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Management of metastatic disease by surgical and oncology services (09HDC02227)

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(09HDC02227, 3 November 2010)

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[1] 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 period.

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 necessary.

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 well.

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 cough.

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 bronchoscopy.

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 if necessary.

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 educational purposes.

Actions taken

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 uncertainties.

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.


[1] Carcinoembryonic Antigen - tumour marker. An early warning sign for metastatic disease. Normal levels are 0.0 - 4.0µg/mL.

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