Case 4 - Olivia Good

Chapter: Case 4
Screening

Olivia Good is a 50 year old female shop worker. She leads a very healthy lifestyle with a diet rich in fruit and vegetables and enjoys playing tennis. She had eczema as a child but grew out of it and both her parents are still alive in their 80s. She is currently taking no prescribed medication, only a daily over-the-counter multivitamin tablet. Having recently turned 50, she receives an invitation to attend for a mammogram for breast cancer screening.

Open Question: In general, what are the requirements of a successful screening programme? Not answered. Feedback: Disease being screened for is an important health problem Detectable latent/early symptomatic stage Good screening test cheap, quick, acceptable, reliable and valid Facilities available for diagnosis and treatment Cost of programme considered in context of resource demands i.e. opportunity costs Agreed policy on whom to treat as a patient Does treatment confer benefit?

Multiple Choice Question: Which of the following cancers are screened for in Northern Ireland? (More than one answer may be correct) Possible answers: 1. Breast cancer [Correct] 2. Cervical cancer [Correct] 3. Colon cancer [Correct] 4. Thyroid cancer [Incorrect] 5. Uterine cancer [Incorrect] Not answered.

Two key aspects of a screening test are the sensitivity and the specificity.

Open Question: Define a sensitive test and a specific test. Not answered. Feedback: A sensitive test has the ability to detect the disease when it is present therefore a sensitive test has few false negatives. A specific test has the ability to detect the absence of disease in healthy individuals therefore a specific test has few false positives.

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Image caption: A new screening test has been devised for condition X

Open Question: Calculate the sensitivity and specificity for the above example. Not answered. Feedback: Sensitivity = true positives/(true positives + false negatives) = 15/(15+5) Specificity = true negatives/(true negatives + false positives) = 150/(150+30) 83% 75%

Teacher's Comment: Two other important properties of screening test are the positive and negative predicitive values. Positive predictive value (PPV) - proportion of individuals who test positive who have the condition i.e. PPV=true positives/(true positives + false positives) Negative predictive value (NPV) - proportion of individuals who test negative who do not have the condition i.e. NPV = true negatives/(true negatives + false negatives)

Mammography

Mrs Good is due to go for her mammogram, and comes to see you, the locum GP, for advice.

Open Question: What is a mammogram? Not answered. Feedback: An X-ray of breast tissue Usually 2 images cranio-caudal and oblique

Mrs Good is unsure as to what the mammogram will involve.

Open Question: Explain to Mrs Good what the mammogram will involve. Not answered. Feedback: Visit will last approx 30 mins She will be given a gown and asked to undress from the waist up Each breast is placed between 2 plates in the X-ray machine Will be mildly uncomfortable but it will be brief Mammogram is then examined by a radiologist If normal (95%) recalled via letter in 3 years If there is a concern, invited to attend breast assessment clinic

Mrs Good attends for her mammogram. The mammogram shows microcalcification within the breast which warrants further investigation. She therefore receives a letter asking her to attend the breast assessment clinic.

At the clinic

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Mrs Good is referred to the breast assessment clinic, where you also work.

Multiple Choice Question: Which of the following are components of the triple assessment? (More than one answer may be correct) Possible answers: 1. Clinical examination [Correct] 2. Pathology [Correct] 3. Quality of life (QOL) questionnaire [Incorrect] 4. Radiology [Correct] 5. Tumour markers [Incorrect] Not answered.

Open Question: What breast symptoms might you ask about? Not answered. Feedback: Lump duration, changes in size, cyclical v constant, pain Skin changes over breast Nipple discharge Pain

Teacher's Comment: At this point, review/look up examination of the breast.

Multiple Choice Question: For younger women, what is the preferred imaging modality? Possible answers: 1. CT [Incorrect] 2. Mammogram [Incorrect] 3. MRI [Incorrect] 4. PET [Incorrect] 5. US [Correct] Not answered.

A sample can be taken by either fine needle aspirate (FNA) or core biopsy (CB).

