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Management of metastatic disease by surgical and oncology services (09HDC02227)
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(09HDC02227, 3 November
District health board ~ Surgical services ~ Oncology
services ~ General practitioner ~ Follow-up of radiological imaging
~ Communication issues ~ Information provided
This complaint from a woman who subsequently died of cancer,
highlights the need for doctors to be very clear with each other
about their respective roles when sharing a patient's care. This
case also highlights the risks of relying on CEA results.
The woman complained in December 2009 about the care provided to
her by her GP, a provincial district health board's (DHB) surgical
service, and the oncology service provided by a larger urban DHB.
The woman had bowel surgery for cancer at the provincial public
hospital in 2004. Her general surgeon, an oncologist from the
larger public hospital, and her GP followed her up over the next
two years, monitoring her CEA blood tests. She had regular physical
checks by the surgeon, and chest and abdominal CT scans during this
In September 2005, a CT scan at the larger city hospital
identified two nodules in her lungs and follow-up was recommended.
The oncologist reviewed the scan but did not believe the nodules
were significant and reassured the woman and her GP. He advised
that re-scanning was not necessary at that time, but if her CEA
levels increased it would be reasonable to do so. The woman's CEA
levels in 2005 had peaked at 19µg/mL in August, but by October 2005
had fallen to 12µg/mL.
In accordance with the radiologist's advice for follow up after
the September 2005 scan, the surgeon who conducted the woman's
bowel surgery ordered a chest and abdominal CT scan in March 2006.
This was reported as being "strongly suspicious of peritoneal
spread" and noted a "significant increase" in the size of the
nodule on the woman's right lung. There is no record that the
surgeon specifically discussed this scan with the oncology service.
The surgeon understood that the woman was being followed up by
medical oncology and saw his role in her management as following up
on the early detection of local (colonic) recurrence.
The GP continued to monitor the woman's CEA and following the
March CT scan, ordered two chest X-rays, in April and May 2006,
which were performed at the smaller hospital.
A radiologist reading the April 2006 chest X-ray believed that
the suspected lesion in the right lung was overlapping ribs, and
suggested a follow-up X-ray in two to three weeks. The repeat X-ray
in May 2006 reported that the right lung lesion was likely to be a
"true pulmonary nodule" and recommended follow-up by a respiratory
physician or the oncology service. The GP faxed the information to
the oncologist for review, noting that there were reassuring blood
tests. The oncologist telephoned the GP, stating that he had no
concerns regarding the woman's latest radiology examinations, but
had ordered a follow-up scan for her. The GP then emailed the woman
to tell her the oncologist's opinion and that she would receive an
appointment for another scan shortly.
The woman's CEA was 5.7µg/mL in May 2006.
In July 2006 the repeat CT scan which was ordered by the
oncologist, reported that there was no apparent change in the size
of the previously reported lung lesion. This scan report was sent
to the GP. There is no copy of the report of the scan in the
woman's hospital oncology record, and the oncologist was not aware
of the result. The GP believed that he had referred the woman to
oncology, but the oncologist understood that he was ordering the
scan for the GP, because GPs cannot order scans. As a result, the
oncologist was not aware that the scan had been performed, while
the GP assumed that the oncologist had the result and would act if
Throughout the next three years, the GP and the general surgeon
were reassured by the woman's favourable CEA levels, as they
continued to monitor her. The woman remained relatively fit and
In June 2009, the woman reported to the GP that she was feeling
tired. He attributed this to her very active lifestyle. This was
the final time that this GP saw the woman as he sold his practice
around this time. She made two subsequent visits to the practice in
August for treatment of a painful right knee and a troublesome
In September 2009, the woman consulted a new GP with these same
symptoms. Blood tests were taken, and X-rays of her chest and knee.
The X-rays revealed metastatic cancer which was confirmed by CT
scan. The woman died a few months later, aged 70.
A review of the service this woman received identified that the
health services failed her. A new consultant medical oncologist at
the larger hospital reviewed the case, and advised that a breakdown
in the appropriate management of the woman occurred when the 11
July 2006 CT scan reported that there was no significant change in
the size of the mass in the right lung compared to the previous
scan in March 2006. He did not believe that the fact that the scan
was performed at a provincial hospital rather than the larger urban
hospital made a significant difference to the management of the
dimensions of this mass.
The consultant stated that the CT scan report, in combination
with the fact that the woman's CEA had fallen to 5.7µg/mL in May,
falsely reassured the doctors that there was no indication of
recurrent disease. He said that the role of serum CEA in the
surveillance of patients who have had bowel cancer is clearly
established in that it can detect early recurrence, but it does not
reliably do so, as the CEA does not rise in all patients. The
consultant said, "Therefore, relying on this tumour marker as an
indication of whether a suspicious lesion may or may not represent
a recurrence is a flawed strategy". A patient in this woman's
situation, with a lung lesion of the size seen on the CT scan in
July 2006 (despite its recent stability) should at least have
continued to have that monitored, or alternatively investigated at
that juncture with a CT guided biopsy of the mass, or
These events highlight the importance of effective communication
between providers. It appears that in this case, the individual
providers were attending to their own areas of expertise rather
than effectively working as a team. The surgeon was continuing to
be reassured by normal colonoscopies and apparently believed that
the March 2006 CT report would be reviewed by the oncology service.
The GP had concerns in March 2006, and appropriately discussed
these issues with the woman's oncologist, but when he was provided
with a further radiological report in July, was reassured by the
result and assumed that the oncologist had a copy of it. Having
been reassured two months earlier, he did not contact the
oncologist again, but continued to follow the original surveillance
plan. The oncologist was reassured by the CEA levels, did not know
about the increase in the size of the lung lesion, and relied on
the GP to make any follow-up referrals back to the oncology service
The conclusion reached was that there are changes that can be
made to improve the monitoring and follow-up systems between the
DHBs and the primary care sector. A deficiency in the GP's record
keeping was identified by HDC's clinical advisor.
The woman's family wanted people to acknowledge the mistakes
made and learning to occur from these events.
HDC recommended that:
- the DHB oncology service uses this woman's case (in an
anonymised form) as a case study to present to the Association of
Medical Oncologists and local GPs,
- the GP review the standard of his record keeping and undertake
a formal audit,
- this case study be sent to the Medical Council of New Zealand,
the Royal Australasian College of Physicians, the Royal
Australasian College of Surgeons and the Royal New Zealand College
of General Practitioners and will be placed on HDC's website for
The oncology service acknowledged that the health system had let
the woman down. It acknowledged the importance of providing
explicit surveillance instructions to primary care providers in
complex cases (which is part of the DHB's usual practice). As a
result of these events the DHB ran a postgraduate education
programme for GPs. The focus of the programme was "Primary care
follow-up of cancer patients", which reinforced best practice and
the importance of good communication and the need to clarify
The original GP provided a letter of apology to the family. He
organised for the New Zealand College of GPs to conduct an audit of
his clinical records and has now made reviewing his record-keeping
a priority of his professional development.
 Carcinoembryonic Antigen - tumour
marker. An early warning sign for metastatic disease. Normal levels
are 0.0 - 4.0µg/mL.