No Screening Discussion, Then Prostate Cancer

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Description

A 62-year-old male with a family history of prostate cancer received routine physical exams by four different internists for six years without discussions about prostate screening options or the patient's preferences, before a diagnosis of prostate cancer with metastasis to the bone.

Key Lessons

  • Clear documentation of age-appropriate discussions with a patient about prostate screening options and the patient's decision can minimize allegations that it was not addressed.
  • Reliable systems to assist providers with screening recommendations include reminders and prompts for follow-up on tests and referrals.
  • Providers transferring a patient's care need to exchange information about preventive health maintenance in order to ensure opportunities for screenings and follow up.

Clinical Sequence

A male with a family history of prostate cancer (maternal uncle) received complete physical exams in a clinic by different internists for many years. At ages 55 and 57, he received digital rectal exams (DRE) by two different physicians with no nodules noted. On both occasions, the patient was given stool cards to test for occult blood, and they were negative. There is no documentation of a discussion of prostate screening options with the patient over the course of his treatment at this clinic.

At age 60, the patient established care with a new PCP. At his initial exam, his DRE was negative and the patient was given stool cards. Later that year, the patient was given stool cards again because the previous set had never been returned. No discussion of prostate screening options is documented.

A year later, the patient had an annual physical exam, during which his PCP recommended both PSA testing and sigmoidoscopy. The physician noted that the patient was uncertain if he wanted PSA testing done and, therefore, was provided literature. A DRE was noted no nodules, and the patient was negative for occult blood. A sigmoidoscopy was scheduled, but was never completed by the patient.

Later that year, the patient established care with a new PCP. The patient declined a colonoscopy, and literature on colon cancer screening was given to the patient. He was due to receive a digital rectal exam at his next physical exam the following year, but never made an appointment.

The patient was admitted to the ED a year after his last physical, with flank pain radiating to his lower right abdomen. An abdominal and pelvic CT scan revealed a nodule in the lung and possible diverticulitis. Colon cancer was suspected and the chest CT scan was suggestive of metastatic disease. The patient's PSA level was found to be 477ng/ml (normal =0-4ng/ml). He was diagnosed with prostate cancer and metastasis to the bone. The patient was treated with chemotherapy and died from metastatic cancer three years later.

Allegation

The patient sued three internal medicine doctors, alleging that a delay in diagnosis and treatment of prostate cancer resulted in his death.

Disposition

At trial, the jury found for the defense.

Analysis

Clinical Perspective
  1. A discussion about prostate cancer screening options for a patient over 45 with a family history of prostate cancer was not documented.
    PSA testing needs to be discussed and offered to all male patients over 50, and at age 45 for those with a family history of prostate cancer. Providers must document a detailed note in the record that the patient has been informed of potential benefits and possible harms, and his (the patient's) decision. The topic should be readdressed (and documented) by the practitioner at subsequent physical exams.

  2. The earliest possible detection of the patient's cancer may have been diminished due to a lack of PSA testing.
    Controversies related to PSA testing include the lack of consistent strong data to show better outcomes with PSA screening tests and even early detection and treatment. The rate of false positives and false negatives is significant, and treatment involves considerable morbidity. Patients must ultimately decide whether to undergo a cancer screen, and need the physician to share information required to make an informed decision.

Patient Perspective
  1. The patient maintained that the doctors did not adequately encourage him to undergo a PSA test to screen for prostate cancer.
    Many patients resist cancer tests without strong motivation and knowledge of risks and benefits. However, because of the risks and questionable benefits associated with early detection and treatment of prostate cancer, PSA is not just a simple blood test. PSA testing should not be done without the patient's consent. The choice belongs to the patient, who needs adequate information from the provider. CRICO/RMF and professional organizations such as The American Cancer Society believe health care professionals should offer a PSA blood test and digital rectal exam yearly for males over 50. Documented informed consent/refusal discussion should include the following points: prevalence of prostate cancer, important risk factors, nature the PSA test itself, normal PSA range, false positives and negatives, advantages/disadvantages to testing, and the risks and benefits associated with treatment if cancer is detected.

Risk Management Perspective
  1. The fact that multiple primary care providers cared for this patient may have impacted the patient's care and the opportunity for prostate cancer screening discussions.
    When patients change primary care providers, the potential for discontinuity and "lost" information increases. Over-reliance on patients to report past treatments or screening tests is one risk. Losing track of recommendations and the patient's follow-through is another. Mishandled transfers are a classic set-up for patient information to fall through the cracks without a robust system to prevent it. A reliable system will include reminders for screening exams and verification of test completion and/or referral follow-through with an ongoing list so that if one provider does not address an issue, it is less likely to be overlooked.

Legal Defense Perspective
  1. A lack of documented discussion of PSA testing potentially emboldened the plaintiff and his attorney to take the case all the way to trial, although the jury ultimately favored the defense argument that the negative digital rectal exams were sufficient evidence that the patient did not have prostate cancer earlier in his care.
    Adequate documentation of screening discussions can help prevent the trauma of malpractice litigation. The most common factors leading to professional liability claims related to prostate cancer in the Harvard medical system include: poor patient assessment (including family history and lack of DRE); test-related missteps (e.g. lack of PSA testing discussion or inadequate follow-up of testing that is done).

  2. Experts who reviewed the case for the defense stated that the cancer was very aggressive and that an earlier PSA test may not have changed the outcome.
    A so-called "causation" defense can be very difficult once the plaintiff meets the requirement to prove negligence. However, the plaintiff must ultimately prove that the ascertained negligence caused the patient harm.