Breaking Bad News OSCE - New Cancer Diagnosis

Case Overview

• Age/Sex: 48-year-old female
• Occupation: Office worker (administrative assistant)
• Setting: Outpatient breast clinic — here for results
• Chief complaint: "I'm here for the test results"

Patient Script

Who I Am

I'm 48, I work full time in an office, and I live with my partner and two teenage children.

What Brings Me In

I've been asked to come back today for the results of the tests they took on my breast.

My Story

About two months ago I noticed a small lump in my right breast in the upper outer area when I was getting dressed. It was painless and I thought it might be nothing, but it hasn't gone away. I saw my GP six weeks ago, who arranged a mammogram and ultrasound three weeks ago, and they did a biopsy one week ago. I was told to come back today for the results.

The lump feels like a firm bit of tissue, roughly the size of a grape when I touch it. I haven't had any redness, fever, or obvious skin changes apart from the lump. I did bruise the same breast after bumping into a cabinet three weeks ago at home — that left a small bruise which has mostly faded, but it made me worry more about the lump. I've also been trying to lose a few kilos and have lost about 4 kg over the last month on a new diet, so I wasn't sure if that was related.

My Medical Background

• Past medical history: mild asthma as a teenager; had mastitis while breastfeeding in my 20s (resolved)
• Medications: occasional salbutamol inhaler, sertraline 50 mg daily for anxiety
• Allergies: penicillin (rash)
• Social: drinks about 5 units of alcohol per week; used to smoke socially but stopped 10 years ago; lives with partner; works full time
• Reproductive: two children, breastfed both; periods are irregular recently (perimenopausal), last period about 2 months ago
• Family history: an aunt (mother's sister) had breast cancer in her 60s

What I Think & Worry About

• I worry this could be cancer — that’s my biggest fear.
• I’m worried about how this would affect my job and my ability to look after my kids.
• I want to know what the tests mean and what the next steps will be.

If You Ask Me About Other Symptoms...

• Nipple discharge: none
• Breast pain: the lump itself is not painful, occasional tenderness after bumping it
• Skin over lump: no obvious dimpling or redness now
• Systemic: no fevers, no night sweats, no new cough, no bone pain
• Weight/appetite: lost weight deliberately (about 4 kg) on a new diet
• Sleep/mood: anxious and having trouble sleeping some nights
• Medications/complementary remedies: using an over-the-counter topical cream for hot flushes (nothing else)

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Clinical Summary

Examination

• Vital signs: HR 82 bpm, BP 128/76 mmHg, RR 14/min, Temp 36.7 °C
• General: alert, mildly anxious, well-nourished (BMI 27 kg/m2)
• Right breast: palpable firm, irregular mass in the upper outer quadrant ~2.3–2.5 cm, non-tender, slight tethering to surrounding tissue on deep palpation
• Left breast: no palpable masses
• Axillae: one palpable right axillary node ~1.2 cm, mobile but firm; no supraclavicular nodes
• Skin/nipple: no ulceration, no spontaneous nipple discharge

Investigations

• Mammogram (right): spiculated radiopaque mass in the upper outer quadrant measuring ~2.4 cm (suspicious for malignancy)
• Ultrasound (right breast): solid hypoechoic lesion 2.3 cm with irregular margins; right axillary ultrasound: one abnormal node 1.1 cm with cortical thickening
• Core needle biopsy (right breast mass): invasive ductal carcinoma, Nottingham grade 2 (moderately differentiated)
• Biopsy immunohistochemistry: ER 90% positive, PR 20% positive, HER2 immunohistochemistry 0 (HER2 negative); Ki-67 approximately 20%
• Ultrasound-guided FNA/core of axillary node: performed/planned (if done: cytology suspicious for metastatic carcinoma) — recommend confirmatory tissue sampling
• Baseline bloods: CBC: Hb 13.1 g/dL, WCC 6.4 x10^9/L, Platelets 250 x10^9/L
• LFTs: within normal limits (ALT 22 U/L, ALP 78 U/L)
• Staging (initial): chest X-ray clear; CT chest/abdomen/pelvis or bone scan pending if node positive/staging required

Diagnosis

• Primary: Invasive ductal carcinoma (right breast), ER-positive, PR-positive, HER2-negative; clinically consistent with cT2 (2–5 cm) and probable ipsilateral nodal involvement → provisional stage cT2N1M0.

  • Evidence: firm, irregular 2.3–2.5 cm mass on exam and imaging; core biopsy confirming invasive ductal carcinoma; ipsilateral abnormal axillary node on exam and ultrasound.

• Important differentials considered and reasoning:

  • Fibroadenoma: usually in younger patients, typically smooth and mobile; imaging and biopsy contradict this.
  • Simple breast cyst: would appear cystic on ultrasound and biopsy would not show invasive carcinoma.
  • Fat necrosis / traumatic scar: history of minor trauma is a red herring; imaging and histology indicate malignancy, not fat necrosis.
  • Mastitis/abscess: usually painful, erythematous, febrile — patient has none of these systemic features.

Management

• Immediate/practical steps:

  • Deliver results clearly and empathetically; allow time for questions and provide written summary of findings.
  • Offer patient support: breast care nurse/cancer nurse specialist contact details and consider psychological support referral.
  • Arrange urgent multidisciplinary team (MDT) discussion (breast surgeon, medical oncology, radiation oncology, radiology, pathology).
  • Confirm nodal status: perform ultrasound-guided core biopsy or FNA of the suspicious axillary node if not already done to confirm nodal metastasis.
  • Complete staging investigations as indicated (CT chest/abdomen/pelvis and bone scan) to exclude distant metastases given node-positive disease.

• Oncologic planning (to be determined by MDT):

  • Surgical options: discuss breast-conserving surgery (lumpectomy) plus sentinel lymph node biopsy or axillary node sampling versus mastectomy depending on tumor-to-breast ratio, patient preference, and nodal status.
  • If axillary node confirmed positive: plan for axillary management (sentinel node biopsy ± completion axillary dissection per guidelines and MDT decision).
  • Adjuvant therapy: endocrine therapy indicated for ER-positive disease (choice of tamoxifen vs aromatase inhibitor depends on menopausal status; discuss with oncology).
  • Chemotherapy: consider adjuvant chemotherapy if node-positive or other high-risk features; discuss benefits/risks with oncology (HER2 negative, Ki-67 intermediate).
  • Radiotherapy: likely required after breast-conserving surgery; discussed with radiation oncology.

• Practical/administrative:

  • Arrange a follow-up appointment with breast surgeon within 1–2 weeks.
  • Provide information leaflets and contact numbers; discuss time off work and support for caregiving responsibilities.
  • Offer genetic counselling/testing if strong family history or patient requests (age 48 may prompt discussion but not automatically required given limited family history).

Key Learning Points

• Always integrate history, imaging, and pathology: receptor status (ER/PR/HER2) from biopsy directs adjuvant systemic therapy and prognosis.
• Assess axillary nodes clinically and with ultrasound; tissue confirmation of nodal metastasis guides surgical and systemic treatment decisions.
• Delivering a new cancer diagnosis requires clear, empathetic communication, prompt MDT referral, and coordination of staging, surgical planning, and psychosocial support.