Malpractice Case Studies

Inadequate Follow Up Alleged Delayed Cancer Diagnosis and Treatment Led to Metastasis

Written by ProAssurance Risk Management | April 2020

Allegation 

Plaintiff Alleged Defendant Internist Breached SOC Due to Lack of Follow-Up. 

Case Details 

The patient, a 69-YOWM (5’3”, 189 lb), presented to the ER with complaints of weakness, fatigue, and dysuria that onset the previous day. Due to the hematuria, a PSA lab was ordered. The PSA revealed a level of 28.5 ng/mL (0.0-4.0). Infectious disease was consulted and the patient was diagnosed with a UTI secondary to an enlarged prostate and partial urinary tract obstructions. The infectious disease physician noted that based on the elevated PSA, the possibility of prostatic cancer should be ruled out. 

The patient was admitted to the hospital and saw a urologist, who diagnosed acute prostatitis and a complicated UTI. The patient was prescribed antibiotics, and was instructed to have a follow-up PSA in five to six weeks. A transrectal ultrasound showed a large hypoechoic mass that was highly suspicious for prostate carcinoma, so a prostate biopsy was also recommended. 

The patient was discharged four days later with instructions to follow-up with the defendant internist in one week, and the previously seen urologist in six weeks. The patient called the urologist’s office to cancel the scheduled cystoscopy because he did not have the money to pay for the procedure; he never followed up with the urologist. 

One week after discharge, the patient saw the defendant internist. The patient completed new patient forms and noted diabetes, high blood pressure, prostate problems, and eye problems as past and current medical history. The patient also documented he was seeing the urologist, and that a PSA lab had been drawn during the timeframe he was admitted in the hospital. 

The patient’s reason for the visit was hospital follow-up and diabetes/hypertension. The defendant noted the patient’s HTN, DM Type 2 causing complication, BPH, and UTI. With respect to the BPH, the defendant internist noted “control with Flomax” and following with urologist. Three months later, the patient returned for follow-up. The defendant internist assessed the patient with DM Type 2 causing complications, HTN, BPH (noted as stable), and UTI. 

Five months later, the patient presented with SOB and an increase in his feet swelling. The defendant assessed the patient with CHF, New York Heart Association class IV, which was pending workup. He prescribed Lasix and the patient was instructed to call if the medication did not relieve his SOB. Due to problems with insurance, the internist scheduled an echo, EKG, and other blood tests later when the patient’s Medicare became available, per the patient’s request. The defendant internist also documented a chronic problem with BPH. 

The defendant internist saw the patient three times over the next six months, and ordered a lipid panel, PSA Screen, thyroid stimulating hormone, and Vitamin D labs during the last visit. The results were provided with the exception of the PSA screen. The PSA screen was not immediately available and was sent to another facility for analysis. Two days after the labs were drawn, the defendant sent a letter stating the lab results but did not mention the PSA results. The PSA lab eventually reported a level of 24.20 ng/ML but the result was not documented in the defendant’s chart. 

The defendant internist continued to treat the patient for the next 2.5 years before leaving the area. The patient continued treatment with the defendant internist’s former practice and saw another internist, who treated his diabetes, HTN, and kidney disease. The patient eventually stopped going to the group, and saw a new family medicine physician. During the patient’s initial visit, a PSA test was conducted which came back elevated at 48.6 ng/ML. The practice notified the patient of the result, and scheduled a urology referral in two weeks. 

The urologist recommended a transrectal ultrasound and biopsy of the prostate that the patient underwent six weeks after first seeing the urologist. One week later, the patient underwent a bone scan, which revealed focal areas of increased uptake in the proximal left humerus, lower right pelvis, and left scapular tip of the posterior left seventh rib, which most likely relates to osseous metastatic disease. 

The next day, the patient returned to see the urologist for a follow-up on the biopsy results. The urologist noted that a Gleason 9 prostate cancer was found in six out of six cores, and referred the patient to oncology. The patient visited the oncologist within a week and was started on Lupron Depot (hormone therapy), which continued to suppress the patient’s prostate cancer for over two years. 

Expert Testimony 

Plaintiff’s experts stated the defendant internist breached the standard of care by failing to obtain hospital records, follow-up on ordered labs, and collaborate with the initial urologist the patient reported seeing. Experts testified that these failures delayed the patient’s cancer diagnosis and delayed treatment resulting in metastasis and reduced survival rate. 

Defense experts stated the patient likely did not have metastasis while being treated by the defendant internist, based upon the various statistics set forth in the literature and prostate cancer nomograms. Supportively, when the patient’s prostate cancer was definitively diagnosed three years later, his metastasis was relatively limited. 

The case was settled with the consent of the defendant internist. 

Resolution 

When a physician orders a test, the physician is obligated to follow-up on the test results. The defendant internist’s failure to follow-up on PSA tests, and failure to refer the plaintiff to an urologist, resulted in a settlement being reached in the case. 

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