CCE-CBD-145

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Jennifer’s breast lump, and how would you justify them?

• Prompt: Discuss common benign and malignant possibilities.
• Prompt: Justify based on Jennifer’s age, risk factors, and examination findings.

Q2. How would you explain the initial findings and management plan to Jennifer?

• Prompt: Discuss BI-RADS classification and what “probably benign” means.
• Prompt: Address her anxiety and fertility concerns.

Q3. What further investigations or referrals would you consider and why?

• Prompt: Discuss indications for biopsy and imaging follow-up.
• Prompt: Discuss referral to a breast surgeon or specialist.

Q4. How would you manage Jennifer’s follow-up and ongoing care, particularly in a regional/rural setting?

• Prompt: Coordinate imaging and specialist care given geographic barriers.
• Prompt: Discuss follow-up imaging schedules and patient support.

Q5. What preventive strategies and patient education would you offer regarding breast health?

• Prompt: Address breast self-awareness and routine screening.
• Prompt: Provide lifestyle advice and discuss risk factors for breast cancer.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Jennifer’s breast lump, and how would you justify them?

Answer:

In Jennifer’s case, the primary differential diagnoses include both benign and malignant breast conditions. These are considered based on her age, clinical presentation, and examination findings.

Benign causes (most likely):

• Fibroadenoma: This is common in women under 40. The lump is described as firm, mobile, and non-tender, fitting the classic presentation. Jennifer’s age and the lesion’s characteristics on ultrasound (well-circumscribed, hypoechoic, BI-RADS 3) support this.
• Breast cyst: Though typically more common around menopause, simple cysts can appear in younger women. They can be mobile and non-tender but are often associated with cyclical breast changes, which Jennifer denies.
• Fibrocystic changes: Diffuse nodularity often worsened premenstrually. However, Jennifer’s lump is isolated and not associated with cyclical pain.

Malignant causes (less likely but important to exclude):

• Early breast cancer: Despite being less common in women under 40 without a family history, it is still a consideration. Features such as firm mass and the need to exclude malignancy warrant further evaluation.
• Phyllodes tumour: Rare, but typically presents as a fast-growing mass. There’s no rapid enlargement in Jennifer’s history, making this less likely.

Justification includes:

• Clinical findings: The lump’s mobility and lack of skin or nipple changes, and no lymphadenopathy.
• Imaging: BI-RADS 3 suggests a lesion probably benign (<2% risk of malignancy), recommending short-term follow-up rather than immediate biopsy.

Q2: How would you explain the initial findings and management plan to Jennifer?

Answer:

I would start by acknowledging Jennifer’s concerns and validating her anxiety. Then I’d explain her results in clear, non-technical language.

• “Jennifer, I understand finding a lump is worrying. We’ve done an ultrasound that shows a well-defined lesion, which is probably benign. It’s classified as BI-RADS 3, meaning it’s likely not cancer, but we monitor it closely to be sure.”
• I would reassure her: “There’s less than a 2% chance this is cancer.”
• Explain the next steps: “We recommend a follow-up ultrasound in 6 months to check for changes. If the lump grows or changes in any way, we’d do a biopsy sooner.”
• Address fertility concerns: “Currently, no treatments are needed that would affect your fertility.”
• Provide emotional support and offer resources: “It’s common to feel anxious, and we can support you with counselling if needed.”

Q3: What further investigations or referrals would you consider and why?

Answer:

Further steps depend on Jennifer’s preference, clinical course, and risk factors.

• Core needle biopsy: While BI-RADS 3 suggests monitoring, if Jennifer prefers definitive answers due to her anxiety, or if there’s clinical suspicion, a biopsy would be justified.
• Mammography: Less useful in younger women due to dense breast tissue, but may be considered if risk factors increase or findings change.
• Breast surgeon referral: For further evaluation if biopsy is warranted, or if Jennifer prefers a surgical opinion.
• Genetic counselling: Not routinely indicated without family history, but should be considered if there’s a new family history or high-risk factors emerge.

Q4: How would you manage Jennifer’s follow-up and ongoing care, particularly in a regional/rural setting?

Answer:

Management would involve timely follow-up and ensuring access to services.

• 6-month ultrasound follow-up, coordinated locally or via telehealth services with specialist radiologists.
• Education: Teach Jennifer breast self-awareness rather than formal breast self-examination.
• Referral pathways: Establish a plan for quick access to specialist care if the lump changes, including referral to the nearest breast clinic or surgeon.
• Support services: Offer local counselling or remote mental health services for anxiety management.
• Documentation: Record findings in her shared health summary for continuity of care.

Q5: What preventive strategies and patient education would you offer regarding breast health?

Answer:

• Promote breast awareness: Encourage Jennifer to note changes rather than perform scheduled self-exams.
• Discuss screening: While she’s under 50, discuss BreastScreen eligibility at age 50. Consider earlier screening if family history develops.
• Lifestyle advice: Maintain a healthy weight, limit alcohol, exercise regularly – all reduce breast cancer risk.
• Hormonal factors: If future hormonal therapies are considered, discuss risks/benefits.
• Provide resources: Cancer Council Australia or Breast Cancer Network Australia for reliable information and support.

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SUMMARY OF A COMPETENT ANSWER

• Provides a broad differential diagnosis with clear justifications.
• Explains BI-RADS 3 and management sensitively, addressing patient anxiety.
• Identifies appropriate investigations (biopsy, surgeon referral).
• Develops a comprehensive rural follow-up plan.
• Promotes preventive health and breast awareness.

PITFALLS

• Over-reassurance without addressing patient anxiety.
• Failing to offer biopsy or specialist referral when appropriate.
• Ignoring rural health barriers to follow-up and specialist care.
• Providing inaccurate information about screening guidelines.

REFERENCES

• Cancer Australia (2023) on Early detection of breast cancer
• RACGP Guidelines on Red Book (10th Edition)
• National Breast Cancer Foundation on Breast Cancer Resources

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MARKING

Each competency area is 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 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information about health needs.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses.
3.2 Demonstrates diagnostic reasoning and clinical judgement.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Applies evidence-based medicine and shared decision-making.

5. Preventive and Population Health

5.1 Provides advice and interventions for health improvement.

6. Professionalism

6.1 Adheres to ethical and professional standards.

7. General Practice Systems and Regulatory Requirements

7.1 Uses health information systems for quality care.

8. Procedural Skills

8.1 Demonstrates procedural skills (e.g., breast examination).

9. Managing Uncertainty

9.1 Manages uncertainty in clinical decision-making.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages patients at risk of significant illness.

Competency at Fellowship Level

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