Primary care expert witness discusses delayed diagnosis of stage-4 adenocarcinoma

A primary care expert witness opines on a case involving a patient who was diagnosed with stage-4 adenocarcinoma after a primary care physician neglected tell-tale symptoms. The patient was a sixty-three-year-old woman with a past medical history of asthma and a 25-pack per year history of smoking. The patient’s asthma was being managed by her primary care physician who prescribed the medications Flovent and Albuterol Sulfate. Whilst under the care of the physician, the physician stated that the patient had no symptoms of shortness of breath or wheezing. Pulmonary function tests were never performed by the treating physician. The patient indicated to her primary care physician that she was in fact experiencing worsening shortness of breath upon minimal exertion. Her primary care physician failed to document this in the notes. He reassured the patient and told her to continue taking her asthma medications for symptomatic relief. Approximately one year after first raising these concerns with her physician, she returned to him complaining of the same symptoms. The symptoms were not very severe and were affecting the patient’s ability to carry out simple daily tasks. She was referred to a cardiologist due to an abnormal EKG. A stress test was conducted and showed that the patient reached 96% maximal predicted heart rate, however the testing was stopped before completion due to patient complaining of severe fatigue and dyspnea. This indicated poor exercise tolerance. Her functional capacity was also noted to be very poor. The cardiologist performed catheterization, the results of which revealed did not warrant intervention. The patient continued to have complaints of shortness of breath to her primary care doctor. The patient was then seen by another physician in the cardiologist’s office who recommended a CT scan to rule out pulmonary embolism which was written for the patient’s complaint of shortness of breath. The CT scan revealed lung nodules consistent with lung cancer. Further investigation diagnosed the nodules to be stage-4 adenocarcinoma. The diagnosis came approximately two years after the patient first complained of dyspnea to her primary care physician.

Question(s) For Expert Witness

Should the patient's complaints about shortness of breath have been ignored by the treating physician?

Expert Witness Response

Complaints of shortness of breath should never be ignored or assumed to be due to asthma. The patient complaining of progressively worsening dyspnea should have raised a red flag. As a smoker, annual spiral CT might have been recommended for screening even without any symptoms. Some of the tests that should have been done would have shown that asthma is not the diagnosis and would have led to CT scan. A chest x-ray is a part of the recommended testing. If it was not done, it should have been, and it may have showed the cancer at a much earlier stage. Early diagnosis of this type of the cancer may have improved this patient’s prognosis. It was a departure from the standard of care not to investigate this patient’s initial complaints of breathlessness.