Failure to communicate diagnosis of abdominal cancer

Presentation

A 29-year-old man came to the emergency department (ED) with complaints of abdominal pain, weakness, and fever. The symptoms began the day before, but became unbearable.

Physician action

The ED physician suspected appendicitis and requested a surgical consult. The surgeon, a defendant in this case, took the patient to the OR for an exploratory laparotomy. The surgeon discovered a ruptured appendix and a mucous-type substance around the appendix. This mucous proved to be a rare cancer called pseudomyxoma peritonei (PMP).

After the surgery, the surgeon told the patient that his appendix had ruptured, and that he had cleaned the peritoneal cavity. There was a dispute between the patient and the surgeon about whether the existence of the PMP was communicated to the patient. The surgeon did not specifically document the disclosure of PMP/cancer/malignancy to the patient. The patient claimed the surgeon told him not to worry about the “jelly-like substance around the appendix” because it had been removed.

Postoperatively, the surgeon sent the patient to a gastroenterologist (also a defendant in this case) to determine if there was any pathology involving the colon. At this visit, they discussed the patient’s family history of cancer, and a colonoscopy was scheduled.

A dispute existed between the gastroenterologist and the patient about whether the diagnosis of PMP was disclosed to the patient by the gastroenterologist. The gastroenterologist later testified that the patient brought the pathology report from the surgery to the office visit. The gastroenterologist’s dictated consultation report quoted language from the pathology report, but the specific disclosure of the PMP diagnosis was not documented.

The patient recalled a discussion about the “jelly-like substance” with the gastroenterologist, but claims the gastroenterologist told him it was a non-issue because it had been removed. The patient also said he was never told to consult with the gastroenterologist for PMP.

The gastroenterologist performed the colonoscopy and the results were normal. These results were reviewed with the patient and forwarded to the general surgeon. The patient was told to follow up with the surgeon, and he never returned to the gastroenterologist.

There was no record of a follow-up visit between the patient and the surgeon, but both testified to such a meeting. The surgeon testified he referred the patient to his primary care physician for follow-up treatment of PMP. The patient testified the surgeon told him “I think we got it all out and if it comes back, we can get it out again.” The patient maintained that neither the surgeon nor the gastroenterologist ever told him he had cancer.

Over the next four years, the patient saw his family physician for a number of unrelated complaints. During these visits, there was no mention of PMP, cancer, or any illness that would require further treatment or follow up.

Approximately five years after the appendectomy, the patient had abdominal pain again. He went to the ED and was seen by a surgeon. This surgeon performed a colonectomy for a pelvic mass seen on films. The patient was again diagnosed with PMP.

The patient was seen by a number of oncologists and ultimately went to a surgical oncologist. He underwent surgery and chemotherapy, and the PMP has not recurred. However, the patient tested positive for signet ring cells intra-operatively, which means there is latent evidence of remaining PMP. The patient must be monitored with CTs and lab work for the next 10 years.

Allegations

Lawsuits were filed against the surgeon and the gastroenterologist alleging failure to inform the patient of the diagnosis of PMP, and failure to refer the patient to a specialist for treatment.

Legal implications

The lawsuit against the surgeon, who was not a TMLT policyholder, was settled during the discovery phase of the claim. The case against the gastroenterologist continued to trial.

At trial, the plaintiffs presented an expert gastroenterologist who testified that the defendant fell below the standard of care in failing to inform the patient about the diagnosis of PMP, and by failing to refer the patient to an oncologist.

The patient’s family physician — who denied any knowledge of the PMP prior to the colonectomy — placed the responsibility for relaying the cancer diagnosis on both the surgeon and the gastroenterologist. He testified that one or both of these physicians “dropped the ball.”

An oncology expert testified that the delay in the treatment of the PMP resulted in more extensive and radical surgical procedures performed on the patient. The defense  gastroenterology expert testified that the defendant had no duty to disclose another physician’s diagnosis to the patient. The defendant was specifically asked to rule out colon pathology on the patient, which he did. He sent the surgeon a letter stating the same. The surgeon clearly did not intend for the gastroenterologist to take the lead and refer the patient to an oncologist because the surgeon told the patient to follow up with his family physician.

Patient responsibility became an issue in this case, with the defense expert testifying that the patient had a responsibility to follow up on his condition. It was suggested that the patient was in denial about the cancer, which is why he never mentioned it to his family physician.

However, the patient’s family physician testified that when he notified the patient of the PMP after the colonectomy, the patient seemed to be totally unaware of the diagnosis from five years earlier.

Disposition

The jury returned a verdict in favor of the plaintiffs, assigning 35 percent of the negligence to the gastroenterologist and 65 percent to the surgeon.

More on communication errors.
Risk management for gastroenterologists.
Risk management for general surgeons.

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