Delayed Diagnosis Allows Cancer to Double in Size

Case Summary

The patient in this matter was initially seen by an advanced practice nurse in the office of Dr. A (a Family Practitioner) in December 2012 with various complaints, among them: coughing, shoulder pain and fatigue. A chest X-ray and CT of head and sinuses were ordered. A diagnosis of sinusitis was made and symptomatic treatment was offered. The chest X-Ray was read by Dr. B (a Radiologist) as “normal”. Ten days thereafter, Dr. A documented that “CXR reviewed” and subsequent notes by Dr. A document pain, coughing, headache, sinus pain without response to saline, Flonase and Prednisone. Despite continued complaints, the diagnosis remained sinusitis and emphysema until the patient went to the Emergency Room one month later complaining of cough and shortness of breath. A chest X-Ray taken there revealed mediastinal and right sided lung mass and leukocytosis – a CT confirmed this finding. In February 2013, a superior vena caval stent was placed, which provided some relief for the patient. A right sided pleural effusion was drained and radiation therapy started. He was transferred out, where his condition further deteriorated – he ended up passing away about one month later.

Questions

Did the initial practitioners properly care for this patient when he presented for various complaints?  Was the imaging read correctly, and if not, did that contribute to a delay in diagnosis of the patient’s cancer? If there was a delay in diagnosis, did it contribute to the patient’s poor outcome i.e. would the patient have been able to pursue earlier interventions to prolong his life, had the cancer been caught earlier?

Expert Findings

AMFS expert (Hematology/Oncology) reviewed this case matter and provided the following opinion:  It is my opinion that the lung cancer was visible and diagnosable on the chest x-ray taken in early December.  It reveals that the mass was visible, and furthermore, the mass appears to have doubled within a few months. Failure to identify it and initiate a workup that would have led to the diagnosis of lung cancer constitutes a breach of the standard of care. It is my opinion that the cancer was in stage II in December of 2013, based on its rapid growth between the two chest X-rays was around 30% at 5 years. More likely than not, the patient would have lived with a reasonable quality of life for at least another two to three years. When he was actually diagnosed, the 5 year survival was close to zero. Treatment, at that time, would have also avoided a great deal of pain and suffering, both in the interval until the cancer was diagnosed and after it was diagnosed, until the patient’s demise.