An article for physicians by physicians
Originally published September 2010 P1003-14-E
Suggestions to reduce risk and optimize the timely diagnosis of lung cancer.
Lung cancer remains the leading cause of cancer death for both men and women in Canada.1 As with other types of cancer, a delay in the diagnosis of lung cancer may have a detrimental effect on the patient's prognosis. However, timely diagnosis may elude even the most skilled physician. System failures and physician performance issues may contribute to a delay in diagnosis.
The CMPA reviewed legal cases and complaints made to a regulatory authority (College) that involved a delay in the diagnosis of lung cancer, including all open cases and those cases closed between 2003 and 2009. A total of 89 cases were identified, of which 78 were closed. Most of the patients in the case series presented with one or more respiratory or systemic symptoms (e.g., persistent cough, hemoptysis, dyspnea, chest pain or weight loss).
System failure: The lack, malfunction or failure of policies, operational processes, or the supporting infrastructure for the provision of health care.
Provider performance problems: Issues affecting the performance of an individual provider, e.g., a gap in the provider's knowledge or skills; a violation or departure from a known, relevant, realistic and clearly written policy; or a health condition of the provider that impedes clinical performance.
Of the 78 closed cases reviewed, half (39) had more than one clinical issue. Peer experts (other physicians working in the same kind of practice) retained to review the cases were of the opinion that the following primary issues contributed to a delay in the diagnosis of lung cancer:
Delay or failure to order initial diagnostic tests,
e.g., chest X-ray
This was most often due to inadequate evaluation of patients who presented with respiratory symptoms (e.g., persistent cough, dyspnea) and/or risk factors (e.g., history of smoking).
Failure to detect an abnormality on diagnostic imaging studies
Delay or failure to respond to abnormal test results or to arrange appropriate follow-up
In many of these cases, system failures contributed to the diagnostic delay. The experts maintained that an effective system or process to manage test results could have prevented the aforementioned issues. These system failures occurred in a variety of care locations including hospitals, clinics, urgent care centres and physicians' offices.
Case summaries — The following case summaries illustrate some of the circumstances that led to a delay in the diagnosis of lung cancer.
A 45-year-old woman who was a heavy smoker presented to her family physician (FP) with flu-like symptoms and a six-week history of right upper chest pain radiating to her neck and right arm. The FP ordered chest and sinus X-rays; the location of the patient's pain was clearly indicated on the chest
X-ray requisition. The radiologist reported both X-rays as normal. After considering the X-ray results, the FP concluded the pain was musculoskeletal in origin and arranged for physiotherapy.
When the chest pain increased 10 months later, the FP requested a second chest X-ray and a thoracic spine X-ray. A different radiologist noted the presence of a four centimetre right upper lung mass. The FP promptly referred the patient to a respirologist. Upon review of both chest X-rays, the respirologist noted the presence of the lung mass on the first X-ray and an increase in mass size on the second X-ray. A computed tomography (CT) scan showed invasion to the chest wall, third rib and thoracic vertebrae. The patient was subsequently diagnosed with a Pancoast tumour. She underwent a surgical resection and radiotherapy. She died three years later. The patient's family started a legal action alleging the first radiologist misread the initial chest X-ray, which led to a delay in diagnosing and treating the lung cancer.
Experts were of the opinion that the first radiologist failed to detect the lesion on the first chest X-ray, even though the clinical information on the X-ray requisition directed him to the correct side. The experts also commented that the second chest X-ray revealed a progression of the lesion by approximately 30% and also revealed signs of posterior mediastinal invasion that were not present on the first chest X-ray. The experts believed the delay in diagnosis may have contributed to the inability to carry out a complete surgical resection of the cancer, and produced a more unfavourable outcome. Without expert support, the CMPA paid a settlement to the estate on behalf of the first member radiologist.
A 60-year-old man with recurrent reflux esophagitis post-hiatus hernia repair presented to the emergency department (ED) with chest pain radiating down his right arm. Querying cardiac or gastrointestinal (GI) conditions, the ED physician ordered a chest X-ray and cardiac workup. There was no radiologist present during the night. The ED physician reviewed the chest X-ray and commented only on the hiatus hernia. Despite a negative cardiac workup, the patient was admitted overnight pending reassessment by his regular FP in the morning. The patient had an uneventful night and most of his discomfort subsided. The patient's FP believed the patient's symptoms were mostly
GI in origin and discharged him with follow-up investigations.
Eight months later, the patient presented to his FP complaining of increasing chest discomfort, shortness of breath and cough. A chest X-ray revealed a large left lung mass with associated pleural effusion. It was at this point that the FP learned that the radiologist had reported a left upper lobe mass on the chest X-ray that had been performed in the ED eight months earlier, and that he had recommended a CT scan of the thorax. On review of the patient's office records, the FP discovered that this initial X-ray report had been filed without his review. The patient was subsequently diagnosed with stage IV non-small cell lung carcinoma with pleural and bone metastases. He underwent palliative treatment and died shortly thereafter. The patient's family started a legal action against the family physician and the hospital, alleging failure to follow-up the initial X-ray report in a timely manner, thereby impairing the patient's survival.
The expert concluded that the patient's cancer was most likely at clinical stage I at the time of the initial chest X-ray. Had the cancer been detected at that time, it would have increased his life expectancy. Although supportive of the FP's care, the expert was critical of the FP's office procedure for reviewing and following-up test results. In addition, the hospital administration discovered that the initial chest X-ray report had not been sent to the ordering ED physician, despite an automated report distribution system. As there was no expert support, the CMPA, on behalf of the member FP, and the hospital, for its role in the diagnostic delay, contributed to a shared settlement to the patient's family.
Managing your Medico-legal risks
Based on expert opinions found in this case series, the following risk management considerations are suggested:
Have you considered lung cancer as part of the differential diagnosis when a patient with risk factors presents with symptoms that may be indicative of this condition? If so, have you performed the appropriate diagnostic tests?
Does the completed diagnostic imaging requisition contain pertinent clinical information?
As a radiologist, have you considered the information on the requisition?
Is there an effective tracking system in place in your practice or facility for the review of diagnostic tests?
Have you followed up with the radiologists' recommendations for further diagnostic tests?
Have you confirmed the appropriate resolution of an imaging abnormality, particularly if the patient's condition fails to improve?
Is there a continuous quality improvement process in place in your practice, hospital or facility?
1. Canadian Cancer Society's Steering Committee: Canadian Cancer Statistics 2009. Toronto: Canadian Cancer Society, 2009. April 2009, ISSN 0835-2976. [cited 2010 Mar 4]. Available from: http://www.cancer.ca/statistics.