Otolaryngology expert witness advises on standard of care in treatment of adenoid cystic carcinoma

An otolaryngology expert witness advises on a case happened in Arizona involving a thirty-five-year-old female who was diagnosed with adenoid cystic carcinoma (ACC) of the salivary gland by her dentist. The patient’s dentist promptly referred her to an ENT. The ENT had never operated on a patient with this condition – nor had he ever seen a patient with ACC. However, he decided to perform a surgical procedure on the patient with an internist and a radiation oncologist assisting. The radiation oncologist had advised the ENT doctor on two separate occasions to monitor the patient with chest x-rays on an annual basis. Written letters were sent by the radiation oncologist to the treating ENT – the radiation oncology group was no longer following this patient and their practice had closed – still, these letters were forwarded to the ENT’s office. The treating ENT never ordered a chest x-ray for this patient. The patient followed up with the ENT for over thirteen-years of treatment during regular, scheduled visits. The ENT does not dispute that he received letters from the radiation oncologist recommending chest x-rays for this patient, still, he never advised the patient or gave her the option or recommendation of a chest x-ray. The ENT does not believe that a chest x-ray is standard of care for this patient – but instead, has stated that it was standard of care to wait until the patient became symptomatic for chest x-rays. The patient never missed an appointment and routinely followed up with this ENT as her treating physician. The patient began to develop respiratory distress and presented to the ER. At this time, she was diagnosed with late stage lung cancer in both lungs, as well as metastatic disease in her brain and kidneys.

Question(s) For Expert Witness

Should a chest x-ray have been ordered for this patient, given her past medical history of ACC along with the recommendations made by a radiation oncologist?

Expert Witness Response

This type of cancer requires long term monitoring for metastatic disease including routine chest X-rays or CT scans. As such, this doctor's decision to wait for chest X-rays was not standard of care and undoubtedly contributed to the delay in the discovery of the metastatic disease. I believe that the standard of care would require at least yearly chest X-rays. Adenoid cystic carcinoma is thought by many to be "incurable", however, and unfortunately the chest x-rays may only serve to document when metastases occur. Once this has happened, there are no reasonable options for the patient. Earlier detection may or may not have prolonged the patient’s life for a short period of time but the ultimate prognosis would have remained the same.