It wasn't there before.
It was new.
It didn't move.
It was small.
Not a big deal.
It will go away, she thought.
Days later, it didn't.
It was still there.
There were no discolorations.
There was no fluid coming from it.
It wasn't painful.
She remembered something her gynecologist had told her years earlier.
If you find something, make an appointment and come in.
Let us look at it.
She was young.
Only 23 years old.
There's no way this could be significant.
There's just no way this could be cancer, she thought.
She's way too young for that.
She had no family history of breast cancer.
That's got nothing to do with her.
She made an appointment with her gynecologist.
The earliest appointment was a few weeks away.
She agrees to this appointment.
She can feel it.
It is more pronounced.
It's in one specific location.
It's in the 12 o'clock position toward the top of her breast.
It doesn't go away.
She's hoping this is sort of like an ingrown pimple.
Maybe it's infected hair follicle.
She tells her when it started.
She tells her how she found it.
She tells her that it's still there and seems to have grown a little bit.
Her gynecologist nods her head in acknowledgment.
She does a breast exam.
She does it while the patient is sitting up.
She checks both breasts.
She can feel the lump.
The patient is correct.
The lump does not move.
She then has the patient lay down to examine her breasts in this position.
Again, she examines both breasts.
She needs to have a number of tests done it immediately.
She needs an ultrasound of her breast.
A breast sonogram.
She needs a mammogram for both breasts.
Everything the gynecologist did up to this point was proper.
These are the appropriate steps to take when presented with a new breast lump.
This diagnostic imaging will help the gynecologist and a breast surgeon evaluates what this lump is.
The biggest concern obviously is that this might be cancer.
On the other hand, this could simply be a cyst.
It could be benign.
It could be nothing.
Doctors have to assume that it is cancerous until proven otherwise.
She takes that slip and makes an immediate appointment.
She feels comfortable knowing that her doctor now has a plan of action.
At the radiology facility she presents her referral slip and has the breast sonogram.
The technician performing the test comments on how young she is and how unlikely it is that she has breast cancer.
She's 23 years old.
She has a palpable breast lump in her breast at the 12 o'clock position.
This breast lump has not gone away or gotten smaller over the past few weeks.
Her gynecologist wants her to have a breast ultrasound as well as a mammogram to evaluate the lump.
She tells the patient that she spoke to her supervisor who tells her that she does not need to have a mammogram performed.
The sonogram looks 'fine' according to the technician.
The sono tech tells the patient that she spoke to the radiologist who said her sonogram looks 'fine'.
The nursing supervisor comes in to reassure the patient that she's fine and does not need to have a mammogram because the findings on sonogram show everything is fine and that she is too young to worry about having breast cancer.
A sono tech is never to communicate to the patient her impression of the test results.
That's for a trained radiologist to do.
Even then, the radiologist doesn't talk to the patient directly.
Instead, the radiologist sends her findings directly to the doctor who referred the patient.
Here, we have a sono tech that reassured the patient everything was fine.
That was miscommunication #1.
Then we have a nursing supervisor who tells the patient that she's too young to have breast cancer.
That was miscommunication #2.
That was miscommunication #3.
Each of these communication errors gave the patient a false sense of security that everything was fine.
In fact, it wasn't.
In fact, the radiologist failed to follow office protocol.
However, the patient didn't know that at the time.
A radiologist who is faced with a young patient with a breast lump, a palpable lump, who has a sonogram and it's interpreted as 'normal', has an obligation to personally examine and physically examine the patient. The radiologist has an obligation to redo the breast sonogram personally.
This radiologist failed to do this.
So now the patient is reassured that everything is okay.
The technician told her the ultrasound was normal.
The nursing supervisor told her that she was too young to have breast cancer.
The sono technician advised the patient that the radiologist looked at the ultrasound and felt that everything was okay.
Remember I mentioned earlier that the gynecologist wanted the patient to be seen and evaluated by a breast surgeon?
"What happened to that?" you ask.
She tried to make an appointment.
With the breast surgeon recommended by her gynecologist.
She couldn't find a breast surgeon that took her insurance.
She was getting frustrated.
Finally, she realized there was no point having a breast surgeon evaluate her condition since the radiology facility and their employees reassured her that her breast lump was nothing to worry about.
Now, keep in mind that the patient was told to follow up with her gynecologist to get the radiology results.
When she called the gyn's office, she was told that her doctor was out on maternity leave.
"If you like, you can see the other doctor in the practice," the receptionist said.
He was a man.
She didn't want to see a male gynecologist.
She was calling with the results of the breast sonogram.
The nurse confirmed what the radiology technician said.
The nurse confirmed what the nursing supervisor had told her that the breast lump was normal.
This gyn nurse was simply reading the radiology report and telling the patient what she already knew.
