Case Study
PCP/Specialist Communication Undermines Prostate Cancer Defense
Description
A 66-year-old male with lower urinary tract symptoms was diagnosed with benign prostatic hypertrophy one year before a diagnosis of advanced prostate cancer.
Key Lessons
- Primary care physicians should notify patients directly of abnormal test results.
- Successful communication between a primary care physician and a specialist, including the specific purpose for the referral, can help prevent a missed or delayed diagnosis.
- Physician practices need a reliable system for referral to specialists and review of their findings.
Clinical Sequence
A 66-year-old Spanish-speaking male with limited English proficiency saw his primary care physician for symptoms of nocturia and polyuria. The patient’s family often accompanied him to his appointments so they could help with translation. The PCP ordered a PSA test, and the level was 12.8 (normal 0-4), prompting a urology referral for further evaluation. The patient was not directly informed of the elevated PSA level; a formal referral outlining the reason for the consult, including a high PSA level, was not documented.
During his initial evaluation of the patient, the urologist referenced lower urinary tract symptoms and nocturia as the reason for referral. A GU examination and DRE were normal. The urologist diagnosed BPH and started the patient on Flomax and Ditropan. No lab values were drawn, but the patient was advised to follow up in a few weeks.
At the follow up appointment with the urologist four weeks later, the patient reported an improvement in symptoms. The urologist repeated the GU exam and DRE, which were unchanged. The patient was advised to follow up in one year with a plan to obtain a PSA level at that time.
The following year, during follow up with the urologist, another GU exam and DRE were unremarkable. The patient’s PSA was 13.3, which raised concern for prostate cancer. A transrectal ultrasound with a needle biopsy confirmed the diagnosis of adenocarcinoma of the prostate, with a gleason score of 7 on the right lobe and 9 on the left. During a follow-up visit to the urologist’s office with his son, the patient was told that he had advanced prostate cancer. He was referred to a radiation oncologist.
The initial evaluation with the radiation oncologist occurred the following month. A bone scan and abdominal/pelvic CT showed no obvious adenopathy or metastases; however on GU exam and DRE, the oncologist identified a fixed pelvic mass with perineural invasion. All treatment recommendations were reviewed through an interpreter. The patient was advised that the cancer was inoperable due to invasion of seminal vesicles and perineural invasion, and that his only option was radiation therapy. The patient was given eight weeks of radiation therapy and two years of hormone therapy. He completed treatment recommendations and his last PSA was normal. The patient, who continues to be monitored, was advised that the advanced stage of the cancer meant he was at high risk of failing local therapy.
Allegation
The patient sued his urologist, claiming that negligent care led to a delay in the diagnosis and treatment of prostate cancer.
Disposition
The case was settled in the mid-range.Analysis
Clinical Perspective
- Faced with worrisome PSA values for this patient, the PCP relied on a referral to urology to diagnose the patient’s symptoms, yet did not share the PSA values with the patient or the specialist, and did not react to the specialist’s report when it did not address the worrisome PSA values.
Patients generally are not reliable reporters of critical clinical information in the referral process. A formal referral should include the concerns and relevant data related to those concerns. Otherwise, a specialist will rely on patient complaints and new evaluations to guide his or her differential diagnosis. A PSA test is not indicated for complaints of nocturia and polyuria. Absent any information about prior PSA testing, a DRE and GU examination would be appropriate to address prostate cancer in a specialist’s differential for those symptoms. A referring physician’s practice should have a reliable system for ensuring that a specialists report comes back and is reviewed by the referring provider.
Patient Perspective
- The patient argued that the urologist should have ordered a PSA level when he presented with urinary frequency and nocturia.
Symptoms such as nocturia and urinary frequency do not indicate increased risk of prostate cancer. Providers treating these symptoms should discuss the limits and risks of PSA testing so patients understand recommendations and conclusions. PSA tests have not been shown to reliably result in earlier diagnosis of prostate cancer; earlier diagnosis of prostate cancer has not been universally shown to significantly reduce mortality and morbidity, as major studies disagree on this point so far. - The patient felt that he should have been diagnosed earlier, and if he had, he would have been an operative candidate; yet one of two DREs, a bone scan, and a pelvic CT failed to confirm the cancer after it had been identified by other means.
Findings between DREs performed by two physicians can be significantly different, reflecting the subjective nature of the exam. Even objective tests, such as CT and bone scan can also fail to detect abnormalities. A patient receiving bad news and disappointing options may find comfort in knowing that the care leading up to the diagnosis was proper, but the reassurance must not be self-serving.
Risk Management Perspective
- Communication between the PCP and the urologist should have occurred before the urology evaluation to specify the reason for referral, and after the evaluation to summarize findings and plan of care.
PCPs can improve the potential for a timely and appropriate evaluation by completing a written referral that outlines diagnostic findings and the reason the patient requires a specialty evaluation. A specialist should provide the PCP with feedback of his findings, including a copy of his initial evaluation, follow up recommendations and plan of care. - The patient should have been notified of his abnormal test result and advised of the need to follow up and discuss further with his physician.
Physicians need a reliable system to notify patients in writing of all abnormal test results. It is necessary to document discussion with the patient about the need to follow up with their physician for further evaluation. - Use of a medical interpreter may have led to a more thorough history and physical. It would also have increased the chances that the patient understood his test results and the need for further evaluation.
Inadequate communication can have tragic consequences. A medical interpreter should be used for communication when a language barrier is present. Family members are not a first choice for interpretation, due to the potential for cultural bias and personal agendas.
Legal Defense Perspective
- The defense successfully argued at tribunal that there are no practice requirements for obtaining a PSA level for prostate screening, and that the patient’s symptoms improved with treatment. Even when a legal defense is successful, the difficulty of enduring a malpractice claim may be avoidable. Several elements of a medical case can lead to allegations of negligent delay in diagnosis: the failure of a provider to notify the patient of abnormal results, lack of communication among providers caring for the same patient, and failure of a specialist to order a diagnostic test. Efforts to create reliable office systems to facilitate communication and follow-through that prevents these failures can help minimize risk of a claim being brought.
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