Ms A, who asked not to be named, was one of 60 women whose mammogram results were urgently reviewed by Pacific Radiology after thousands of possibly incorrect scan assessments were discovered.
Her second scan was passed, but six months later she was diagnosed with stage 3 cancer and has had to undergo a radical mastectomy, radiation therapy and chemotherapy.
Ms A’s initial mammogram, in March 2021, was read as clear.
However, Pacific Radiology, the radiology firm contracted by BreastScreen Otago Southland, discovered after an internal audit that a doctor reading scan results was routinely not detecting cancers spotted by other doctors.
It reviewed 7500 scans the doctor - who no longer works for the firm - read from January 2020 to May 2021 and 60 women, including Ms A, were called in for reassessment.
In September last year, Pacific Radiology told the Otago Daily Times that all the women whose files had been reviewed had been cleared of having cancer.
Ms A, who has three young children, was told her second scan was normal. However, it transpired an ultrasound taken as part of the audit potentially displayed an abnormality which was missed.
In March this year, Ms A noticed a lump in her right breast.
A mammogram four days later detected what surgery eventually revealed was a tumour 12cm in diameter.
"They have totally failed ... They should have called me back [after the second scan]," Ms A said.
"It was only six months before I got scanned again, but with cancer six months can make a huge difference. It was a missed opportunity."
By now lacking confidence in local radiologists, Ms A went overseas for radiation treatment.
She has been told her cancer has a high risk of recurrence and has self-funded a new cancer treatment drug which has shown encouraging results overseas in preventing a return of cancer but which is not funded for use in New Zealand.
Concerned that she might not be the only woman whose reassessment might have missed something, Ms A has complained to the health and disability commissioner about the process followed in her case.
Ms A had a history of breast cysts and was a self-referred private patient rather than a woman scanned as part of BreastScreen Otago Southland’s routine screening programme.
"They talk about the importance of early diagnosis," she said.
"I took matters into my own hands, I presented myself, I was doing what I thought was right, I gave myself every chance."
Reassured by the clear result of her first scan, Ms A was not on high alert when called back for a second scan.
"I felt great. I felt reassured that they did an ultrasound and did the mammogram again, and then six months later I found, I wouldn’t say it was a lump, it was more like a mass, on my right side.
"It was very obvious to me that it was not normal - I actually rang Pacific Radiology before I even rang my GP," Ms A said.
In a letter to Ms A, Pacific Radiology said that a retrospective review of the audit ultrasound had found that it might have shown a "subtle area of abnormality".
"However, the assessing radiologist thought it was normal at the time, the abnormality is subtle, and in the context that the mammogram was thought to be normal we were unsure if it was in fact significant."
Ms A said she accepted she would have developed cancer but felt strongly that it should have been detected much earlier.
She said she had been told in a telephone call from Pacific Radiology that the radiologist had not taken enough images to fully assess an area of "architectural distortion", although this was not mentioned in the subsequent letter.
She questioned why, if there might have been issues with the first scan and questions over the reliability of her second, why utmost caution was not applied, further tests done, and a specialist breast radiologist asked to review the results.
"This is not just a missed diagnosis, this is a failure in their process," she said.
"Due to the uncertainty they should have done biopsies and an MRI."
In its letter to Ms A, Pacific Radiology expressed its "sincere regret" that her cancer had not been diagnosed earlier, and wished her all the best for her ongoing treatment and recovery.
Pacific Radiology radiologist Jacqueline Copland said that due to the small number of cases involved in the recall it was unable to give detailed information on those patients for privacy reasons.
"The total number of interval cancers arising from the period covered by the breast imaging audit will not be known until at least 2023 as women who had a mammogram in May 2021 will not be due for rescreening until May 2023."
Dr Copland said that any breast-screening service would expect to see small numbers of cancers emerge between audits as part of the natural process. She said Pacific Radiology maintained the quality-control system which had detected the original problem, and said all mammograms were always read by at least two radiologists.
"Each radiologist is fully trained, with performance monitored three-monthly, and is required to meet ongoing performance standards."