Open Question: What are the differences between the two in terms of The type of sample taken? The time taken for results to be issued? Not answered. Feedback: The type of sample taken FNA cells are taken, smeared on slide and stained CB core of tissue removed and processed The time taken for results to be issued

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 FNA 10-15 mins CB 24 hours

Open Question: What features suggest malignancy on a fine needle aspirate? Not answered. Feedback: Large nuclei with variation in shape and size (pleomorphism) Loss of normal cohesion between cells Absence of normal myoepithelial cells (bipolar bare nuclei)

Results

24 hours later, the results from the core biopsy are ready. The image on the left shows the core biopsy result and the image on the right shows normal breast tissue at a different magnification.

Histological examination shows breast ducts expanded by a solid cellular proliferation of epithelial cells associatd with calcification. There is no invasion.

Multiple Choice Question: Which of the following pathologies is in keeping with the above information? Possible answers: 1. Acute inflammation [Incorrect] 2. Ductal carcinoma in situ [Correct] 3. Granulomatous inflammation [Incorrect] 4. Invasive ductal carcinoma [Incorrect] 5. Invasive lobular carcinoma [Incorrect] Not answered.

Open Question: List 2 other anatomical sites of malignancy in situ.

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Not answered. Feedback: Squamous carcinoma in situ/Bowens disease (skin) Malignant melanoma in situ/lentigo maligna (skin) Cervical carcinoma in situ [equivalent to CIN grade III] Carcinoma in situ of the bladder

Open Question: Compare and contrast ductal carcinoma in situ (DCIS) and in situ lobular neoplasia (ISLN) [formerly known as LCIS] in terms of: Presentation Site Risk of invasion Not answered. Feedback: Presentation DCIS calcification on mammogram (or lump rare) ISLN incidental finding on biopsy Site DCIS unilateral ISLN bilateral Risk of invasion DCIS significant risk of invasion ISLN lower risk of invasion but both breasts are at risk

Mrs Good receives the diagnosis from the surgeon. She explains the procedure to remove the region of DCIS, and arranges a slot on her operating list.

Worries

Mrs Good is anxious about her forthcoming surgery.

Open Question: Explain why patients might be anxious about admission to hospital. Not answered. Feedback: Lack of information about the diagnosis may be real or perceived Lack of information about the treatment Unfamiliar nature of the environment Loss of autonomy and control over their own activities Concern about dependents e.g. children/elderly relatives (especially for female patients)

Open Question: How can patients be psychologically prepared to reduce their anxiety? Not answered. Feedback: Provide information about procedure what it involves, how they will feel afterwards ... Behavioural instructions inform patient what to do before and after surgery, especially what to do after the procedure to improve healing and reduce pain Autonomy allow patients choice about date/time if appropriate or give recovery exercises that they can choose when to do Discuss their worries and allow them to ask questions Cognitive coping focus on the long-term benefits of the procedure Allow patient to discuss problems with a patient who has experienced the procedure

Open Question: Give 2 differences between males and females with regard to hospital anxiety.

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Not answered. Feedback: Females Benefit from expressing emotion and sharing with other patients Main care givers worried about children/elderly relatives More concerned about procedure leading to a change in physical appearance e.g. mastectomy Males Dont talk about symptoms or share with other patients More concerned about procedure leading to a deterioration in physical function

It's complicated

Mrs Good undergoes the excision of the abnormal area. She is kept under observation until that evening and is then discharged with an upcoming outpatient appointment. 6 days later, Mrs Good presents to her GP with redness around the wound. It is swollen and tender, with some pus.

Open Question: What is the most likely diagnosis? Not answered. Feedback: Surgical site infection

Multiple Choice Question: What type of operation was the breast surgery? Possible answers: 1. Clean [Correct] 2. Clean-contaminated [Incorrect] 3. Contaminated [Incorrect] 4. Dirty [Incorrect] Not answered.

Multiple Choice Question: What type of organism is most likely the cause in this case? Possible answers: 1. Anaerobes [Incorrect] 2. Coliforms [Incorrect] 3. Enterobacter [Incorrect] 4. Staph. aureus [Correct] 5. Strep. viridans [Incorrect] Not answered.

Open Question: What is the management of this infection? Not answered. Feedback: Swab wound and send sample of pus if available

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 Open and drain wound - if appropriate Empirically treat with flucloxacillin (if non-penicillin allergic) and consult microbiology

Further results

Her infection improves and Mrs Good attends her appointment for discussion of her pathology report.

