Delayed Diagnosis of Lung Cancer Leads to Metastasis

This case involves a fifty-two-year-old female patient who presented to the emergency room complaining of an irritating cough for the past three months. The patient had a family history significant for lung cancer on both the maternal and paternal sides. Over the course of several weeks, the symptoms became worse and were not responding to conservative treatments. According to the records, the patient had several episodes of hemoptysis which prompted the patient’s primary care physician to order chest imaging that was interpreted as normal. The physician assumed the hemoptysis to be from persistent coughing and did not investigate further. The health care provider continued to regularly follow up with the patient but failed to advise further investigations like a high-resolution CT or bronchoscopy in spite of the patient having a high risk for cancer. The patient continued to display similar symptoms over the next six months until finally another CT-chest was ordered that showed a 5 cm mass in the left upper lung lobe. She was placed on a chemotherapy treatment using Taxotere, but was diagnosed with metastatic cancer in the liver; neither a lung nor liver transplant could have saved her by the time the diagnosis was made.

Question(s) For Expert Witness

1. Did this patient's symptoms require further workup such as a high-resolution CT or bronchoscopy to stage the disease?

Expert Witness Response

Lung cancer is one of the leading causes of mortality in both females and males worldwide. Risk factors include a family history of lung cancer, history of smoking, and even exposure to secondhand smoke. The treatment options include radiation, chemotherapy, and surgery, but deciding which modality to pursue is dependent on a detailed and accurate assessment patient. Lung cancer staging involves identification of the tumor, lymph node involvement, and metastatic spread. In this case, the primary care physician should have further worked up the unresolved hemoptysis by consulting pulmonary for possible bronchoscopy and further evaluation, given the patient's family history of lung cancer and symptoms. The workup of any newly diagnosed lung malignancy includes high-resolution CT and bronchoscopy would have helped in diagnosis of the tumor confirming lung malignancy. A bone scan or PET scan should also be performed to evaluate for metastasis.