You are an FY2 in a GP surgery
Personal Details:
Name: Susan Clarke
Age: 57
Medical Record:
Past medical history: Menopause 8 years ago. No other significant history.
Regular medication: None.
Allergies: None known.
Notes:
She had a routine mammogram as part of the routine NHS breast screen, which showed some calcifications.
Susan is attending for the results of a breast biopsy. She is very health-conscious and performs regular self-examinations.
Subsequent biopsy was performed, and the results came back: “Ductal Carcinoma In Situ (DCIS)”
Task:
Break the results and address her concerns, and outline the next steps.
Opening Sentence: “Hello, Doctor. I’m here for my biopsy results. I’m hoping it’s nothing to worry about.”
Open History (to give freely): “I’ve always been so careful, checking myself for lumps. It was a real shock when the mammogram showed something, as I couldn’t feel anything at all.”
Cues to give: “My friend had breast cancer, and she had to have chemotherapy. It was awful.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I know that breast cancer can be removed by surgery.”
Concerns: “Why did I get this? I’ve always been healthy. What will you do now? I really don’t want to have chemotherapy and lose my hair.”
Expectation: “I’m expecting you to tell me what the result is and what the plan is.”
How to Act: You are calm, composed, and pragmatic. You are not overly emotional but are clearly concerned and want factual information.
More History (only if asked): You have no family history of breast cancer. You do not smoke and only drink occasionally. You have never taken HRT or the contraceptive pill.
Social History: You are a retired teacher, married with two adult children.
Questions to ask:
“So, is it cancer or not?”
“What does ‘in situ’ mean?”
“Will I need my whole breast removed?”
Opening & Setting the Scene:
Hi Susan, thank you for coming in. I have your biopsy result here. Is there anyone you’d like to have with you while we discuss it?
Breaking the News (Warning Shot): I’m afraid the news from the biopsy is not what we were hoping for. It does show some abnormal cells. The result shows a condition called Ductal Carcinoma In Situ, or DCIS. Have you heard of that before? (Pause, allow for reaction)
ICE (Ideas, Concerns, Expectations): I know this is a lot to take in. What are your first thoughts on hearing that? You mentioned your friend went through chemotherapy. Is that your biggest worry? What were you hoping the plan would be from here?
Exploring Risk Factors/Context: Just to complete the picture, do you have any family history of breast or ovarian cancer? Have you ever taken HRT in the past?
Explain the results:
Hi Susan, thanks for coming in. I have the result of the biopsy here, and I’m afraid it is difficult news. The biopsy has shown that there are some cancerous cells in one of the milk ducts in your breast. This condition is called Ductal Carcinoma In Situ, or DCIS.”
(Pause, allow for reaction.)
Addressing and answering the patient’s ICE:
I can see this is a lot to take in. You asked, ‘Is it cancer?’ The answer is yes, but it is a very specific, non-invasive type. The name ‘in situ’ means ‘in its original place’. This means the abnormal cells are contained entirely within the milk duct and have not spread into the surrounding breast tissue or anywhere else in your body. It’s the very earliest form of breast cancer, and finding it at this stage is actually very good news.”
Next Steps:
You’re worried about chemotherapy. Because the cells are contained, most women with DCIS do not need chemotherapy. The standard treatment is surgery to remove the area of DCIS, followed by a course of radiotherapy to the breast to reduce the risk of it coming back. The surgeon will discuss the exact type of surgery with you – it might be a lumpectomy, which is just removing the affected area, rather than the whole breast.
The next step is that I will be referring you back to the specialist breast care team. You will meet with the surgeon and a specialist nurse who will discuss the surgical options in detail and support you through the whole process. They will be your main point of contact from now on.
Answer her questions:
You asked why you got this. Unfortunately, for most women, we don’t know the exact cause. It’s just bad luck. You have done everything right by going for your mammograms and being so aware of your health. That is why we have caught this so early, which gives you an excellent prognosis.
Addressing ideas, concerns, and expectations: Clearly explain what DCIS is, emphasising the non-invasive nature (“in situ”). Directly address her fear of chemotherapy by explaining it’s usually not required for DCIS. Manage her question of “why me?” with honesty and reassurance.
The management is to explain the standard treatment pathway (surgery + radiotherapy) and to make an urgent referral back to the breast surgical team and specialist nurse.
What is scenario testing? This case tests the candidate’s ability to break bad news of a cancer diagnosis but also to provide nuance and reassurance by explaining the specific, favourable prognosis of DCIS. It requires clear, simple explanations of complex pathology terms (“in situ”) and the ability to manage a patient’s preconceived fears about cancer treatment (chemotherapy).