Throughout fellowship, my experiences working with patients in clinic have taught me many lessons.
Faisal Musa, MD
Throughout fellowship, my experiences working with patients in clinic have taught me many lessons. In particular, I’ve learned the true value of a physical exam. While working in a continuity clinic alongside my program director, who has a special interest in breast cancer, I’ve had a special opportunity to observe and learn from him the proper way to conduct a breast exam. Working with this program director has also taught me to be mindful of certain important considerations in patients with metastatic disease.
Patient Case Explored
In this article, I present the case of a woman with widespread disease in the bone, lung, and colon. Initially, she was thought to have colon cancer based on imaging results. However, a simple physical breast exam revealed something very different.Our patient is a 66-year-old woman with an unremarkable past medical history. In fact, this patient reported no history of ever being seen by any healthcare provider. She presented to the emergency department with worsening neck pain and right-sided chest pain, which had been bothering her for weeks. She denied symptoms of weakness, tingling, numbness, and urinary or fecal incontinence. When she was seen by our team, her initial physical exam was normal.
Upon meeting with this patient, our team ordered a CT scan of her neck. Results revealed multiple lytic lesions, with C5 cord compression. Because these findings raised suspicion of malignancy, a CT scan of the patient’s chest and abdomen was conducted as well. Results of the second scan revealed diffuse osseous metastatic disease. Extraosseous soft-tissue components were noted at numerous levels in the cervical, thoracic, and lumbar areas of her back. The scan further revealed several bilateral pulmonary nodules with mediastinal adenopathy and indeterminate mural-based soft tissue that involved a short segment of the ascending colon. An MRI scan of the woman’s spine also revealed diffuse osseous metastatic disease throughout her spine, with cord compression at C5 and epidural disease at L1 and L2.
In light of this information, an oncology service at an outside hospital was consulted. The patient’s physical examination, which included a neurological exam, was normal. It was after this that she received a recommendation to be transferred to our facility for a neurosurgical and radiation oncology evaluation, as metastatic colon cancer had been suggested as a diagnosis based on imaging results. She was transferred to our hospital and examined by the neurosurgery service, who (since she had no neurological deficit), preferred to wait to make a treatment decision until receiving an actual tissue diagnosis. However, she was started on high-dose steroids and our service was consulted.
When I reviewed her chart, I really did not feel that this patient had metastatic colon cancer. I considered her amount of bone disease and her intact liver. I also considered the basic principles of medicine and noticed that despite being seen by several doctors, not one had performed a simple breast exam. After getting up to speed on this patient’s medical history, I asked her if she had noticed any changes in her breasts or other symptoms, such as discharge. She said she had felt something in her right breast 8 months earlier that she thought was a painless cyst and showed no concern about it.
I conducted my own physical exam and, as it turned out, she had a 5-cm mass in the middle of her right breast. The mass was firm and nontender to palpation. The patient had nipple inversion, but no signs of rash or erythema. Her axillary exam was normal. This right-breast mass was not previously detected during any of this woman’s imaging scans.
The results of an ultrasound-guided biopsy of her right breast were consistent with estrogen-receptor/progesterone-receptor—positive and human epidermal growth factor receptor 2–negative invasive ductal carcinoma. Neurosurgery deferred surgery, and radiation oncology started treating her C5 disease since there was no neurological defect.
I communicated these findings to the initial oncologist who had seen this woman, and he was very appreciative of my attentiveness and willingness to dig deeper into this patient’s case. He explained to me that, “We, as oncologists, sometimes forget to do a breast physical exam because of all of the imaging technology available. But this patient serves as an excellent example of why it is important to conduct a complete physical exam, especially during an initial patient encounter.”Cases such as this one highlight an important principle in oncology. We frequently talk about pathology and imaging results, but we rarely talk about physical exam findings, even in tumor boards. This case clearly demonstrates the importance of the physical examination in oncology, as it can play a huge role in a patient’s diagnosis and treatment.