Relaying information that was inaccurate.
Communication error #5: The nurse from the gyn office she never inquired whether she had gone for a breast surgery evaluation.
Remember, her gynecologist wanted her to be evaluated by a breast surgeon.
For good reason.
At this point, she still had not seen any breast surgeon.
Communication error #6: The gyn nurse never asked the patient why she had not returned to the gynecologist's office for follow-up.
These communication errors, individually and collectively, led the patient to believe that there was absolutely nothing wrong with her and her breast lump.
It simply reassured her that this was benign and nothing to worry about.
This breast cancer went undetected for over a year.
Growing and spreading without ever being diagnosed and treated.
All because of a series of miscommunications by health care professionals.
The patient's own treating physicians later confirmed that had her breast cancer been diagnosed at the time when she first complained about it to her gynecologist, it would have been in the earliest stage of breast cancer known as stage I.
That would have prevented the spread of breast cancer into her lymphatic system and prevented if from spreading throughout her body.
Instead, these medical errors and miscommunications led this woman to wrongly believe that everything was fine, when in fact it wasn't.
More than a year went by.
She had ignored the lump.
She just lived with it.
It didn't get bigger.
It didn't get smaller.
It was just there.
One day the patient notices that the lump in her breast appears to be larger than it had in the past.
It's still in the 12 o'clock position.
Over the next few days, she notices it has grown.
It is still fixed in the same position.
She's told her gynecologist is still on maternity leave.
She's asked if she wants to see her partner, the male doctor.
She does not want to see the male gynecologist.
She feels uncomfortable seeing a man.
Her appointment is a few weeks away.
"She's waited this long, what's another few weeks," she says to herself.
When meeting her new gynecologist, she gives a history.
She explains about how she learned of her lump, what tests her gynecologist wanted done and what the radiology center told her.
She returned back to the same radiology center to have a new breast sonogram done.
This time, the results were not good.
She is told that in all likelihood she has breast cancer.
She is immediately seen by a breast surgeon who performed a biopsy.
Based upon the length of time that the lump existed together with its current size, the breast surgeon is not hopeful.
He creates a plan of treatment that includes a double mastectomy and extensive chemotherapy.
This all must be done immediately.
A week later she has a double mastectomy.
Both breasts are removed.
Remember, she's only 23 years old.
The pathology results are not good.
It has spread.
It is now stage IIIB breast cancer.
Her prognosis is not good.
Especially for a young woman like her.
Her breast surgeon cannot understand how the nursing supervisor and the technician told her that it was unlikely she had any breast cancer because of her young age.
This was outrageous!
This was improper!
Our medical experts, a board-certified breast surgeon and a board certified radiologist specializing in reading and interpreting breast sonograms and mammograms, could not understand how the radiologist who read and interpreted the original breast sonogram did not perform a physical examination on this patient.
Years later, during this lawsuit, I had an opportunity to question the radiologist who read and interpreted the original breast sonogram.
I questioned her under oath.
In her attorney's office.
This was pretrial testimony.
There was no judge present.
There was no jury present.
Just her attorney.
Just the court reporter.
The four of us sitting at a conference room table.
It was my chance to find out what happened.
It was my chance to learn what she did and didn't do.
It was my chance to learn what the standard of care was for this radiologist.
I needed her to explain, in her own words, what the standard of care was.
I got her to establish the standard of care.
She confirmed she should have personally examined this breast lump.
She confirmed she should have repeated the breast sonogram.
She confirmed that she did not repeat the breast sonogram.
I got her to admit, reluctantly, that failing to perform a physical exam in this specific situation was a clear violation from the basic standards of good radiological care.
I also got her to admit that failing to repeat the breast sonogram was also a clear violation from the basic standards of good radiological care.
You should know that during the course of this lawsuit, the defense tried to claim they were not totally to blame here.
The defense argued that the patient failed to follow up with a breast surgeon despite being told to do so by her gynecologist.
This was true.
The patient never followed up with a breast surgeon.
That was a big problem for us.
Because the defense correctly argued that this patient may have caused or contributed to her delay in diagnosing her condition.
If she had seen a breast surgeon when she was supposed to, in all likelihood, her breast cancer would have been diagnosed and treated.
It would not have progressed beyond Stage I at that time.
We felt we had a good reason why the patient didn't go to the breast surgeon.
Would a jury understand why the patient had been reassured?
Would the jury understand that she felt a breast surgery evaluation was really needed since she'd been fully reassured that her breast lumpt wasn't cancerous.
This was worrisome.
Yet, I still felt we had a stronger argument than the defense did on this point.
A series of miscommunications led to a significant delay in diagnosing this patient's breast cancer.
Might the patient be partially at fault?
Then again, maybe not.