Screen-recalled calcifications with low-grade DCIS on core biopsy — consent, BI-RADS, upgrade rule and surveillance-versus-surgery choice

Model answer

(A) Consent for screening — benefit with harm in one breath (4 marks)

• Screening mammography cuts breast-cancer mortality by about one-fifth: relative risk 0.80 across 11 randomised trials in the Marmot review — the benefit half of consent.^[7]
• The harm half travels beside it: overdiagnosis in 11% of invited-group cancers long-term (19% of active-screening-period cancers) — defined as screen-detected cancers that would never have surfaced clinically in her lifetime.^[7]
• Her pathway matches USPSTF 2024: biennial mammography from 40 to 74 carries a B recommendation on moderate certainty of moderate net benefit — she is exactly the woman the recommendation describes.^[2]
• Add the recall honesty relevant to her story: she is living the 8-to-10% recall experience, and roughly one-third of biennially screened European women face at least one recall per decade — programmes own this anxiety.^[39][40]

(B) BI-RADS 4A and the upgrade rule (3 marks)

• BI-RADS 4A means tissue diagnosis with low-but-real suspicion: National Mammography Database biopsy predictive value 7.6%, against 22% for 4B and 69.3% for 4C — so 4A biopsies are mostly benign but never optional.^[27]
• The core result does not close the case: about one in four core-biopsy DCIS diagnoses (25.9%) prove invasive at excision — consent the upgrade before consenting anything else.^[32]
• Her predictors favour the low end (low grade, 11 mm, calcifications only, non-palpable, vacuum-assisted sampling assumed) versus the upgrade flags: 14-gauge device, high grade, size over 20 mm, mass pattern, palpability.^[32]
• Next tissue step: vacuum-assisted excision-biopsy correlation with clip placement and multidisciplinary review — a benign-against-4C rule in reverse: imaging-pathology concordance decides, and discordance re-biopsies.^[27][32]

(C) Surveillance versus surgery for low-grade DCIS (3 marks)

• Counsel the no-survival-effect fact first: surgery, radiotherapy and optional endocrine therapy cut local events with no effect on survival outcomes — every DCIS choice is local control, not rescue.^[36]
• Offer the two legitimate paths with LORIS-generation honesty: standard excision (with radiotherapy discussion) versus active surveillance for low-risk DCIS under trial-grade follow-up — noting biomarkers cannot yet pick progressors, so surveillance means uncertainty accepted explicitly.^[36][37]
• Her low-grade, small, calcification-only profile is the surveillance conversation's best case; high grade, larger size, mass or palpability would keep her in the treatment pathway.^[32][36]
• Ongoing plan regardless of path: return to programme mammography (biennial 40-to-74 logic; annual consideration with her new risk status), annual clinical review, and a written recall plan naming who explains the next result.^[2][41]