Journal of General Internal Medicine

, Volume 24, Issue 6, pp 702–709 | Cite as

Process of Care Failures in Breast Cancer Diagnosis

  • Saul N. WeingartEmail author
  • Mark G. Saadeh
  • Brett Simchowitz
  • Tejal K. Gandhi
  • Larissa Nekhlyudov
  • David M. Studdert
  • Ann Louise Puopolo
  • Lawrence N. Shulman
Original Article



Process of care failures may contribute to diagnostic errors in breast cancer care.


To identify patient- and provider-related process of care failures in breast cancer screening and follow-up in a non-claims-based cohort.


Retrospective chart review of a cohort of patients referred to two Boston cancer centers with new breast cancer diagnoses between January 1, 1999 and December 31, 2004.


We identified 2,275 women who reported ≥90 days between symptom onset and breast cancer diagnosis or presentation with at least stage II disease. We then selected the 340 (14.9%) whose physicians shared an electronic medical record. We excluded 238 subjects whose records were insufficient for review, yielding a final cohort of 102 patients.




We tabulated the number and types of process of care failures and examined risk factors using bivariate analyses and multivariable Poisson regression.


Twenty-six of 102 patients experienced ≥1 process of care failure. The most common failures occurred when physicians failed to perform an adequate physical examination, when patients failed to seek care, and when diagnostic or laboratory tests were ordered but patients failed to complete them. Failures were attributed in similar numbers to provider- and patient-related factors (n = 30 vs. n = 25, respectively). Process of care failures were more likely when the patient’s primary care physician was male (IRR 2.8, 95% CI 1.2 to 6.5) and when the patient was non-white (IRR 2.8, 95% CI 1.4 to 5.7).


Process failures were common in this patient cohort, with both clinicians and patients contributing to breakdowns in the diagnostic process.


breast cancer diagnostic errors medical errors quality of health care 



Funding for this project was provided by a grant from the Risk Management Foundation of the Harvard Medical Institutions.

Conflict of interest

None disclosed.


