News: In 2004, an elderly man presented to a physician for a regular check-up, during which his prostate-specific antigen (PSA) levels were tested to screen him for prostate cancer. The result of the PSA test revealed unhealthy levels, suggesting cancer. Counter to the medical care facility’s procedures, the physician failed to refer the patient to a urologist. The patient returned numerous times for additional check-ups unrelated to prostate cancer. The physician screened the patient for prostate cancer several times during these visits.

Eleven years after the first PSA test, the patient visited a urologist at the same medical care facility who noted his high levels from 2004 and conducted another PSA test that revealed an increase in the protein to 130, well above healthy levels. The patient filed suit alleging, inter alia, the failure to diagnose caused a reduction in his life expectancy. However, because of the patient’s old age, the jury ruled for the defense because it found that an early diagnosis would not have prevented a life expectancy reduction since treatment would have been impossible.

Background: A man presented to his long-time primary care physician for a regular check-up in April 2004. The patient consented to a prostate cancer screening blood test for PSA. The PSA test returned a result of 4.5, but the patient was never informed of the results. The contemporary medical consensus is that a PSA result of 4.0 and less is a negative test result, and a result of more than 4.0 requires a biopsy to determine whether cancer is present.

In the years following the medical examination, the patient was seen at the same medical facility on numerous occasions, including for routine diabetes care, “well adult visits,” minor illnesses, and elective surgeries. The patient continued to see the primary care physician for annual visits and minor illnesses.

On Sept. 16, 2009, the patient presented to the physician for a well adult visit. The physician presented the patient with information about prostate screening. The patient consented to the prostate screening, which included digital rectal exam and PSA. The digital rectal exam was charted as normal and the patient was not notified of any abnormal PSA result. No follow-up was ordered, and the patient’s medical records did not reflect that a PSA was performed.

On Dec. 21, 2011, the patient presented to the physician for a “planned care visit to review medications, chronic conditions, and develop care plans as necessary.” The patient received information about prostate screening, just as he did in 2009, which included both PSA and rectal exam. The patient consented to the prostate screening. The digital rectal exam was described as: “prostate soft, normal-sized, non-tender, and symmetric without nodules.” The patient never was informed of any abnormal PSA result. No follow-up was ordered, and the patient’s medical records do not reflect that a PSA was performed.

Four years later, the patient saw a urologist at the same medical facility, who reviewed his medical record and recognized his high PSA levels in 2004 and the lack of follow-up PSA testing. The urologist also informed the patient of the medical facility’s policy that any patient with a PSA as high as 4.5 is required to be referred to a urologist. The urologist recommended a follow-up PSA test, which returned a result of 130. The patient then underwent X-rays and a prostate biopsy, which confirmed metastatic prostate cancer. The patient then quickly began cancer treatment, including chemical treatment and surgical castration, which likely caused him to have a shorter life expectancy.

The patient filed suit against the medical facility and the primary care physician, alleging that medical malpractice resulted in several types of damages. The defendants stipulated the physician was negligent in failing to follow up on the abnormal PSA test results and that such failure caused a delay in diagnosis of prostate cancer. The defendants disputed whether that breach in the standard of care proximately caused injury to the plaintiff, as his cancer was not treatable for cure in 2004 and, once the cancer was discovered and treated, the plaintiff responded well to treatment. The case proceeded to a two-week jury trial, resulting in a verdict in favor of the defense.

What this means to you: At first blush, this is a relatively straightforward failure-to-diagnose case, but the essence of this case is that the patient’s cancer would not have been cured in 2004 if the physician had made the proper diagnosis and followed up appropriately, resulting in a defense verdict. It is still unfortunate for the patient in this case that his diligence in consenting to prostate screening was met with a marked lack of diligence by the physician. At two distinct points, the patient consented to follow-up PSA testing, but did not undergo PSA tests.

Note also that the PSA test in this case can be used to establish its own baseline. When patients are treated for prostate cancer, it is imperative that physicians take a PSA reading after treatment. The patient should return later for another PSA reading. This process permits medical professionals to determine whether PSA levels increase post-treatment, indicating a cancer recurrence. One test showing a PSA increase is inconclusive evidence of a recurrence, or “biochemical relapse.” PSA tests may give false-negative or false-positive results, and a better indication of recurrence is a trend of increasing PSA levels over time. Thus, best practices for medical facilities in a prostate cancer case dictate multiple PSA tests for patients post-treatment.

The industrywide understanding within the medical community changes as a function of time. The patient in this case was castrated, a typical treatment for prostate cancer. Metastatic castration-resistant prostate cancer remains incurable despite decades of treatment improvement and evolution. This case provides an excellent study of why medical facilities must adopt policies that take change into consideration. Physicians must be encouraged to review the medical records to ensure test results and symptoms that were previously unimportant in the medical community are not alarming given current understandings. Had the physician reviewed the patient’s medical record with a careful eye in the numerous occasions during which he treated the patient, he would have noted the high PSA levels. Hopefully, armed with that knowledge, he would have followed the medical care facility’s procedures and referred the patient to a urologist.

In 2015, the patient was 80 years old and had a number of health comorbidities. As such, treatment of his cancer was likely dangerous, even in 2004. In fact, the defendants argued that the patient’s cancer in 2004 was untreatable given his comorbidities and old age. While the jury ultimately agreed with the defense’s position, the facts of this case highlight an important issue in the medical industry: treatment strategies of the elderly. When an elderly individual presents to a medical facility for specific treatment, it is critical that medical professionals establish a baseline of the patient’s comorbidities. Physicians should check for commonly occurring ailments that affect elderly patients, such as arthritis, heart disease, cancer, respiratory diseases, osteoporosis, diabetes, Alzheimer’s, dementia, influenza, and pneumonia. Creating a baseline allows medical professionals to see a high-level view of the patient’s overall health and permits a control to which one may refer when treatments change.

Moreover, at the very least, this patient deserved a discussion with the physician about his test results and the facility policy to refer him to a urologist for further workup. Regardless of age and number of comorbidities, every patient has the right to be informed about his or her medical condition, test results, options for care, and possible consequences for refusal of care. The physician’s failure to inform the patient of the possible presence of prostate cancer, a common killer of elderly men, was negligent. This patient was denied the ability to be informed about his health, make choices in his options for follow-up, and possibly extend his life expectancy.

Metastatic prostate cancer usually manifests in bone. It is a very painful condition that causes rapid deterioration in health. It is not a way anyone would choose to die. If the physician purposefully omitted telling the patient about the abnormal test result because he felt the patient was too old for treatment, then the negligence was deliberate and unconscionable. It denied the patient the right of self-determination. The defense in this case was very fortunate that the jury decided that the prior failure to follow up did not cause harm. Otherwise, if harm had been caused as a result of a deliberate decision denying the patient the right of self-determination, the patient’s lawyers would have pursued other causes of action, potentially yielding punitive damages.

REFERENCE

Decided on May 10, 2017, in the Superior Court of Washington, King County; Case No. 2016-2-10418-5.