Winnipeg Free Press - PRINT EDITION
Breast cancer mix-up admitted
Lumpectomy unneeded, patient's treatment stalled
One woman had an unnecessary lumpectomy while another woman's breast cancer treatment was delayed for 10 weeks after their biopsies from the Breast Health Centre were accidentally switched.
Officials from the Winnipeg Regional Health Authority and Diagnostic Services Manitoba announced Monday the mix-up has been declared a critical incident and review teams are investigating what led to the biopsy swap.
DSM CEO Jim Dalton said a pathologist performing a routine comparison of a patient's initial biopsy with a biopsy taken during surgery, ended up discovering the discrepancy in early July.
The patient's biopsy was negative but was switched with another patient's, which tested positive for cancer. The pathologist later discovered the biopsy removed during the lumpectomy tested negative.
Dalton said DNA tests confirmed on July 16 the woman's initial biopsy -- a small tube of tissue from the breast about a centimetre long -- was accidentally switched with a similar biopsy from another woman. The result was the woman who underwent surgery did not have cancer, and the woman who did have cancer waited 10 weeks for a diagnosis.
Both women were informed of the mistake last week.
Officials say further information -- such as whether the cancer is aggressive or if the mix-up will affect the patient's prognosis -- is not being released. However, they confirmed the woman's surgical treatment for cancer is being expedited.
"They were obviously and understandably distressed by the news," said Tania Sloan, director of WRHA's Breast Health Centre. "We've apologized to both patients and we've provided the opportunity for both patients to receive counselling services."
Health officials will not name the laboratory where the mix-up occurred, but Dalton confirmed it was a public lab run by DSM. He said officials wanted to speak openly about the critical incident to reassure the public they can "have faith in the health system." Dalton said a pathologist did not misinterpret a tissue sample, and that all of the biopsies were read correctly.
"It's really exceedingly rare," he said. "It's the only one we know of where a specimen mix-up has led to an incorrect diagnosis."
Dalton said critical incident review teams will determine what led to the swap and issue recommendations that can help prevent the situation from occurring again. WRHA officials said the review's findings will be shared with both women, but it is too early to say whether the cause of the mix-up will be made public.
"Publicly, we will be saying what changes we implement as a result of the review," said Heidi Graham, WRHA spokeswoman.
Tory health critic Myrna Driedger said she was shocked to hear about the incident and that it raises questions about the quality of tests performed in Manitoba labs. She said a recent whistleblower complaint raised concerns about overworked pathologists and a backlog of tests, and she hopes the latest critical incident doesn't point to a larger systemic problem.
jen.skerritt@freepress.mb.ca
Republished from the Winnipeg Free Press print edition July 20, 2010 A3
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