Primary Care Physician Fails to Identify Signs of Lung Cancer

This case involves a middle-aged man who had a delayed diagnosis of spindle cell carcinoma of the lung. Prior to his diagnoses, the patient had a long and detailed history of asthma, which was being managed by his primary care doctor with standard medications. During this time period, the physician stated that the patient had no symptoms of shortness of breath nor wheezing, and pulmonary function tests were never performed in office. The patient indicated to his primary care doctor that he was in fact having shortness of breath upon minimal exertion. His primary care doctor reassured him to take his asthma medications, and that no additional follow up was warranted. Several months later he was referred to a cardiologist due to an abnormal EKG. The patient continued to complain of shortness of breath to his primary care doctor. Eventually, a CT scan revealed lung nodules consistent with lung cancer.

Question(s) For Expert Witness

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

2. What testing should be done when these types of complaints occur?

Expert Witness Response E-006845

When shortness of breath is a complaint, it is a complicated situation. Testing may include a physical exam, spirometry, and depending on the scenario, referral to cardiology or referral to pulmonary. Maybe sometimes a chest x-ray or a CT scan, but not always. For example, an asthmatic complaining of shortness of breath and still wheezing can be short of breath from uncontrolled asthma. At some point, a PFT is appropriate if things don't get better. For asthma, PFTs would be the right test to evaluate dyspnea. There is only now a weak and controversial indication for screening CT scans in asymptomatic heavy smokers.For a primary care doctor referral to a pulmonologist is appropriate when a patient's dyspnea is unexplained. It took a year, but specialist referral to cardiology suggests that the internist did acknowledge the dyspnea and look for help. Stage 4 lung adenocarcinoma is indeed bad news. By the time the lung mass is advanced enough to cause dyspnea, advanced stage is already present and little damage is caused by the delay. Unexplained dyspnea does warrant a CXR or CT scan. That scan would look for PE or degree of emphysema or other condition. Lung cancer might have been picked up as an incidental finding.