CASE INFORMATION

Case ID: MNB-001
Case Name: Sarah Williams
Age: 52
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Code: B72 – Malignant Neoplasm of Breast

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations. 1.2 Demonstrates active listening and empathy. 1.4 Communicates effectively in delivering difficult news.
2. Clinical Information Gathering and Interpretation	2.1 Takes a comprehensive history, including risk factors and symptoms. 2.2 Identifies red flags suggestive of malignancy.
3. Diagnosis, Decision-Making and Reasoning	3.1 Establishes a working diagnosis based on clinical findings and investigations. 3.2 Recognises when urgent referral is required.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan. 4.5 Provides pharmacological and non-pharmacological recommendations. 4.7 Ensures shared decision-making in treatment options.
5. Preventive and Population Health	5.1 Identifies modifiable and non-modifiable risk factors. 5.2 Provides education on breast cancer screening and early detection.
6. Professionalism	6.2 Provides compassionate support while addressing patient concerns.
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and referral pathways.
9. Managing Uncertainty	9.3 Recognises the emotional impact of a cancer diagnosis and supports patient through uncertainty.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises the need for multidisciplinary care in cancer management.

CASE FEATURES

Middle-aged woman presenting with a recently detected breast lump.
Concerned about malignancy, requiring sensitive communication.
Requires urgent referral to a breast clinic for further assessment.
Need for shared decision-making regarding treatment options.
Addressing the emotional and psychological impact of a potential cancer diagnosis.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history.
Outline the differential diagnosis and key investigations required.
Address the patient’s concerns.
Develop a safe and patient-centred management plan.

SCENARIO

Sarah Williams, a 52-year-old high school teacher, presents with a recently discovered lump in her left breast. She noticed it two weeks ago while showering and describes it as firm, painless, and not mobile. She has no nipple discharge, skin changes, or pain but feels the lump may have grown slightly.

Her observations today are:

BP: 128/82 mmHg
HR: 76 bpm, regular
Temp: 36.6°C
RR: 16 breaths/min
Oxygen saturation: 99% on room air

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Williams
Age: 52
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular

Past History

No known breast issues
No previous mammograms

Social History

Occupation: High school teacher – sedentary work
Smoking: Never smoked
Alcohol: 1-2 glasses of wine per week

Family History

Mother: Diagnosed with breast cancer at age 65
Father: Hypertension, no cancer history

Vaccination and Preventative Activities

Influenza vaccine – up to date

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

ROLE-PLAYER SCRIPTS

Opening Line

“Doctor, I found a lump in my breast two weeks ago, and I’m really scared it could be cancer.”

General Information

You are a 52-year-old high school teacher with no significant past medical history.
Two weeks ago, while showering, you felt a firm lump in your left breast.
The lump is not painful, but it doesn’t seem to be going away.

Specific Information

(Only Provide If Asked)

Background Information

You haven’t told anyone yet, including your family, because you are afraid of what it might mean.
You haven’t had a mammogram before, even though you were invited for screening at 50.
You feel anxious and overwhelmed, and you want clear answers quickly.

Symptoms & Red Flags

You feel the lump every time you check, and it seems slightly larger than before.
It is firm, non-mobile, and located in the upper outer quadrant of your left breast.
You have no pain, nipple discharge, or skin changes.
You have not noticed any new lumps in your armpits.
You haven’t lost weight unexpectedly or had night sweats or fevers.
You have no difficulty swallowing or other systemic symptoms.

Family & Lifestyle Factors

Your mother had breast cancer at age 65, but there’s no known BRCA mutation in the family.
You don’t smoke and drink 1-2 glasses of wine per week.
You have two children and breastfed both for a short period.
You haven’t used hormone replacement therapy (HRT).
Your diet is fairly balanced, but you often eat processed foods due to your busy schedule.
You walk occasionally but don’t follow a structured exercise routine.

Concerns & Emotional State

You are terrified this is cancer and feel guilty for not getting a mammogram earlier.
You’re worried about your future, particularly what will happen if you need chemotherapy or surgery.
You’re concerned about how to tell your family, especially your children.
You’re worried about the wait for results and how quickly things will move.

Concerns & Expectations

You want to know if this is cancer and how serious it might be.
You want to understand what tests you need and how soon you’ll get results.
You are worried about treatment options (surgery, chemotherapy, radiation).
You don’t want to wait too long for answers.
You are worried about the financial and emotional burden of a diagnosis.

Possible Questions for the Candidate

“Do you think this is cancer?”
“What tests do I need, and how soon will I get results?”
“If this is cancer, what are my treatment options?”
“Could this lump be something else, or is it always cancer?”
“Should I have had a mammogram earlier?”
“How do I tell my family?”
“What happens next if this is serious?”
“How long do I have to wait for a biopsy or results?”

How to Respond to the Candidate’s Explanations

If the Candidate Explains That This Needs Urgent Investigation but May Not Be Cancer:

“So, you’re saying it could be something else? What are the other possibilities?”
“How often do lumps like this turn out to be cancer?”

If the Candidate Recommends a Mammogram, Ultrasound, and Possible Biopsy:

“How soon will I get the results?”
“Do I have to wait for all the tests to be done before I know anything?”