Open Question: What are the clinical implications of this report? Not answered. Feedback: As several of the surgical margins are involved by DCIS, the patient will require a second operation, possibly a mastectomy.

In contrast to the previous pathology report, the following is an example of a standard pathology report template that is normally used for patients with invasive breast cancer.

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At the start of the report, two fields to complete are the hospital number and NHS number (known more commonly as the Health and Care Number in N. Ireland).

Open Question: What is the difference between a hospital number and a Health and Care Number? Not answered. Feedback: Any given patient could have multiple hospital numbers, as they attend for appointments at various different hospitals. The Health and Care number on the other hand is a 10 digit number that is unique to each individual. Use of the Health and Care number reduces the risk of medical information from patients with similar names and date of births being mixed up.

Open Question: What is the signficance of a tumour being

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 Oestrogen receptor +ve? Her2 receptor +ve? Not answered. Feedback: Oestrogen receptor +ve tumours will benefit from Tamoxifen/aromatase inhibitors Her2 receptor +ve tumours will benefit from treatment with Herceptin

Open Question: Why are axillary nodes removed in patients with invasive breast cancer but not with DCIS? Not answered. Feedback: By definition, as DCIS is non-invasive, there is no possibilty of tumour spreading to local lymph nodes, whereas in invasive cancer, there is this risk and either the sentinel node or all the axillary nodes are removed.

CPC 4

Teacher's Comment: A key skill in medicine is being able to summarise and present a case to a colleague in a concise and precise manner. Prior to the CPC try to summarise this case in 4-5 sentences. It would be useful to revise the following topics, which will be explored in more detail at the CPC. Wound healing Invasive and in situ cancer Laboratory handling of surgical specimens

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Assessment Summary
Case 4 Open Question: In general, what are the requirements of a successful screening programme? Answered Not answered Multiple Choice Question: Which of the following cancers are screened for in Northern Ireland? (More than one answer may be correct) Answered Not answered Correctness Retries 0 Score 0/1

Open Question: Define a sensitive test and a specific test. Answered Not answered Open Question: Calculate the sensitivity and specificity for the above example. Answered Not answered Open Question: What is a mammogram? Answered Not answered Open Question: Explain to Mrs Good what the mammogram will involve. Answered Not answered Multiple Choice Question: Which of the following are components of the triple assessment? (More than one answer may be correct) Answered Not answered Correctness Retries 0 Score 0/1

Open Question: What breast symptoms might you ask about? Answered Not answered Multiple Choice Question: For younger women, what is the preferred imaging modality? Answered Not answered Correctness Retries 0 Score 0/1

Open Question: What are the differences between the two in terms of The type of sample taken? The time taken for results to be issued? Answered Not answered Open Question: What features suggest malignancy on a fine needle aspirate?

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Answered Not answered Multiple Choice Question: Which of the following pathologies is in keeping with the above information? Answered Not answered Correctness Retries 0 Score 0/1

Open Question: List 2 other anatomical sites of malignancy in situ. Answered Not answered Open Question: Compare and contrast ductal carcinoma in situ (DCIS) and in situ lobular neoplasia (ISLN) [formerly known as LCIS] in terms of: Presentation Site Risk of invasion Answered Not answered Open Question: Explain why patients might be anxious about admission to hospital. Answered Not answered Open Question: How can patients be psychologically prepared to reduce their anxiety? Answered Not answered Open Question: Give 2 differences between males and females with regard to hospital anxiety. Answered Not answered Open Question: What is the most likely diagnosis? Answered Not answered Multiple Choice Question: What type of operation was the breast surgery? Answered Not answered Correctness Retries 0 Score 0/1

Multiple Choice Question: What type of organism is most likely the cause in this case? Answered Not answered Correctness Retries 0 Score 0/1

Open Question: What is the management of this infection? Answered Not answered Open Question: What are the clinical implications of this report? Answered Not answered

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Open Question: What is the difference between a hospital number and a Health and Care Number? Answered Not answered Open Question: What is the signficance of a tumour being Oestrogen receptor +ve? Her2 receptor +ve? Answered Not answered Open Question: Why are axillary nodes removed in patients with invasive breast cancer but not with DCIS? Answered Not answered

Total score: 0 / 6 (0%)

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