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Screening Expectations

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Background

Allegations that a patient’s colorectal, breast, or lung cancer should have been diagnosed sooner are among the most common type of malpractice claim. Over the past 10 years, 
44 percent of 113 such cases filed against CRICO-insured providers have resulted in a payment to the plaintiff— compensation (on average $773,000) for a missed opportunity for curative treatment or, at least, a better life with the cancer. However, claims alleging that an asymptomatic patient was not offered screening at the recommended age or interval are much less common than cases involving patients with known symptoms, a personal history of cancer, a family history of cancer, or a combination of those factors.

Patients—and clinicians—are challenged in how to sort out the vast amount of information available about cancer screening. For example:

study reported in the April 2007 Radiology supports the use of CT screening for detecting lung cancer early enough to enable a 10-year survival. Conversely, the United States Preventive Services Task Force recommends against general lung cancer screening on the grounds that earlier detection does not reduce mortality.

The New York Times recently suggested that the United States death rate for colorectal cancer could be cut in half if everyone over age 50 underwent screening. Meanwhile, White House Press Secretary Tony Snow reported that he was first diagnosed with stage III colon cancer after undergoing screening “every two to three months” because of a strong family history of the disease. He has since been diagnosed with an aggressive recurrence.

And, a study published in the online edition of the journalCancer indicates that fewer women had a mammogram in 2005 than did five years earlier. While access and cost are often cited as reasons why women skip annual mammograms, ineffectiveness is also being noted. Coincidentally, over that same five-year period, CRICO claims alleging a failure to diagnose breast cancer have declined significantly.

Our Recommendation

A sincere recommendation by a trusted physician is one of the key motivators cited by patients who do get screened. But primary care providers (PCPs) may need to be cautious about “overselling” cancer screening. For an asymptomatic patient, a screening recommendation requires a discussion beforehand to set appropriate expectations about the realistic benefits and limitations associated with each screening modality. After the results are known, the communication needs to continue—either to properly frame a negative report, or to address an abnormal finding.

When a patient declines recommended cancer screening, the PCP needs to explore (and document) such a decision to be certain that it is based on a full and accurate understanding of what the screening entails, the benefit of early detection, and the risk of a delayed diagnosis. For patients with a higher-than-average risk (i.e., personal history of cancer, family history, genetic markers) who refuse testing, the physician may need to make a more concerted effort to persuade compliance.


June 1, 2007
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