Would revealing test results have changed cancer outcome?

Question asked in my local paper to MD - DO YOU AGREE WITH ANSWER?


"Question: My husband has stage 4 prostate cancer with a Gleason score of 9. He has metastatic disease to multiple sites in his spine, pelvis and shoulder. He was diagnosed January 2015. His PSA was 85.3. He is receiving the standard care with androgen deprivation
therapy (Lupron, Zytiga and infusions of taxotere). His prognosis is grim. A routine checkup in October 2013 revealed a PSA of 11.2. Our doctor did not act on this elevated lab. We were not notified of the abnormal results, and no retest was ordered, no referral to urology or biopsy was recommended. When my husband started having
symptoms (urinary frequency) at the end of 2014 and sought treatment, he already had advanced disease. We are now being
told that because his Gleason score is 9, it doesn’t matter that he was not treated in October 2013. His prognosis still would be terminal. We are having a hard time believing that he would not have
a better outlook if it had been treated early, before it spread outside the prostate, even though his cancer is aggressive. My husband
is 62 years old and has always been strong and healthy, until now. —
C.C.

Answer: I am very sorry to hear about your husband. The Gleason score is a measure of the cancer cells’ aggressiveness and rate of growth. It isn’t a perfect test, but the higher the Gleason score
the more likely the cancer is to spread. It certainly is true that cancers with high Gleason scores are harder to cure, and that
even if it had been acted upon earlier, he still may have developed advanced disease.
There are some prostate cancers that cannot be found by any currently available technology at a stage when they are early
enough to cure, and this may have been one of those types.
However, there is no way to know for sure. The doctor’s apparently overlooking the results was a serious mistake, based on what you are telling me.
Even if it weren’t curable, intervening earlier at least
would have had the possibility of slowing down the
progress of the disease.
As a physician, I realize that none of us is perfect, including me."

Bobby Mac

PSA level 4 has been the standard used to suggest start diagnoses. Early on, he should have been put on anti-biotics to see if that would lower the PSA. If it failed then further investigation should have been done.

This is a sad sad situation and imho totally inexcusable. Frankly I had a somewhat albeit much less onerous situation. My PSA doubled but was less than 4.0 and since I was taking finasteride the reading should have been doubled. My doc said nothing until a year later when it doubled again and passed the " magic" 4.0 threshold. Then he retested to confirm the reading and sent me to a urologist who ordered a bx which found gl9 PCa. A few months later I had RP which disclosed that PCa had escaped the prostate. I was very upset and considered suing my GP. But no one would take the case saying malfeasance would be too hard to prove.
Sadly, this proves the point that one must look out for ones own interests. I would have asked until I had an answer about the high PSA reading assuming of course that I had received, and if not, requested a copy of my labs.
With GL9 it most likely would not have made a difference in the long run but surely the development of distant mets could have been delayed if not halted with radiation and ADT.
Bob

Reminds me a little of someone's question long ago: "For those for whom a cure is possible, is it necessary, and for those for whom a cure is necessary, is it possible?". Or something like that.

I think it's harsh to just throw up his hands at G9 diagnosis and say it was hopeless from the outset. That is missing a great deal of progress in treatments. Maybe that was true 20 years ago, but I don't think it is today. Much can be done for us that simply wasn't available until just the last few years.

Cure? Probably not, but likely a decent remission and many years of good life. I always come back to our own forum's dear Todd1963 as a lighthouse of hope to anyone facing a severe diagnosis. We're in treacherous seas for sure, but there is absolutely hope. I would be quite disappointed in a doctor with such a defeatist mindset, and would fire him immediately.

Anytime a doctor doesn't deal with and inform the patient of any test that is outside the normal range they are breaching the standards of good practice. If you are not going to do anything with the results then why did you order the test? At the very least send them to the patient.

This situation would be like the doctor taking my blood pressure and finding it was 200/120 for a few years and never once mentioning it to me. Clearly malpractice.

Mel said...
I'd also like to add: I suspect the doctor knows he screwed up royally and is just blowing smoke to try and deflect that fact that he made a major, inexcusable error.

Just to be clear, the MD responding has a syndicated column in newspapers and is not the MD in question, who ordered the PSA test.

Bobby Mac

BobbY:

I understand. But the original question in the column said:

>>>>>>>>>>
We are now being
told that because his Gleason score is 9, it doesn’t matter that he was not treated in October 2013. His prognosis still would be terminal.
>>>>>>>>>>>>>>>>
This is what I was referring to. The doctor (not the one answering the question in the newspaper) is blowing smoke, knowing he screwed up.
Anyway, that's my supposition.

Mel

JNF: I agree. It would be hard to establish damages, although I am convinced this is malpractice.

In fact, take the more extreme case: A doctor ignores a test/scan result that clearly shows a tumor. It is discovered 2 years later. Damages? I think the plaintiff would prevail.

In fact, could punitive damages be a possibility?

Mel

I'd be very angry. My husband's GP told me to cool down after we waited 2 weeks for a consult after a PSA of 28 with no appt in sight and I was losing my mind. She was shocked when I mentioned the high risk of PCa and said, "I never said anything about cancer". I obtained the blood results and it was there is black and while, along with a low PSA free ratio. OVER 90% RISK OF PROSTATE CANCER. GP clearly hadn't even bothered to read them.

The doctor hadn't even placed an urgent consult. We haven't returned to her because if she's not tearful and apologetic, I'm afraid of what I might do. Like the doctor she took over for, she doesn't do PSA screens and "let" my husband have a PSA test when he was symptomatic. Of course, he had to pay $52 for it.

Regarding the legal liability of the case in the original post, I wonder what the effect of the Task Force Guidelines would be? The Guidelines challenge the benefit of routine screening. If a GP convinced a man that PSA screening would do more harm than good, and he was later found to have high risk/mets cancer, I think the Guidelines would protect the doctor from legal liability.

My son responded.
He prefers not to be quoted.

So, let me just say that it is VERY complicated and depends GREATLY on the State.

The laws vary tremendously, especially in terms of how the standards of damages are set.

I'll leave it at that: an academic discussion.

Mel

I think the elephant in the room as we speak is the fact that even now... unless I missed it...is how is the patient doing....( drum roll...cymbal crash)...right now and what could even an avg attorney do with that information??

Yeah.

The first uro I went to (twice) found nothing, but I thought his attitude sucked...arrogant and that constant lying thing..."it will only take 15 minutes" before 45 minutes of torture. Screw that, went to my current uro when the PSA went up to 11.1 from 7.5. The rest is history for me.

My opinion here is this: "let the buyer beware". YOU are your own best advocate. YOU must get educated on the topic so YOU can make the best decisions for YOU.

THAT is why you are here and not twiddling your thumbs elsewhere while someone else makes these life-or-death decisions for you.

I gots to ask...Bobby Mac...How is the patient doing at this point...I guess Im just silly...but it does seem very very germane to the discussion....Or is this just another news report that gives the bad news and not any following good news...cause good news deflates and bad news inflates..I will consider no response to the question...as...you don't know....I just thought of something...maybe Im the elephant in HW's parlor...ouch...