Delay in diagnosing colon cancer

Presentation
A 44-year-old man came to his family physician with a three-day history of rectal bleeding.

Physician action
Anoscopy revealed a torn internal hemorrhoid and a double contrast barium enema showed diverticulosis. The patient returned to the family physician eight months later and reported continued rectal bleeding. At this visit, the patient claimed that the physician told him that the rectal bleeding was due to his diverticulosis and was not life threatening. For this reason (according to the patient), the patient never reported continued rectal bleeding to the physician, despite numerous office visits and op­portunities to do so.

Four years later, the patient came to the physician’s office with rectal bleeding and severe abdominal complaints. The family physician referred the patient to a gastro­enterologist.

Colonoscopy and later surgery revealed Stage IV colon cancer with metastasis to the liver. The patient underwent colon resection and chemotherapy but his prognosis was very poor.

Allegations
A suit was filed against the family physician alleging failure to fully evaluate symp­toms suggestive of colon cancer and delay in diagnosing colon cancer.
 

Legal implications
In reviewing this case, defense consultants stated that a double contrast barium enema was inadequate to investigate the patient’s rectal bleeding when he first mentioned it to the family physician. The standard of care required that either a colo­noscopy or sigmoidoscopy be performed.

The physician was also unable to testify that he had inquired about continued rectal bleeding when he saw the patient eight months later. The consultants felt the standard of care required the physician to inquire about the previous rectal bleeding instead of relying on the patient to report a continued problem.

Disposition
This case was settled on behalf of the family physician.

Risk management considerations
Failure or delay in diagnosing colorectal cancer is one of the leading causes of litiga­tion against physicians. Physicians can consider the following guidelines to help reduce liability in the area of colorectal cancer screening and diagnosis:

1. Stay current with clinical practice standards.
2. Screen your patients for colon cancer following a reasonable, authoritative guideline.
3. Have an informed consent discussion and include the risks, benefits, alternatives, and limitations of screening and the procedures involved. Document informed con­sent, and if appropriate, informed refusal.
4. Assess and document your patients’ family histories for hereditary risk factors, with special care toward ascertaining hereditary nonpolyposis colon cancer and familial adenomatous polyposis.
5. If the preparation for flexible sigmoidoscopy or colonoscopy is inadequate, repeat the procedure.
6. Document cecal intubation and careful withdrawal techniques in the colonoscopy report.
7. Recommend appropriate follow up, and consider implementing a patient reminder system.
8. Document informed consent, refusal, procedures, and follow-up recommendations.
9. Ensure adequate support systems, particularly patient reminder systems.