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Material by Professor Omar Hasan Kasule Sr. for discussion at Year 1 Semester 1 Biomed PPSD session on 15th September 2008
Background
Mrs Ali was a 40-year old nurse married and with 7 grown-up children. She had worked on the surgical ward and the major operating theater for the past 15 years. The surgeons always wanted to work with her on major operations like breast removal (mastectomy) because she was so diligent. She was always careful about her health. She had special fear of breast cancer because her mother and 2 elder sisters had died from the disease. She had enrolled in a mammography program and also attended courses on breast self examination. The doctors at the health center advised her to examine her breast regularly. They also advised her to come for breast examination every 5 years. For the next 15 years no anomaly was detected in her breast.
Q1. What is the implication of disease in the mother and sisters?
Discovery of a lump
One morning while changing to put on a theater gown she noticed a lump in her left breast. She had been scheduled for routine mammography the next day. Later at home she palpated it and found it to be hard and non-tender. She was very worried but told nobody about it both at home and at work. The mass grew bigger bit she still refused to do something about it. Eventually her coworkers complained about a foul smell in the theater. She started using very strong perfumes and the complaints ended. She started avoiding sitting with others or even engaging them in conversation. She never entered the theater changing room if someone else was there.
Q2. What is the reason for failure of pre-clinical detection of cancer in this case? Whose fault is it?
Examination by the surgeon
She was eventually forced to see a surgeon because of severe bleeding from the left breast. The surgeon examined the mass and also requested several investigations: mammography, ultrasound, and MRI. She used a needle to aspirate tissue from various parts of the breast and sent it for histological examination. The results were as follows:
Examination | Findings |
Clinical | Solid non-cystic mass |
Mammography | Mass with calcification. No cysts |
Ultrasound of the breast | Results same as mammogram |
MRI | Confirmed mammography and ultrasound findings |
Pathology | Fine needle aspiration (FNA) in one place found non-invasive carcinoma in situ |
The surgeon also carried out a chest x-ray, a bone scan, routine hematology, and routine biochemical investigations and found no abnormality.
The surgeon told her that since she had no pain in the right breast there was no need to examine it.
Q3. What conclusion do you draw from the above information?
Q4. Can you identify medical negligence / malpractice in this case?
Surgery
When told of the diagnosis she refused to accept it and insisted that she had only a breast abscess. ‘I have seen many women operated for breast cancer losing their breasts’ she said. I never thought that I could one day be one of them. I do not want to lose my breast. I do not have cancer’. The surgeon considered referring her to the hospital psychiatrists and social workers but desisted because he thought she would not agree to talk to them. The surgeon stayed in touch with Mrs Ali over the next 6 months but she refused any surgery. Finally the surgeon managed to persuade her to talk to a religious scholar who managed to convince her to accept the diagnosis and later to consent to surgery. The left breast was excised and axillary lymph nodes were removed.
Pathological findings
The histopathological report showed an invasive grade 2 disease with metastases in the axillary lymph nodes.
Q5. Do the pathological findings indicate medical negligence / malpractice? Explain your answer.
Further treatment and prognosis
Mrs Ali consented to radiotherapy to remove remaining disease. She was also put on tomoxifen (adjuvant therapy). The doctor told her that her disease was 100% cured and that she could lead a normal life once again.
Q6. Is it ethical for the surgeon to provide a favorable prognosis to the patient? Does the evidence support the surgeon’s prognosis?
Disease recurrence
After 5 years Mrs Ali felt a mass in the opposite breast that had not been touched at all. Examination showed early stage disease. Disease was also found on the chest wall where the breast had been excised. Evidence of metastases was found in the chest and the bones. Mrs Ali was very angry and prepared to sue the surgeon.
Q7. Does the surgeon have legal liability for a prognosis assessment that turns out to be wrong?
Q8. Is the surgeon legally liable for the recurrence of the disease?