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.