  1. 1.
    Schaefer M. Overview of CRICO cancer-related diagnosis claims 1992–2001. RMF Forum. 2002;22:4–9.Google Scholar
  2. 2.
    Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006;145:488–96.PubMedGoogle Scholar
  3. 3.
    Richards MA, Westcombe AM, Love SB, Littlejohns P, Ramirez AJ. Influence of delay on survival in patients with breast cancer: a systematic review. Lancet. 1999;353:1119–26.PubMedCrossRefGoogle Scholar
  4. 4.
    Phillips RL Jr, Bartholomew LA, Dovey SM, Fryer GE Jr, Miyoshi TJ, Green LA. Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Health Care. 2004;13:121–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Chandra A, Nundy S, Seabury SA. The growth of physician medical malpractice payments: evidence from the national practitioner data bank. Health Aff (Millwood). 2005;Suppl Web Exclusives: W5-40–W5-49.Google Scholar
  6. 6.
    Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from four liability insurers. Ann Emerg Med. 2007;49:196–205.PubMedCrossRefGoogle Scholar
  7. 7.
    Rogers SO Jr, Gawande AA, Kwaan M, et al. Analysis of surgical errors in closed malpractice claims at four liability insurers. Surgery. 2006;140:25–33.PubMedCrossRefGoogle Scholar
  8. 8.
    Studdert DM, Thomas EJ, Burstin HR, Zbar BI, Orav EJ, Brennan TA. Negligent care and malpractice claiming behavior in Utah and Colorado. Med Care. 2000;38:250–60.PubMedCrossRefGoogle Scholar
  9. 9.
    Burstin HR, Johnson WG, Lipsitz SR, Brennan TA. Do the poor sue more? A case-control study of malpractice claims and socioeconomic status. JAMA. 1993;270:1697–701.PubMedCrossRefGoogle Scholar
  10. 10.
    Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261–71.PubMedCrossRefGoogle Scholar
  11. 11.
    Kreuter MW, Strecher VJ, Harris R, Kobrin SC, Skinner CS. Are patients of women physicians screened more aggressively? J Gen Intern Med. 1995;10:119–25.PubMedCrossRefGoogle Scholar
  12. 12.
    Lurie N, Slater J, McGovern P, Ekstrum J, Quam L, Margolis K. Preventative care for women—does the sex of the physician matter? N Engl J Med. 1993;329:478–82.PubMedCrossRefGoogle Scholar
  13. 13.
    Lurie N, Margolis KL, McGovern PG, Mink PJ, Slater JS. Why do patients of female physicians have higher rates of breast and cervical cancer screening? J Gen Intern Med. 1997;12:34–43.PubMedCrossRefGoogle Scholar
  14. 14.
    Kösters JP, Gøtzsche PC. Regular self-examination or clinical examination for early detection of breast cancer. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD003373. doi: 10.1002/14651858.CD003373.
  15. 15.
    Weinmann S, Taplin SH, Gilbert J, et al. Characteristics of women refusing follow-up for tests or symptoms suggestive of breast cancer. J Natl Cancer Inst. 2005;35:33–8.Google Scholar
  16. 16.
    Remennick L. The challenge of early breast cancer detection among immigrant and minority women in multicultural societies. Breast J. 2006;12:103–10.CrossRefGoogle Scholar
  17. 17.
    Gorin SS, Heck JE, Cheng B, Smith SJ. Delays in breast cancer diagnosis and treatment by racial/ethnic group. Arch Intern Med. 2006;166:2244–52.PubMedCrossRefGoogle Scholar
  18. 18.
    Taplin SH, Ichikawa L, Yood Mu, Manos MM, Geiger AM, Weinmann S, et al. Reason for late-stage breast cancer: absence of screening or detection, or breakdown in follow-up? J Natl Cancer Inst. 2004;96:1518–27.PubMedCrossRefGoogle Scholar
  19. 19.
    Halliday T, Taira DA, Davis J, Chan H. Socioeconomic disparities in breast cancer screening in Hawaii. Prev Chronic Dis. 2007;4:1–9.Google Scholar
  20. 20.
    Ives DG, Lave JR, Traven ND, Schulz R, Kuller LH. Mammography and pap smear use by older rural women. Public Health Rep. 1996;111:244–50.PubMedGoogle Scholar
  21. 21.
    Centers for Disease Control and Prevention. Use of mammography services by women aged ≥65 years in Medicare—United States, 1991–1993. MMWR Morb Mortal Wkly Rep. 1995;44:777–81.Google Scholar
  22. 22.
    Wells K, Roetzheim RG. Health disparities in receipt of screening mammography in Latinas: a critical review of recent literature. Cancer Control. 2007;14:369–79.PubMedGoogle Scholar
  23. 23.
    Kaplan CP, Crane LA, Stewart S, Juarez-Reyes M. Factors affecting follow-up among low-income women with breast abnormalities. J Womens Health. 2004;13:195–206.CrossRefGoogle Scholar
  24. 24.
    Caplan LS, May DS, Richardson LC. Time to diagnosis and treatment of breast cancer: results from the National Breast and Cervical Cancer Early Detection Program, 1991–1995. Am J Public Health. 2000;90:130–4.PubMedCrossRefGoogle Scholar
  25. 25.
    Tartter P, Pace D, Frost M, Bernstein JL. Delay in diagnosis of breast cancer. Ann Surg. 1999;229:91–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Sainsbury R, Johnston C, Haward B. Effect on survival of delays in referral of patients with breast-cancer symptoms: a retrospective analysis. Lancet. 1999;353:1132–35.PubMedCrossRefGoogle Scholar
  27. 27.
    Hardin C, Pommier S, Pommier RF. The relationships among clinician delay of diagnosis of breast cancer and tumor size, nodal status, and stage. Am J Surg. 2006;192:506–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Afzelius P, Zedeler K, Sommer H, Mouridsen HT, Blichert-Toft M. Patient’s and doctor’s delay in primary breast cancer: Prognostic implications. Acta Oncol. 1994;334:345–51.PubMedCrossRefGoogle Scholar
  29. 29.
    Arndt V, Sturmer T, Stegmaier C, Ziegler H, Dhom G, Brenner H. Patient delay and stage of diagnosis among breast cancer patients in Germany—a population-based study. Br J Cancer. 2002;86:1034–40.PubMedCrossRefGoogle Scholar
  30. 30.
    Hanna D, Griswold P, Leape LL, Bates DW. Communicating critical test results: safe practice recommendations. Jt Comm J Qual Patient Saf. 2005;31:68–80.PubMedGoogle Scholar
  31. 31.
    Ell K, Vourlekis B, Lee PJ, Xie B. Patient navigation and case management following an abnormal mammogram: a randomized clinical trial. Prev Med. 2007;44:26–33.PubMedCrossRefGoogle Scholar
  32. 32.
    Heyding RK, Cheung AM, Mocarski EJ, Moineddin R, Hwang SW. A community-based intervention to increase screening mammography among disadvantaged women at an inner-city drop-in center. Women Health. 2005;41:21–31.PubMedCrossRefGoogle Scholar
  33. 33.
    Localio AR, Lawthers AG, Brennan TA, Laird NM, Hebert LE, Peterson LM, Newhouse JP, Weiler PC, Hiatt HH. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991;325:245–51.PubMedGoogle Scholar
  34. 34.
    Brennan TA, Localio AR, Leape LL, et al. Identification of adverse events occurring during hospitalization. A cross-sectional study of litigation, quality assurance, and medical records at two teaching hospitals. Ann Intern Med. 1990;112:221–6.PubMedGoogle Scholar
  35. 35.
    Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377–84.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • Saul N. Weingart
    • 1
    • 2
    Email author
  • Mark G. Saadeh
    • 1
  • Brett Simchowitz
    • 1
  • Tejal K. Gandhi
    • 2
    • 3
  • Larissa Nekhlyudov
    • 2
    • 4
    • 5
  • David M. Studdert
    • 6
  • Ann Louise Puopolo
    • 7
  • Lawrence N. Shulman
    • 1
    • 2
  1. 1.Center for Patient SafetyDana-Farber Cancer InstituteBostonUSA
  2. 2.Harvard Medical SchoolBostonUSA
  3. 3.Division of General Internal MedicineBrigham and Women’s HospitalBostonUSA
  4. 4.Department of Ambulatory Care and PreventionHarvard Medical SchoolBostonUSA
  5. 5.Harvard Vanguard Medical AssociatesBostonUSA
  6. 6.Melbourne Law SchoolUniversity of MelbourneMelbourneAustralia
  7. 7.Risk Management Foundation of the Harvard Medical InstitutionsBostonUSA

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