High risk patients are encouraged to get low dose CT scans of their chest each year for early detection of lung cancer. They anxiously await the results each year and have a quiet internal celebration when they learn their annual screening looked clear. Another year to take a cancer-free breath. In this weeks case, our pre-litigation expert explains how a “negative” test gave a false sense of relief.
What Happened
The patient was a middled-aged man with a long smoking history and a family history of lung cancer. He had quit several years back, but he was still very high risk.
His pulmonologist had very appropriately been ordering low-dose screening CT scans for the last 4 years. Each year, they came back with the same reassuring message of “No suspicious nodules” and a recommendation to continue annual screening.
When the calendar flipped and it was time for his next screening, he felt a sense of calm. After all, the prior scans had all been perfect and he hasn’t smoked in years. This should be no different.
But it was.
The result came back quickly with a “CRITICAL FINDING”.
There wasn’t just a suspicious nodule… there was full-blown metastatic cancer throughout his lungs. He passed away in less than 3 months.
What Went Wrong
Lung cancer can develop and spread quickly… but not typically THIS fast.
A quick glance at the DICOM images of our the prior year’s screening CT by our pre-litigation medical director confirmed our suspicion. Plain as day… an isolated tumor in the upper left lung.
This was not a subtle finding. It was right there for anyone to see. The only explanation is that the radiologist never saw these films… or they were going so fast that an obvious tumor wasn’t seen.
How We See It
Liability in this case is clear. It was a clean miss by the radiologist. When you put the normal CT from the year prior next to the CT with the missed finding, it is clear as day. There is not a juror on the planet who couldn’t recognized and assign liability to the radiologist.
Another consideration is whether the pulmonologist holds any liability as the physician who ordered the CT scans. This is a grey area with no CLEAR answer. In general, interpretation of a screening CT for lung cancer is not the responsibility of the ordering physician. Unless there is an equivocal finding by the radiologist, there would be no reason for the pulmonologist to independently review these images. This differs from the acutely ill patient in the hospital, where it is much more typical for ordering providers to independently review images in real time to make rapid clinical decisions.
Causation in missed cancer cases can be difficult to determine. Typically, just a few months of diagnostic delay has minimal impact on clinical outcome. In this case, however, the patient had a full year without treatment. Had the CT scan not been misinterpreted, the patient would have been much more likely than not to have a better outcome.
Pre-Litigation Pearls
When reviewing cases involving imaging, it is absolutely critical for our pre-litigation experts to receive and review the images themselves… not just the radiology report. A quick glance at the facts of this case… without the images themselves… would have resulted in a “DO NOT PURSUE” recommendation. After all, the prior year CT was interpreted as having no suspicious nodules, so why would there be a case?
Additionally, it is important to obtain the DICOM images rather than other image formats. This is the industry standard file format for radiology imaging and provides the most high-definition views. There are several free DICOM viewers available for download on both PC and Mac. Health systems ALL have access to these files and CAN get them to you in both disc and downloadable formats. Don’t let them tell you otherwise.
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(Cases in this series are real cases reviewed by our pre-litigation physician reviewers. We modify some details of the case and will occasionally modify some bigger factors to be certain the cases remain anonymous and can’t be identified by third parties. The take-home-points remain valid.)
