Counselling · Intermediate · Surgery

Breast Lump - Discussion About Diagnosis and Management Options

Practise this PLAB 2 counselling station on Ductal Carcinoma in Situ. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a breast clinic. Mrs Petra Winkler, a 54-year-old woman, has been diagnosed with ductal carcinoma in situ (DCIS) of the breast following biopsy. You need to explain her diagnosis, clarify that it is pre-cancerous (not invasive cancer), discuss surgical options (wide local excision versus mastectomy), and address her anxieties about the condition and treatment.

Background notes: PMH: Hypertension, Migraines (occasional), Appendicectomy (aged 20)

What this station tests

  • Distinguishing DCIS from invasive cancer: cells confined within ducts, have not invaded surrounding tissue
  • Correcting misconceptions about chemotherapy: DCIS does not typically require chemotherapy (major relief for the patient)
  • Explaining breast conservation: wide local excision with radiotherapy is often sufficient, mastectomy is not automatic
  • Framing treatment as preventive: removing DCIS before it can become invasive
  • Acknowledging screening success: this is exactly what the programme is designed to detect

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, establish what patient already knows and understands.
  • 1-3 min — Explain Condition: Explain diagnosis or condition using chunk-and-check technique. Use simple language, avoid jargon.
  • 3-5 min — Management Options: Discuss treatment options. Shared decision-making. Risks, benefits, alternatives.
  • 5-7 min — Address Concerns: Explore and address specific concerns. Check understanding. Discuss lifestyle implications.
  • 7-8 min — Closing: Summarise agreed plan. Safety netting. Arrange follow-up. Written information offer.

Consultation approach

The opening

Explaining DCIS requires correcting common misconceptions: it is not invasive cancer, it may not need chemotherapy, and breast conservation is often possible. Mrs Winkler is 54, diagnosed with DCIS on screening mammogram biopsy. She thinks she has breast cancer and will need chemotherapy and mastectomy. Open with: 'Mrs Winkler, I know you have been given a lot of information and it must be very frightening. Before I explain the results, can you tell me what you understand so far?'

Core approach

Correct the key misconception first. 'The biopsy showed abnormal cells inside the milk ducts of your breast. This is called DCIS. The important thing to understand is that these cells have NOT spread outside the ducts. This is not the same as invasive breast cancer.' This distinction is the most important message. She thinks she has cancer and will die.

Explain what DCIS means. 'If left untreated, DCIS has a risk of developing into invasive cancer over time, perhaps 25 to 50% over 10 to 20 years. That is why treatment is recommended, because we want to remove it before it has any chance of progressing.' Frame treatment as preventive, not curative of existing cancer.

Treatment options. Breast-conserving surgery (wide local excision) with radiotherapy is often possible for localised DCIS. Mastectomy is needed for extensive DCIS but is not automatic. Chemotherapy is NOT usually required for DCIS (this will be a huge relief). Hormonal therapy (tamoxifen) may be recommended depending on receptor status. Address each of her fears directly: no chemo, breast conservation likely, this is not invasive cancer.

Closing and safety netting

Summarise the good news: 'This was found early through screening, it has not spread, and the treatment is very effective. The screening programme has worked exactly as it should.' Explain the MDT: 'A team of specialists including a surgeon, oncologist, radiologist, and nurse will discuss your case and recommend the best treatment plan for you.'

Offer breast care nurse contact for ongoing support. Written information about DCIS. Safety net: 'If you notice any new lumps, skin changes, or nipple discharge before your next appointment, come in.' Follow-up: MDT discussion, then surgical planning appointment.

How examiners mark this station

Examiners will assess your ability to explain ductal carcinoma in situ and its management in a patient-centred way. Domain 2 (Clinical Management) and Domain 3 (Interpersonal Skills) are equally weighted and primary. Expect marks for accurate information delivery, shared decision-making, chunk-and-check technique, and addressing the patient's specific concerns. Domain 1 (Data Gathering) is assessed through how well you establish the patient's baseline understanding and elicit their concerns.

Domain 1: Data Gathering, Technical and Assessment Skills (Supporting)

Scores well: Establishing her current understanding. Checking what she has been told. Assessing her emotional state. Checking family history of breast cancer.

Costs marks: Not checking her understanding. Not assessing emotional state.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: DCIS accurately explained (pre-invasive, confined to ducts). Treatment options presented (WLE vs mastectomy). Chemotherapy not needed (stated explicitly). MDT pathway explained. Hormonal therapy mentioned. Breast care nurse referral.

Costs marks: Calling DCIS invasive cancer. Not mentioning chemotherapy is unlikely. Not explaining treatment options. No MDT mention.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Correcting misconceptions gently. Addressing each fear individually (chemo, mastectomy, death). Framing screening as having worked. Providing hope. Offering ongoing support.

Costs marks: Not correcting misconceptions. Being alarmist. Not providing hope. Leaving fears unaddressed.

Common examiner feedback (and how to fix it)

Did not provide adequate explanation or plan to the patient

Fix: Use chunk-and-check: deliver one concept, check understanding, then move to the next. Offer all relevant treatment options with risks and benefits before helping the patient decide.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Before and during counselling, explicitly ask what concerns the patient most. Respond to emotional cues with empathic statements before continuing with information.

Common mistakes in this station

  1. Calling DCIS 'cancer' without qualification. DCIS is pre-invasive. Calling it cancer without explaining that it has not spread causes unnecessary terror. The correct framing is: 'abnormal cells that have not spread outside the ducts.'
  2. Not addressing the chemotherapy fear. She thinks she needs chemotherapy. Explicitly stating that DCIS does not usually require chemotherapy provides enormous relief and must not be omitted.
  3. Not explaining breast conservation. She thinks she will lose her breast. Many DCIS cases are treated with wide local excision. Candidates who do not mention this leave her with a false expectation of mastectomy.

Resitting PLAB 2?

If counselling stations have been a challenge, the most common issue is information overload: delivering too much clinical detail without checking understanding. Practise the chunk-and-check technique until it becomes automatic. Remember that shared decision-making, not lecturing, is what scores highly in Domain 3.

Example opening

Hello, my name is Dr [Name]. I understand you've come in today to discuss [topic]. Before I explain things, could you tell me what you've been told so far, so I know where to start?

Frequently asked questions

How should I approach ductal carcinoma in situ counselling in this PLAB 2 station?

Explaining DCIS requires correcting common misconceptions: it is not invasive cancer, it may not need chemotherapy, and breast conservation is often possible. Mrs Winkler is 54, diagnosed with DCIS on screening mammogram biopsy. She thinks she has breast cancer and will need chemotherapy and mastectomy.

What are examiners marking in this ductal carcinoma in situ station?

Marks are won for: Establishing her current understanding. Checking what she has been told. Assessing her emotional state. Checking family history of breast cancer. Marks are lost for: Not checking her understanding. Not assessing emotional state.

What is the most common mistake candidates make in this ductal carcinoma in situ station?

Calling DCIS 'cancer' without qualification. DCIS is pre-invasive. Calling it cancer without explaining that it has not spread causes unnecessary terror.

How do I prepare for this station if I have not managed ductal carcinoma in situ in clinical practice?

Structure beats experience here. Focus on correcting misconceptions about chemotherapy: DCIS does not typically require chemotherapy (major relief for the patient). Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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