Report from NCBC: Multiple forces shape breast imaging standard of care

March 1, 2005

Conventional wisdom holds that radiologists who adhere to the standard of care in breast imaging should have no fear of malpractice charges. But standard of care is a moving target, shaped by both formal guidelines and informal adoption of new technologies.

Conventional wisdom holds that radiologists who adhere to the standard of care in breast imaging should have no fear of malpractice charges. But standard of care is a moving target, shaped by both formal guidelines and informal adoption of new technologies.

The classic definition of standard of care - what a reasonable and prudent physician would do under similar circumstances - still holds true, said Dr. R. James Brenner, chief of breast imaging at the University of California, Los Angeles Eisenberg Keefer Breast Center in Santa Monica. He spoke Monday at the National Consortium of Breast Centers annual meeting in Las Vegas.

How an expert witness will interpret that standard, however, depends on a number of statutes, guidelines, common law decisions, and preferred modes of care, Brenner said.

Statutory guidelines such as the Mammography Quality Standards Act are uncontestable. Professional guidelines such as those developed by the American College of Radiology are not standards, but they are often cited during malpractice suits as benchmarks of care. Standards of care are also emerging from common law decisions made at the appellate court level.

More influential, and potentially more dangerous, are standards that evolve from preferred methods of care, or adoption of new cutting-edge technologies. Examples include dose dense chemotherapy, sentinel node biopsy, and accelerated partial breast irradiation.

"Regarding accelerated partial breast irradiation, it's one thing to say, 'This is a treatment that is acceptable and reasonable,' and another to say it's the standard of care. That's going too far," Brenner said.

Use of MR imaging for staging breast cancer in newly diagnosed patients is another example. While MRI can be extremely helpful, it can also create problems, he said.

"Sometimes we'll get an MRI and call it 'Pandora's breast' because so many things light up," he said. "The fact that in select cases many will use it doesn't mean that it is applicable across the board as a standard of care in every patient diagnosed with breast cancer."

When it comes to establishing negligence in a breast cancer case, Brenner cautioned expert witnesses to distinguish between preferred care and standard of care. And for radiologists seeking to avoid malpractice claims, he advised strict adherence to statutory guidelines such as the MQSA. Most important are timely reporting and communication of results.

"Communicating results may be as important as the diagnosis itself," he said. "We attend these meetings trying to learn how to do a better job in positioning patients, consulting, and interpreting. It's not necessarily what you know but how you apply what you know in the clinical arena that influences whether you end up in court."