Case Study
Colon Cancer Diagnosis Delayed
Description
A 68-year-old man was never screened before being diagnosed with colon cancer.
Key Lessons
Systems are vital to facilitate reminders for routine screenings.
A presumptive diagnosis may blur the response to subsequent complaints/symptoms.
Patients can play a role in reducing risk if they are engaged in their care and understand the importance of recommended tests.
Clinical Sequence
A 68-year-old man, with a past history of cardiac disease, diabetes, hypertension, an MI six years prior, and prostate cancer two years prior (with radical prostatectomy, radiation and chemotherapy) saw his PCP of 20 years for a routine check-up. His physician noted that the patient “was fairly up-to-date, screening wise, but should have a colonoscopy sometime.” He had never had one, and the PCP intended to discuss this with him when he saw him for a more complete exam. Six months later, the patient returned to the PCP for a full physical, however, a discussion of a screening colonoscopy did not occur and no occult blood testing was done.
A year later, the patient presented to the emergency department complaining of epigastric pain for the prior three days. He was discharged, but returned the next morning with the same complaint. An abdominal and gall bladder ultrasound revealed a large gallstone. A GI cocktail was given and the patient’s symptoms resolved and he was discharged home.
Four days later the patient followed up with his PCP, again complaining of epigastric pain and reporting a 25-pound weight loss. No change in bowel habits or blood in his stool were noted. The PCP diagnosed the patient with peptic ulcer disease and prescribed Nexium. A month later, an upper GI was negative for an ulcer or mass.
After another six months, the patient called his PCP with complaints of crampy abdominal pain and bloody stools. The PCP referred the patient to the emergency department to rule out a GI bleed. In the emergency department, the patient reported lower abdominal symptoms for the past three weeks with the first incidence of bright red blood nine days prior. A colonoscopy was done and found to be positive for colon cancer. Subsequent testing revealed metastasis to the liver. The patient died three years later from his disease.
Allegation
The patient’s family sued the PCP for failure to properly screen for colon cancer, or follow up on symptoms, causing a delay in the diagnosis of colon cancer, and resulting in the patient’s death.
Disposition
The case was settled in the high range.
Analysis
Clinical Perspective
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According to clinical guidelines at the time, the patient did not receive colorectal cancer screening appropriate to his risk, based on age.
Use of current national colorectal cancer screening and clinical practice guidelines, such as the CRICO/RMF Colorectal Cancer Screening Algorithm, can assist clinicians in 1) assessing a patient’s level of risk for developing the disease, 2) offer an appropriate screening modality according to that risk level and the patient’s preference, and 3) identify the advantages and disadvantages of each selected screening modality.
For those individuals at “Average Risk,” the following screening modalities should be considered: either colonoscopy every 10 years; flexible sigmoidoscopy every five years, with or without fecal occult blood testing (FOBT); or annual FOBT (home test with three separate stools). For those at higher risk see the CRICO/RMF Colorectal Cancer Screening Algorithm. The patient’s symptoms were not adequately addressed by the PCP.
Having a cognitive fixation or narrow diagnostic focus can contribute to failing to timely identify a serious condition. Knowing a patient very well can lull a clinician into a lack of objectivity. Clinicians need to be encouraged to broaden their differential diagnoses, seek additional information, or consider a consult when dealing with a patient with continued symptoms or significant unexplained weight loss.
Patient Perspective
The patient was not aware of the importance of the recommendations for screening colonoscopy.
A long-term relationship between patient and physician is usually a positive attribute, and patients often take the recommendations of their doctor very seriously. Physicians should strive to increase awareness and encourage regular colorectal cancer screening at age-appropriate intervals. Document the counseling, education, and physician recommendations, along with the patient’s response, including deferral or refusal.
Risk Management Perspective
The PCP did not readdress a screening colonoscopy following the routine physical, as he had planned.
Health care providers are extremely busy people with an incredible amount of things to remember when seeing and evaluating their patients. Although a physician may contemplate ordering a screening test, a reliable system must be in place to ensure that the issue is addressed at the patient’s next visit. To ensure important issues don’t get overlooked, providers should routinely review their documentation of previous visits (e.g., previous complaints, tests ordered, results of those tests, previous plans of care, etc.) before evaluating their patients. Providers should also develop systems, whether electronic (e.g., imbedding guidelines/algorithms into their EMR) or paper (e.g., paper tickler file) that remind them when routine screenings should be scheduled.
Legal Defense Perspective
Experts for the defense team were unable to support the PCP, based on the standard of care for cancer screening.
Juries tend to support physician defendants when presented with evidence that they did what any other qualified physician in the same specialty would do. When guidelines exist for a specific clinical situation, documentation of the defendant’s adherence or rationale for following, or not following the guideline for a particular patient is crucial. Otherwise, the likelihood of a successful defense at trial is reduced, and financial settlement is in everyone’s best interest.
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