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Some More Talk About PSA

By Jock Hoffman, CRICO

Related to: Clinical Guidelines, Diagnosis, Primary Care

Liability related to prostate cancer is not about the efficacy of PSA testing. To reduce your risk of being sued, your best strategy is to talk the talk and walk carefully through the process.

Recently, the debate over the value of PSA testing to screen for prostate cancer spilled over from the clinical arena into the public discourse. In the public media, evidence-based medicine is undergoing a trial by jury…a jury of researchers, vested interests, public health administrators, politicians, and the blogosphere. Common data on the efficacy, timing, and cost/benefits of PSA tests are often cited to support contrary recommendations. Not surprisingly, patients of a certain age (although that too lacks consensus) are left to wonder what to do. Doctors too.

Whichever way the PSA winds blow, you will—now more than ever—need to discuss the options with your patients. If you agree on a course of action, document that decision. If a patient demands or refuses testing against your judgment, document that dissent and then work toward a mutually acceptable decision. Note, however, that once you do begin the PSA screening process, even non-symptomatic patients rely upon your ongoing attention to it (e.g., subsequent tests and your clinical judgment based on their results).

Since 2006, six of 19 cases naming a CRICO-insured defendant and alleging a failure to timely diagnose prostate cancer have closed with a payment to the plaintiff (average $396,000). Detailed study of CRICO’s prostate cancer cases—and those in our national comparative benchmarking system—indicates they most commonly involve communication or documentation breakdowns in: 1) discussions about screening; 2) tracking test results; and 3) following up those results with appropriate referrals or treatment. When we look even further, we note weakness at key points in the overall diagnostic process.

 


Common Factors in Failure-to-Diagnose
Prostate Cancer Cases

N=35 cases asserted 2006–10

percent
of cases*

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Patient fails to note problem and/or seek care 6%
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Inadequate history/physical and evaluation of symptoms 51%
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Failure to order diagnostic/lab tests 57%
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Faulty performance of tests 3%
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Misinterpretation of tests 14%
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Mismanaged receipt/transmittal of test results 40%
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Lack of physician follow up with patient 51%
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Mismanaged referral 34%
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Patient non-compliant with follow-up plan 14%
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* A case may have more than one contributing factor

 

PCPs are best protected by a proactive approach and perseverance. This begins with a (documented) discussion with risk-stratified patients about prostate cancer screening, particularly PSA testing. Patients who understand a) the limitations (and risks) of testing—including false positive and false negative results, b) the requirement for periodic retesting, and c) the ramifications of a worrisome finding, are able to make an informed decision.

The need for vigilance is universal. For patients who decline PSA testing, the topic should be revisited periodically (i.e., “no” is not necessarily “never”). Once PSA testing has been initiated, a system to track the results and trigger subsequent testing is essential. And, when patients present with non-cancerous prostate ailments (e.g., benign prostatic hyperplasia), the treating physician has to keep sight of the cancer screening regimen and beware of attributing all symptoms to the acute condition.

To help primary care providers in managing the risks associated with prostate cancer screening, CRICO has published PSA Testing for Prostate Cancer as a guide for the physician-patient discussion about the screening process. In addition to the relevant clinical information for physicians, the document features patient-education discussion points related to key elements of the PSA testing decision.

It’s a good conversation starter.

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October 3, 2011
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