively, without hard data proving the value of a strategy. This article will review these problems, placing specific emphases on screening and follow-up procedures and on strategies for breast cancer. Factors that limit efficacy and increase both cost and diagnosis-associated morbidity will also be explored.

Popularity of less frequent follow up for breast cancer in randomised study: initial findings from the hotline study

“…Despite these doubts routine follow up continues to be the norm, with many physicians assuming that patients are reassured by frequent contact with their oncologist 8. This view is not universal, however, as evidenced by wide disparities in follow up practice on both sides of the Atlantic9 10 11; disparities that have been attributed to defensive perceptions by physicians unsure as to the efficacy of treatment and monitoring 12 13. For these reasons many authorities have lately acknowledged the need for a prospective randomised study to determine the benefits of the tradition of routine follow up 14 15 16 17…”

Patient, physician and presentational influences on clinical decision making for breast cancer: results from a factorial experiment*

“…In another study using written vignettes, younger physicians tended to recommend more aggressive treatment such as chemotherapy, compared to their older colleagues, who were more likely to recommend that their patients participate in clinical trials (Belanger et Physician attitudes, values and beliefs have also been hypothesized to influence behaviour (Eisenberg 1985; Mogielnicki et al 1991). For example, physicians' attitudes towards malpractice may influence breast cancer care given the increasing number of lawsuits involving the diagnosis and management of breast cancer (Spratt & Spratt 1990) and previous research demonstrating that threats of malpractice have a negative impact on physicians' practice (Smith et aL 1989). Even physician personality has been shown to relate to some types of medical practice behaviour.…”

Comparisons of Strategies to Prevent Breast Cancer Mortality

“…Preventive practice in general is not insulated from these pressures, as the case of breast cancer screening illustrates. Failure to "reasonably" interpret a mammogram that results in delayed diagnosis of cancer can be considered a "proximate cause of injury" and subject to the law of medical negligence (Brenner, 1990;Spratt & Spratt, 1990). Additionally, as screening technologies have undergone rapid improvement in recent years-both with respect to imaging techniques and their interpretation-community norms of practice, the standards by which physician performance is judged, have experienced equally rapid change (Brenner, 1990).…”