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No Screen, Then Colon Cancer


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No Screen, Then Colon Cancer

By Tom A. Augello, CRICO and Michelle Bondurant, RN, CRICO

Related to: Ambulatory, Clinical Guidelines, Communication, Diagnosis, Cures Act: Opening Notes, Primary Care, Other Specialties

An office practice lacked systems to screen every patient over 50.


  • Yvona Trnka, MD; Harvard Vanguard Medical Associates; Boston, MA


The following case abstract is based on closed claims in the Harvard system. Names and some details have been changed to mask identities.

A 62-year-old female patient presented to her long-time PCP with complaints of blood in her stool. A guaiac test in the office was negative. Her past medical history included hypertension, arthritis, peptic ulcer disease, obesity, and coronary artery disease.

She had never received colorectal cancer screening. Based on a 20-year relationship that included frequently missed appointments, the physician believed she would refuse screening tests for colorectal cancer.

Three months after her complaint of bloody stool, the patient returned with a complaint of abdominal pain. The physician prescribed an H2 blocker, Zantac, and noted a plan to obtain a right upper quadrant ultrasound if there was no improvement in her symptoms.

Failing to keep the next two appointments, the patient presented months later with improvement of her abdominal pain on Zantac and a stable weight. The patient was not anemic, and a CEA was within normal limits.

Over the next two years, the patient was seen for chest, abdominal and back pain, as well as hypertension. She was treated with Biaxin and Prilosec for presumptive H. Pylori. Three years after she first complained of blood in her stool, she received a comprehensive exam, and the physician noted a nine-pound weight loss. He characterized his review of gastrointestinal and urinary systems as negative “in general.”

Documentation does not include family history. This is significant since the patient’s sister had died of colon and lung cancer four years earlier. The patient had a pelvic exam during this visit, and subsequently went for a screening mammogram. But the record does not indicate that a rectal examination was performed. Lab results included low MCV/MCH; hemoglobin was 12.1, and hematocrit was 37 percent, both on the low end of the normal range and decreased somewhat from previous measures.

Recommendations on the lab sheet suggest follow up to include additional hemoglobin and stool tests. However, this information was apparently not addressed by the PCP nor communicated to her, even during an office visit four months later for a different complaint.

Two months after that—three and a half years after her initial complaint of blood in her stool—the patient presented to the emergency department with complaints of chest and abdominal pain. A chest X-ray was positive for pulmonary nodules and suggestive of metastatic disease. The patient died from metastatic colorectal cancer a month later.

Her children sued the PCP and the medical group, alleging failure to provide proper screening and testing, resulting in a delay in diagnosing colon cancer. The case was settled in the high range.

To discuss the patient safety and risk management aspects of this case, we spoke with Dr. Yvona Trnka. Dr. Trnka is Chief of Gastroenterology at Harvard Vanguard Medical Associates, a multi-site group practice in Boston.

Dr. Trnka, guidelines around colorectal cancer screening have been evolving in recent years, but was this patient a clear candidate for a colorectal cancer screen?

Yes, I believe she was.  She was 62 years old.  Even though there has been some evolution in the recommendations for colon cancer screening the longstanding recommendation was that screening of some sort begins at age 50.  It used to be screening sigmoidoscopy; now the thinking has shifted and the recommendation is that a screening colonoscopy, flexible sigmoidoscopy, and barium enema remain alternatives, but the preferred approach is colonoscopy and that is for asymptomatic patients starting at age 50.  So, she is 62 and a colon cancer screening possibility should have been brought up at age 50. 

And she has had symptoms so that in itself is a red flag and should raise the question again. Even if the patient may have refused in the past, for instance colon cancer screening for instance, when they later present with bleeding is another opportunity to raise the issue. And usually when patients are symptomatic they are a little bit more receptive to discuss the possibility of screening

Why didn't she get one? Can we read between the lines a little and recognize lingering barriers?

She is a noncompliant patient.  She doesn’t routinely come for frequent visits.  The physician may have made an assumption that she would refuse screening.  On the other hand she did agree to a screening mammogram so she obviously does believe in some form of screening and is compliant in that regard.  I think there is not only a patient barrier, but sometimes physicians feel that if the procedure is uncomfortable they may have a prejudice that the patient may not agree, but they should give them the option of discussing that and making that decision themselves.  

I believe that things really should not get into the way of possibly even discussing it at age 50.  I think it needs to start.  I actually strongly believe that the discussion should start already at age 40-45 where the physician should start asking about family history of the patient if they have anyone in the family with colon cancer or colon polyps should they have then obviously at the age of onset for those index members of the family is important. Because in that group of patients the colon cancer screening may start earlier, maybe recommend it at age 40.  So, from my perspective I think that it is very important for primary care physicians or any physician that is in contact with the patient, seeing them for another reason, if they see that screening has not occurred just mention it and raise the issues.

What kind of systems in the office practice are suggested by the fact that the patient's family history wasn't known, that recommended follow-up tests were not done, and even the non-compliance of this patient?

I think that there are several things that can be helpful.  Sometimes an intake form that the patient fills out as they are waiting to be seen is very helpful because if you put in certain categories that you want the patient to notice and fill out that may trigger what you’re going to do in the office.  So, in my office the intake form does have family history in it, what types of cancers are present in the family, and if the patient had colon cancer screening.  So, if you see that this has not been done then you can ask the patient right there and then and follow through.  I think that there are certain things that also need to have reminders in the office.  So, if I have a patient who has not done colon cancer screening or there has been some hesitancy about proceeding I send myself a reminder and the next time I see the patient in the office I raise the issue with the patient again.  If you have a patient who has had rectal bleeding, for instance, you need to have a reminder to ask them the next time you see them in the office has the bleeding recurred?  What’s going on?  If the bleeding is continuing obviously again approach the issue of colon cancer screening.

I think any office needs to be careful about how to document screening recommendations, patient refusal, lack of follow up, whether it is mammography or whether it is colon cancer screening or whether it is a PAP smear.  It is a high risk exposure for the physician and it is a potentially major problem for the patient if you have not screened them in a timely manner and not diagnosed something at an early stage as opposed to when it is metastatic. So, I think that every office should have some kind of a system where whether it is a problem list or whether it is failed recommendations or screening lists that you check to make sure that you mark “recommendations,” “patient response,” “follow up.”  That should be right when you open the chart so that you can remind yourself that something has not happened.

January 1, 2007
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