Blood cancers

Doctor not at fault over delayed lymphoma diagnosis


A negligence case brought against a GP who missed a case of non-Hodgkin’s lymphoma has been dismissed after a court ruled the practitioner could not be expected to have a specialist’s understanding of the disease.

Based in Canberra, the GP had a therapeutic relationship going back to 2012 with the patient, an Indigenous woman in her 50s with chronic mental health issues who was a long-term recipient of a disability pension.

She presented in October 2016 complaining of severe pain in her lower back and one leg, receiving a brief physical examination, a prescription for the NSAID naproxen, and a full count blood test to rule out anaemia arising from iron deficiency, inflammatory processes and muscle tissue damage.

This came back negative and the GP ordered no further tests until June of the following year, when the patient returned complaining of worsening pain as well as unexplained weight loss, lethargy and incontinence.

A second blood test showed some abnormalities, with an Alkaline Phosphatase and CRP, while the GP ordered x-rays out of concern of possible arthritis.

The ACT Supreme Court heard it was only after this came back with no major abnormalities that the GP referred her for an MRI of the lumbar spine.

This identified “bony lesions – metastasis multiple”, eventually leading to a confirmed diagnosis of diffuse large B-cell lymphoma, which was still active when the case went to trial last year.

With a terminal prognosis, the patient sought up to $375,000 in damages  from the doctor for pain and suffering, plus $174,000 for treatment expenses and $220,000 in funding for domestic assistance.

Pointing to the 12-month delay between initial presentation and diagnosis, the patient brought a case accusing the GP of negligence, arguing they had failed to adequately investigate her symptoms, nor offer timely follow-up and specialist referral to achieve a diagnosis.

The GP was also alleged to have failed to conduct an appropriate physical examination during the initial consult, and to have not recorded her symptoms accurately in their clinical notes, which reported pain in her right leg when it was actually in the left.

“If a diagnosis could not be made, it was then incumbent upon [the GP] to organise a follow up appointment or refer [her] for further investigations so that she would not be left without any diagnosis for what was significant pain in her left leg,” the patient’s lawyers said.

Haematologist testimony

Appearing as an expert witness for the patient, haematologist and oncologist Professor Richard Fox said low grade lymphoma was the most reasonable cause for her symptoms as far back as the first consultation.

This would likely have been picked up in a PET scan and, if detected early, should have led to “complete remission and therefore a long disease-free [period] or potentially cure”.

“If … a real effort [was made] to find out why this woman had the issues she had with her legs and pain and weakness, you would have made a diagnosis properly in, going through the process, two or three weeks,” he told the court.

But ACT Supreme Court Associate Justice Verity McWilliam ruled that while the GP did not investigate the patient’s symptoms “as fully as what ought to have occurred”, there was no evidence of real negligence.

The GP was “to be judged according to the standard of a reasonably skilled general practitioner, not of a specialist oncologist,” the judge added.

And in their defence, although there was no concrete diagnosis, the NSAID prescribed at the first consult had been effective at relieving the patient’s pain for several weeks, Justice McWilliam said.

“Although an oncologist might have read the blood test results in a different way, I am not persuaded that the results were such as to require the reasonably competent general practitioner to refer the plaintiff to an oncologist at that point, without having at least obtained further relevant x-rays,” she found.

“Even with elevated blood results, it was reasonable for those x-rays to be carried out before considering what specialist referral was appropriate.”

She also dismissed the suggestion that the GP should have considered a potential diagnosis in light of the patient’s incontinence, saying it was reasonable for them to suspect a more common condition such as arthritis instead.

“On balance, the expert evidence does not establish the plaintiff’s symptoms were such that they would have caused the reasonably skilled general practitioner to take different precautions,” the judge found.

“Requesting x-rays of the plaintiff’s hip, left knee and a pelvic x-ray, and an ultrasound of her left gluteus muscles was reasonable insofar as those scans targeted areas where pain was reported.”

Awareness of blood cancer symptoms

The verdict, handed down last month, followed concerning research showing 70% of Australians were unaware that blood cancers were the second most commonly diagnosed malignancies and second most common cause of cancer-related deaths in Australia.

Released by the Leukaemia Foundation, the figures also showed 78% of people were not familiar with the symptoms of blood cancer and almost a third weren’t sure they would consult their GP about them even if they had them.

Leukaemia Foundation CEO Chris Tanti said the research highlighted the need to educate the public.

“The first step to defeating blood cancer is raising awareness and making Australians aware of the symptoms,” he said.

“If you don’t know what you’re looking for, it can result in a delayed diagnosis and impact your chance of survival.”

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