Analysis of The Doctors Company's claims experience reveals that suits alleging delayed diagnosis of cancer continue to proliferate. Among the most common are suits involving colorectal cancer.
Colorectal cancer is common. One in every 20 American men and women will develop this disease. The following are primary reasons for delayed diagnosis of colorectal cancer.
Rectum and Rectosigmoid
Colorectal cancer is not necessarily the most likely diagnosis for any of these symptoms, yet the possibility must be considered each time a patient is evaluated for one or more of them.
This message was dramatically underscored by a study that retrospectively evaluated 100 consecutive cases of colorectal cancer.2The median delay from the onset of symptoms to diagnosis was 9.7 months. However, 30 of these cases were characterized by "severe delay" (median of 18.1 months, of which 14.7 months was attributable to physician delay and only 3.4 months to patient delay).
The lesson is not that every woman with menometrorrhagia requires a barium enema. Rather, every patient with iron deficiency requires screening for fecal blood loss and rigorous evaluation if any is found.
Inadequate evaluations are also frequently performed on patients with positive Hemoccults who:
In each of these settings, there is a tendency to feel that gastrointestinal blood loss is explained. It cannot be emphasized too strongly, however, that each episode of bleeding requires complete evaluation. The ease of iron replacement should not obscure the need to identify the cause of the problem.
Because symptoms often occur only relatively late in the natural history of the disease, physicians should carefully consider screening patients they see regularly.
The American Cancer Society (ACS) recommends yearly cancer-related checkups for people 40 and older. Beginning at age 50, ACS recommends the following colorectal testing schedule for both men and women:
With more than 100,000 new cases yearly, it is essential for physicians to be familiar with the specific risk factors for colorectal cancer. Patients with any of the following risk factors should begin colorectal cancer screening earlier and/or undergo screening more often:
With the widespread availability of barium enemas and colonoscopy, the diagnosis of colorectal cancer can usually be made easily. Unfortunately, the diagnosis can also be easily ignored until very late in the natural history of the disease.
Specifically note that the carcinoembryonic antigen (CEA) is not sufficiently sensitive to be used as a screening test for colorectal cancer.4In one study of 2,372 adults, 73 had an elevated CEA and 9 of those had an underlying cancer. 5By contrast, 25 patients in this group had cancer with a normal CEA. Thus, 88 percent of the CEA elevations were in patients without cancer. Expressed differently, there were 64 false positives for each new case of cancer detected by CEA testing.
*The digital rectal examination should be done at the same time as sigmoidoscopy, colonoscopy, or double-contrast barium enema. The American Cancer Society, Cancer Facts and Figures, July 1998, Atlanta, Ga.
Richard E. Anderson, M.D., F.A.C.P., a medical oncologist, is chairman and chief executive officer of The Doctors Company. A member of the American Society of Clinical Oncology and a fellow of the American College of Physicians, Dr. Anderson was a clinical professor of medicine at the University of California, San Diego, and is past chairman of the Department of Medicine at Scripps Memorial Hospital, where he served as senior oncologist for 18 years. Dr. Anderson is the editor of a book on medical malpractice, and his commentaries on legal reform and defensive medicine have been widely cited. He is the 2004 recipient of the PLUS Foundation Award for Outstanding Leadership in Healthcare Professional Liability.