Family Doctor Misses Bladder Cancer in Geriatric Patient

This case involves a sixty-eight-year-old male who became concerned after noticing blood in his urine. The man had recently retired from his job as a rubber factory worker. He also experienced difficulties with urination, which he described as painful and more frequent. His family physician believed that he had a kidney stone and worked him up for that diagnosis. After some testing, the physician indicated that he did not have a kidney stone and explained that his symptoms were most likely due to benign prostatic hyperplasia (BPH). The physician reassured him that many men his age experienced the medical condition. He was prescribed finasteride, to shrink the size of his prostate. A follow-up appointment was scheduled, and during his follow-up visit, the man indicated that the medication was not alleviating his symptoms. The physician reassured him that the medication took time to be effective. A month later, the man began to notice weight loss and was having trouble sleeping. He consulted another physician, who instantly became bothered by his symptoms and recommended he undergo a cystoscopy. He was referred to a urologist who performed the cystoscopy and diagnosed him with bladder cancer. Treatment required surgical removal and holmium laser enucleation with chemotherapy, which was poorly tolerated by the patient. The urologist told the man that he would not have required chemotherapy if the diagnosis was made earlier. Eventually, the man’s bladder needed to be completely removed with a neobladder reconstruction. He was given an artificial bladder that leaked and frequently caused infections.

Question(s) For Expert Witness

1. Did the family physician follow the standard of care for this patient?

Expert Witness Response

This physician properly listened to the patient’s concerns but did not consider all options for his symptoms. Although kidney stones or BPH would be a more common diagnosis, bladder cancer should always be considered in a patient with bloody urine. In this case, occupational history is paramount. Working in a rubber factory would expose someone to certain carcinogens that are responsible for the development of bladder cancer. Other contributing factors for bladder cancer include smoking, recurrent cystitis, low water consumption, and gene mutations. A cystoscopy should have been ordered to rule-out bladder cancer or other potential causes of symptoms. During the cystoscopy, a biopsy of the tissue will be taken to stage the cancer and determine treatment. Surgical treatment ranges from tumor resection to radical cystectomy. Chemotherapy and radiation may also be required for certain cancers.