Jodi L. Nofsinger, trial lawyer and partner at Berman & Simmons

Medical Malpractice—Basic Rules of Cancer Screening

Early diagnosis and treatment of cancer is important because it leads to gentler and more effective forms of treatment. Responsibility for providing the testing that leads to early diagnosis rests primarily with family doctors, who are trained to understand and use widely available screening tests, even for patients without symptoms. This article provides background information on screening for four common cancers that can and should be caught early through the use of inexpensive and widely accepted screening tools. A physician’s failure to inform patients of the availability and advisability of routine screening can result in significant delays in diagnosing cancer, and may be negligence that severely harms a patient.

Colorectal Cancer Screening
In primary care medicine, the rule for screening an asymptomatic patient for colorectal cancer is crystal clear: the standard of care is that each patient who is at “average-risk” should be referred to a specialist for a flexible sigmoidoscopy or colonoscopy at 50 years of age. An “average risk” patient is one with no history of adenoma (pre-cancerous polyps), no prior diagnosis of a colorectal cancer, no history of inflammatory bowel disease, and no close family members with a history of adenomas or colorectal cancer. If the scoping procedure reveals no polyps or cancer, then future scoping procedures should occur at regular intervals (every 10 years if by colonoscopy, every 5 if by sigmoidoscopy). If adenomas are found, they are removed during the procedure and examined by a pathologist. The type and size of polyps then determines what screening the patient will require in the future. A patient with small, low-risk adenomas will require a colonoscopy in 5 years. A patient with larger or higher-risk polyps will require a colonoscopy in 3 years.

Because there is a strong genetic component to colorectal cancers, patients with significant family history may require screening before they reach 50 years of age. Patients who have signs or symptoms of colorectal cancer require earlier or more frequent diagnostic examinations and tests. The most common complaint made by patients who have an undiagnosed colorectal cancer is rectal bleeding. Colorectal cancers are also known to cause anemia, weight loss, loss of energy, changes in bowel habits (size of stool, constipation, diarrhea), and abdominal cramping/discomfort. Regardless of age, a patient who complains of rectal bleeding should be asked about the bleeding and family history of cancers and adenomas. The doctor should look for the source of the bleeding (e.g. hemorrhoids) and perform additional testing until the source is found.

Breast Cancer Screening
Women should be screened for breast cancer at annual physical examinations beginning in the early 20s. The doctor should look for any palpable masses, nodules, skin changes, or thickened areas of breast tissue. A 20-40 year old patient with no suspicious findings on exam, no personal history of breast cancer and no significant family history of breast cancer, is a low-risk patient, and repeat examination need only be done every 1-3 years. Once this low-risk patient reaches the age of 40, she should have a mammogram every year.

Patients who have complaints or findings of lumps or masses require diagnostic testing (mammogram, ultrasound, and possibly biopsy) to determine whether there is benign or cancerous growth. Mammography cannot identify every breast cancer. Some women have dense breast tissue that can hide masses or make them difficult to see, and some lumps and masses can only be properly evaluated by ultrasound or biopsy.

Prostate Cancer Screening
There is significant debate among clinicians as to whether male patients should be routinely screened for prostate cancer through PSA (prostate specific antigen) testing. At a minimum, there should be a discussion between the doctor and the patient about whether an individual patient should undergo early detection screening. At age 40, the provider should initiate this discussion about the risks and benefits of prostate cancer screening. The argument against early testing is that some prostate cancers can be very slow growing, and may do less harm to the patient over time than the treatment for the cancer might. Surgical and adjuvant (chemotherapy and radiation) treatment can cause impotence, incontinence, and other complications. The problem with that argument, however, is that many prostate cancers, if left untreated, will cause the patient far more harm than the treatment for the cancer, and may lead to early death. The discussion with the patient must include both ends of the spectrum so that the patient can make an informed decision.

If the patient elects to undergo screening, there is clear consensus on how the screening is conducted. Beginning at age 40, the patient undergoes a digital rectal examination so that the provider can palpate the prostate gland to see if it feels normal. Blood is taken to test for PSA. If the PSA result is less than 1 mg/ml, the PSA test is repeated at regular intervals in the future. If the PSA result is greater than 1, or if there is concerning family history, the rectal examination and PSA testing is repeated annually. If the PSA score is over 4, then additional work must be done to determine if the elevated PSA is because of cancer or a benign condition.

Lung Cancer Screening
Unlike breast, colon, and prostate cancer screening, only high risk patients are screened for lung cancers. Risk factors for lung cancer are smoking history, radon exposure, some occupational exposures (certain chemicals and substances), personal cancer history, and family history of lung cancer, underlying lung disease, and second-hand smoke. For older, high-risk patients (typically with a long, and heavy smoking history), screening may be appropriate. Such patients receive a CT scan. If that scan reveals a nodule or an opacity (area that cannot be seen through), follow-up to assess that area is required.

Because lung cancer screening is currently only recommended for these high-risk patients, lower-risk patients are often not diagnosed until lung cancer has reached an advanced stage. Patients who complain of chronic coughing, blood with coughing, chest pain, or shortness of breath may require CT scanning and other testing. CT scanning is known to locate lung tumors as small as 5 millimeters.

Conclusion
Primary care providers are a patient’s first line of defense against cancer. They should know about the early cancer screening tools and when to use them. They should also know about the factors that increase a patient’s risk for cancer and the signs and symptoms of cancer. Although there may be benign causes of a patient’s complaints, it is the provider’s responsibility to rule out the most dangerous causes, such as cancer. Failing to follow well-established standards of care can lead to delay in finding and treating cancer, which can cause serious complications and death. Our firm handles many cases where providers have failed in this responsibility to their patients, and have allowed cancers to grow and spread, resulting in significant harm. If your life has been changed by the late discovery of cancer, it may be appropriate to have your medical records reviewed by an independent professional to evaluate whether you have been harmed by medical negligence.

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Berman & Simmons is the leading personal injury and medical malpractice law firm in Maine. For more than 100 years, our trial attorneys have represented those who have been injured or harmed by the actions of others. These personal injury cases range from car and truck accidents to the most complex litigation involving defective products and malpractice by healthcare providers. We are known as the firm that will stand up and fight for injured Mainers in disputes against big corporations and powerful interests.