If the Candidate Discusses Treatment Options for Breast Cancer (If Confirmed):

“Would I need surgery, or are there other options?”
“Does every breast cancer patient need chemotherapy?”

If the Candidate Mentions the Emotional and Psychological Impact:

“I haven’t told my family yet. How do I even start that conversation?”
“How do most people cope with this uncertainty?”

Role-Playing Tips for the Candidate Assessment

You are extremely anxious and want clear, direct answers.
You are overwhelmed and unsure how to process this information—if the candidate is too vague, ask “What exactly do I need to do next?”
You fear the worst but are open to reassurance if given a logical explanation.
You want things to move quickly—if the candidate doesn’t mention timelines, ask “How long will this take?”
If the candidate dismisses your concerns too quickly, push back. Ask, “But how do you know for sure?”
If the candidate is overly technical, ask for simpler explanations. “Can you explain this to me in plain terms?”

Final Line (If the Candidate Handles the Case Well)

“Thank you, Doctor. I feel a little better knowing what happens next. I’ll go ahead with the tests, and I’ll try to talk to my family about it.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including risk factors, symptoms, and red flags for malignancy.

The competent candidate should:

Engage the patient with open-ended questions, allowing them to express concerns.
Take a detailed history, including:
- Onset, duration, and changes in the breast lump.
- Presence of associated symptoms (nipple discharge, skin changes, pain, weight loss).
- Menstrual, pregnancy, and breastfeeding history.
Assess family history of breast and ovarian cancer, particularly first-degree relatives.
Identify modifiable risk factors (smoking, alcohol intake, hormone use).
Address psychosocial concerns, as the patient is fearful and anxious.
Determine screening history (previous mammograms, breast self-examinations).
Look for red flags, such as:
- Hard, immobile, irregular mass.
- Skin dimpling or nipple retraction.
- Axillary lymphadenopathy.

Task 2: Discuss your differential diagnosis and outline an initial management plan.

The competent candidate should:

Explain that the most likely cause is a breast lesion that requires urgent assessment.
Outline possible differentials:
- Benign causes (fibroadenoma, cyst, mastitis, fat necrosis).
- Malignant causes (invasive ductal or lobular carcinoma).
Explain the triple assessment approach:
- Clinical examination.
- Imaging (mammogram ± ultrasound).
- Biopsy (core needle biopsy if suspicious lesion is identified).
Reassure the patient that many breast lumps are benign, but early investigation is essential.
Arrange urgent breast clinic referral, ensuring results are followed up.
Offer emotional support and provide written resources.

Task 3: Address the patient’s concerns about breast cancer and discuss appropriate investigations.

The competent candidate should:

Acknowledge the patient’s anxiety and validate their concerns.
Explain that most breast lumps are benign, but investigations are necessary to rule out malignancy.
Outline the stepwise approach to diagnosis:
- Mammogram and ultrasound to assess the lump.
- Biopsy if imaging suggests a suspicious lesion.
Clarify timeframes for results and ensure follow-up is arranged.
Discuss treatment options if cancer is confirmed, including:
- Surgical options (lumpectomy vs. mastectomy).
- Radiotherapy, chemotherapy, and hormone therapy based on pathology results.
Provide information on support services (breast care nurses, cancer support groups).

Task 4: Develop a comprehensive management plan, including urgent referral, support services, and follow-up care.

The competent candidate should:

Urgent referral to a breast surgeon or breast clinic for triple assessment.
Ensure clear communication of results and follow-up within one week.
Support the patient emotionally, addressing their fears about cancer and treatment.
Provide educational resources about breast cancer and available support services.
Arrange ongoing GP follow-up to discuss results and coordinate further care.

SUMMARY OF A COMPETENT ANSWER

Takes a detailed history, focusing on symptoms, family history, and risk factors.
Recognises red flags for malignancy, ensuring urgent assessment.
Explains the triple assessment approach clearly to the patient.
Provides reassurance while acknowledging the patient’s concerns.
Ensures timely referral and follow-up, coordinating multidisciplinary care.
Discusses potential treatment pathways, ensuring the patient feels informed.

PITFALLS

Failing to recognise the need for urgent referral, leading to diagnostic delays.
Over-reassurance without appropriate investigation, missing a malignancy.
Not addressing the patient’s emotional distress, increasing anxiety.
Not explaining the diagnostic process, leading to confusion and uncertainty.
Neglecting to provide follow-up arrangements, risking missed results.

REFERENCES

MARKING

Each competency area is rated on the following scale from 0 to 3:

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Engages the patient to understand their concerns and expectations.
1.2 Demonstrates active listening and empathy.
1.4 Communicates effectively in delivering difficult news.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history, including risk factors and symptoms.
2.2 Identifies red flags suggestive of malignancy.

3. Diagnosis, Decision-Making and Reasoning

3.1 Establishes a working diagnosis based on clinical findings and investigations.
3.2 Recognises when urgent referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.5 Provides pharmacological and non-pharmacological recommendations.
4.7 Ensures shared decision-making in treatment options.

5. Preventive and Population Health

5.1 Identifies modifiable and non-modifiable risk factors.
5.2 Provides education on breast cancer screening and early detection.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD