The MDU supported over 100 doctors over a two year period with complaints and claims relating to a delayed diagnosis of prostate or testicular cancer. Cases can arise for a variety of reasons but common themes included allegations of a failure to refer the patient, poor monitoring and problems with continuity of care when patients were seen by a number of different clinicians.
Below we examine the cases in more detail to help doctors learn lessons from the concerns raised by patients and their relatives and carers.
Types of cancer
Prostate cancer is the most common cancer in men in the UK. It is generally a disease of older men, aged between 65 and 79 years, but approximately 25% of cases occur in men below this age group. It is generally diagnosed after a finding an elevated prostate-specific antigen (PSA) level in the primary care setting.
Testicular cancer is less common, accounting for about 1% of cancers that occur in men. It tends to affect younger men between the ages of 15 and 49 years. Symptoms can include a painless swelling or lump in the testis or a change in the texture or shape of the testicles. There are different types of testicular cancer with the most common type being a seminoma, which accounts for approximately 50% of testicular cancers.
Of the 106 cases from 2015 and 2016 in which the MDU supported doctors, 92% involved GPs, with the other 8% being consultants. The majority of these were urologists, but other consultant specialities included general medicine, radiology and oncology.
Given that prostate cancer is more common, this may be why the majority of cases alleged a delayed diagnosis of prostate cancer (81%), with the other 19% alleging delayed diagnosis of testicular cancer.
Over half of the cases (57%) led to a claim for clinical negligence. The rest were NHS complaints with four complaints being made to the GMC.
Reasons for complaints included:
Patients diagnosed with testicular cancer commonly alleged there had been a delayed referral after they found a lump or other abnormality of the testis. One patient was diagnosed with an advanced seminoma secondary to an undescended testis. Three patients had metastatic disease by the time they received their diagnosis.
- Continuity of care problems
Patients alleging a delayed diagnosis of prostate cancer commonly had a variety of symptoms and medical problems, including urinary symptoms, haematuria, back and hip pain, erectile dysfunction and prostatic hyperplasia. In some patients who had seen a number of different doctors, poor continuity of care was felt to be a contributory factor to the diagnosis delay.
In one third of the cases related to a delayed diagnosis of prostate cancer, there had been a failure to act on a high PSA result or the patient had not been appropriately followed up with a repeat test or examination. One patient had prostatic hyperplasia and a raised PSA level. Another requested a PSA test due to a positive family history but had been refused, and was ultimately diagnosed with prostate cancer.
Avoiding diagnosis delays
Diagnosis of male cancers is by no means straightforward as symptoms and signs can be difficult to distinguish from less serious illnesses. However, there are steps that doctors can take to minimise the risk of a delayed diagnosis and the harm that can be caused to the patient. These include:
Be aware of recommended guidance
NICE recommends that a PSA test and digital rectal examination is performed for men who present with any lower urinary tract symptoms, including nocturia, urinary frequency, hesitancy, urgency or urinary retention. They should also have a PSA and rectal examination if they present with erectile dysfunction or visible haematuria.
Men should also be referred under a suspected cancer pathway referral if their prostate feels malignant on digital rectal examination or if their PSA level is above the age-specific reference range.
You should make a consideration for a referral under the suspected cancer pathway for patients presenting with a non-painful enlargement or change in the shape or texture of the testis. Also, consider a direct access ultrasound scan for men with unexplained or persistent testicular symptoms.
Diagnosis of male cancers is by no means straightforward as symptoms and signs can be difficult to distinguish from less serious illnesses.
Communicate your management plan
Good communication between a doctor and patient is paramount and can reduce the chance of a delayed or missed diagnosis, so discuss your management plan and agree the next steps with the patient. The management plan should include any investigations you intend to pursue, your proposed treatment and what response the patient might expect, possible side effects of any medications, the timescales of the treatment and plans for follow-up.
It is often helpful to give this information to the patient in writing (with diagrams if necessary) so they have a record of what you discussed and can refer to it in the future. Your discussion should also include safety netting advice, which tells the patient when to return if their symptoms do not improve and highlights signs and symptoms of concern that should prompt them to return more urgently. This information should also be noted in the patient's record.
Make referrals promptly
Have a robust system for reviewing and following up patients where an abnormal result has been noted to ensure action is taken. Where patients need further investigations, refer them quickly and efficiently for tests or to a specialist, and make sure you have systems in place that prompt you to write referral letters as soon as possible after a consultation.
Consider having a system in place for tracking test results, so if they don't arrive in the expected timescales you can follow them up. Similarly, it is important to have an arrangement in place for communicating urgent and non-urgent test results to patients so that any serious concerns can be quickly addressed.
Keep accurate records
Document the patient's relevant clinical history in the notes along with the details of any physical examination, including both positive and negative findings and any investigations you intend to carry out. Keeping accurate records is particularly helpful where a number of doctors are likely to be involved in the patient's care, to ensure that symptoms and test results are not missed and referral is not delayed.
When things go wrong
If something does go wrong you should be honest with the patient, explain was has happened and offer an apology. It is also important to try to put matters right by taking appropriate steps to deal with the consequences and arrange appropriate treatment and follow-up. Adverse incidents should be reviewed under your clinical governance procedures, in order to allow you to analyse and learn from any mistakes made.
Prostate test not acted on
A patient requested a prostate check as his father had died of prostate cancer in his early 60s. The patient was over 50 and the GP had agreed to check his PSA level and did a digital rectal examination, which revealed a smooth but slightly enlarged prostate gland.
The patient was told that he would be contacted if there was any concerns about the result, which was abnormal but was unfortunately filed away before it was reviewed by a doctor, and no follow-up was therefore arranged. The result came to light when the patient saw the GP a year later with urinary symptoms and was found to have prostate cancer.
Delayed diagnosis of testicular cancer
A 45-year old patient presented with a soft swelling in his right testicle, which he felt was abnormal. The GP examined this and diagnosed varicose veins and reassured the patient. The patient later presented with groin pain and was advised by another GP that this was muscular in origin.
The patient did not mention the previous consultation about the swelling, which was still present, and the second GP did not notice this in his records. The patient presented some months later with an enlarged and painful right testis. After an urgent referral, he was diagnosed with testicular cancer with renal metastases.
Dr Kathryn Leask BSc (Hons) MBChB (Hons) LLB MA MRCPCH FFFLM DMedEth
MDU medico-legal adviser
Kathryn has been a medico-legal adviser with the MDU since 2007 and is a team leader, trainer and mentor in the medical advisory department. Before joining the MDU, she worked in paediatrics gaining her MRCPCH in 2002 and did her specialty training in clinical genetics. She has an MA in Health Care Ethics and Law, a Bachelor of Law and a Professional Doctorate in Medical Ethics. She is also a fellow of the Faculty of Forensic and Legal Medicine and has previously been an examiner and Deputy Chief Examiner for the faculty exam. Kathryn is currently a member of the faculty's Training and Education Subcommittee.
See more by Dr Kathryn Leask BSc (Hons) MBChB (Hons) LLB MA MRCPCH FFFLM DMedEth