Texas Medical Liability Trust

Failure to diagnose: prostate cancer

Clinical presentation
A 52-year-old man presented to a urologist in 1991 with an abnormal prostate. The physician felt a nodule on the prostate during the exam.

Physician action
The urologist suggested a prostatic ultrasound with possible biopsy. The patient said he was busy and would have a relative (a radiologist) do the ultrasound and return with the results. The physician did not hear from the patient until 1994, when he returned for a follow-up exam. The patient stated the ultrasound had been done in 1991 and the results were normal. He also indicated he had a normal PSA level, per his family physician. During the physical examination, the urologist determined there was still a small nodule in the left lobe, unchanged in three years. The patient was asked to forward the previous ultrasound and PSA results to the urologist’s office.

The patient returned 10 months later, March 1995, complaining of urinary frequency and decreased flow rate. The physician noted the prostate was enlarged and the PSA was slightly elevated to 4.04. Believing the elevation was due to prostatitis, the physician prescribed Floxin and asked the patient to return in two weeks.

The patient returned in April 1995 with a PSA of 4.3. The physician felt the increase was insignificant and due to infection. He wrote in his chart on a lab slip that the patient was to return in three months for a repeat PSA and exam. He did not document the repeat PSA in his progress note.

Three months later (July 1995), the patient returned complaining of a cyst on his scrotum. The physician did not recheck the PSA or perform a digital rectal exam as he indicated he would three months earlier. The cyst was described as benign.

The physician next heard from this patient in April 1996 when he called in for a prescription refill. The refill was authorized and the patient was instructed to come in for an annual exam. In July 1996, the patient called in for another refill and was told if he did not return for his annual exam, no more refills would be approved. The patient returned in August 1996. The prostate was still enlarged, but without a distinct nodule. During this visit, the patient stated he had been self-treating his symptoms with Floxin samples obtained from a urologist friend in Tennessee. The physician did not check the patient’s PSA, but instructed him to return in one month.

A month later (September 1996), the patient called in for a prescription refill, which was filled over the phone by the urologist’s partner. During this time, the patient had been to the gastroenterologist who took a PSA. The PSA was now 9.0. The gastroenterologist faxed the PSA results to the urologist, and told the patient to see his urologist due to the possibility of prostate cancer.

The patient did not return to the urologist, but called in for another refill in February 1997. At this time, the physician authorized the prescription and told the patient to come in for an exam. One month later, the patient returned to the urologist with a PSA of 12.0. A biopsy was scheduled for April 1997, and the patient later called and cancelled the appointment. After the physician personally called the patient and urged him to keep his appointment, he came in for the biopsy. The biopsy revealed a very aggressive form of prostate cancer. It was later found the disease had metastasized into the lymph nodes.

Allegations
• failure to diagnose prostate cancer in a timely manner

Legal principle
Initially, this case appeared defensible due to the patient’s noncompliance. However, the weakness in the case was the physician’s deviation from the standard of care in July 1995 by not following his own treatment plan and rechecking the patient’s PSA. TMLT consultants were supportive of the urologist’s actions, only criticizing his action in July 1995.

The plaintiff experts argued that, had the physician performed a PSA in July 1995, the cancer may have been detected, thus preventing the spread to the lymph nodes. However, it is impossible to tell what the PSA would have been in July 1995 and whether or not the cancer would have spread.

Disposition
Deviation from the standard of care and lack of proper follow-up contributed to the difficulty in defending this case, and resulted in a six-figure settlement during trial.

Risk management issues
The physician had no system to track diagnostic tests, in this case, both the ultrasound in 1991 and the repeat PSA test in 1995. Initially, the patient either failed to have the ultrasound or failed to forward the results to the physician. In April 1995, the physician noted the repeat PSA test on the lab slip, but failed to document it in his progress note or on a tracking system and it was overlooked at the next office visit. This, as well as failure to perform a digital rectal exam, was a deviation from the standard of care.

It is recommended that offices develop a tracking system to ensure that tests are performed and results are received. Physicians may wish to maintain a “diary” system to determine if results have been received by certain dates. Additionally, schedule test appointments for patients, and request that you be advised if the patient does not keep the appointment.

The patient was noncompliant and did not keep appointments. Physicians should develop a protocol for follow-up on cancellations and no-shows to assist in identifying patients whose conditions require a revisit. This reminds patients that it is important to follow through with appointments. Patients should be notified, either by telephone or mail. Documenting these calls or letters also demonstrates your efforts to contact patients should a problem subsequently occur.

Additionally, it is important for continuity of care, to document the return visit in the medical record. This process enables office staff to schedule the return visit while providing a system, which may prevent allegations of failure to diagnose and treat.