Lung Cancer Goes Untreated Despite Discovery of Malignant Cells

This case involves a male patient with a long history of chronic obstructive pulmonary disease (COPD) as well as several other respiratory issues. On one occasion, the patient had a severe episode of COPD that required him to be admitted to the hospital. During examination, a quantity of fluid was found in his lungs, and subsequent lab testing of that fluid revealed the presence of irregular cells that were ultimately found to be malignant. Additional testing on the patient’s lungs performed during this same hospital visit also revealed the presence of a mass in the lung, however this was considered symptomatic of pneumonia infected by Legionella bacteria at the time. After a year had passed from his original hospital visit, he was again admitted at the same hospital in relation to COPD. Some time during his stay in the hospital the patient attempted to get out of bed in order to use the bathroom and fell, causing him to suffer additional injuries. As a part of his workup for these additional injuries, the patient underwent a CAT scan that revealed an area of density in his lung, as well as potential pneumonia. After the scan was read, the radiologist recommended that the patient undergo a bronchoscopy to examine his lungs more closely. However, this recommendation was never conveyed to his treating physician, and the patient received no further testing on his lungs to positively identify the mass. The patient was eventually discharged from the hospital, and after a few days at home he began experiencing significant breathing issues as well as a loss of consciousness. As a result, he was taken to another hospital where he was quickly diagnosed with lung cancer. His condition quickly deteriorated and he died in the hospital several weeks later.

Question(s) For Expert Witness

Expert Witness Response E-009046

If the fluid collected from his lung was positive for malignancy during his initial hospital visit, then there is clearly a question as to why additional testing was not ordered. That being said, the response of malignant pleural effusions (the type of malignacy most likely described here) to systemic chemotherapy is generally disappointing, so whether the patient could have expected a more favorable outcome from earlier diagnosis is somewhat unclear. That being said,  exceptions to this include pleural effusions due to lymphoma, breast cancer, small cell carcinoma of the lung, germ cell tumors, prostate cancer, and ovarian cancer, so it is not unreasonable to expect that there would have been some benefit. Regardless, we are dealing with a very significant delay in diagnosis here. Clearly, whatever stage he was in when he first presented to the hospital for his COPD, had the lung cancer diagnosis been made he would not have died when he did. Questions remain as to the nature of this original malignancy – it is possible that it was a lung cancer but it could also have been some other malignancy. However, patients with diagnosed malignancies must be properly staged, and in lung cancer there are several other tests that should be conducted at the time of first diagnosis. For example, a brain scan is a routine test that should be done to rule out brain metastases. In addition, bronchoscopy is usually done to evaluate airway obstruction by a suspect mass, and sometimes a stent will be inserted in order to secure airways. A CT scan performed during his initial hospital stay may also have suggested an obstructive process that would have made a bronchoscopy necessary. The general lack of follow up on the initial findings of malignancy is not within the standard of care.

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