GI cancer

Court backs hospital doctors over diagnosis of pancreatic cancer

A court has rejected a medical negligence legal action from a woman who claimed that doctors at Canberra Hospital failed to provide timely diagnosis and treatment of pancreatic cancer.

The 47-year old woman took action in the Supreme Court of the ACT against the hospital operator, the ACT government, claiming that the hospital failed to adequately investigate and manage her  chronic pancreatitis symptoms despite numerous hospital visits between December 2017 and November 2018.

She also claimed that her cancer would have been diagnosed and treated earlier if gastroenterologists had discussed her case with surgeons and involved them earlier in her care.

The patient, who was eventually diagnosed with a rare molecular subtype of pancreatic adenocarcinoma in November 2018, claimed that the hospital had failed in its duty of care by not taking action after three CT scans performed between January and April 2018 .

However the court heard from expert medical witnesses who said that doctors at the hospital had acted appropriately and had continued to consider a tumour as a possible diagnosis despite negative or inconclusive test results from investigations including CT and tumour markers.

The court heard that gastroenterologists at the hospital had agreed with radiologists that ‘poorly defined’ features seen on CT scans in the pancreatic tail were likely of inflammatory origin, but needed ongoing follow up in the form of a repeat CT. Medical experts told the court that 80-90% of pancreatitis cases were caused by gallstones or alcohol, whereas pancreatic cancer was the cause of only 1% of cases of recurrent acute pancreatitis, most in people over the age of 55.

Over a period of several months the patient underwent numerous other investigations including abdominal ultrasound and MRCP, and was referred to see Professor Jeremy Wilson at Liverpool Hospital, described as “a leading and pre-eminent pancreatologist in Australia”.  After reviewing her CTs and MRCP results in August 2018, he also was of the opinion that that the lesion in the tail of her pancreas seemed to be resolving and it  “looks more inflammatory than neoplastic”.

The court heard that during this period the patient made numerous presentations to the hospital ED, often by ambulance, seeking treatment for pain. However she sometimes left against medical advice and on some occasions did not attend for follow up appointments. She was also unable to complete follow up investigations including biopsies and MRI scans due to factors such as taking anticoagulants and claustrophobia.

Following another abdominal ultrasound in November 2018 results from a fine needle biopsy in November were consistent with adenocarcinoma.

The patient had a pancreatectomy and splenectomy and was started on chemotherapy, but discontinued due to side effects. When cancer recurred in 2021 she travelled to Germany to undergo liquid nitrogen therapy. Her treating oncologist suggested that her life expectancy was now in the order of 18 months, which attributed to a successful trial of the recently approved drug larotrectinib .

In making his decision, the judge did not accept the testimony of expert witnesses for the plaintiff, who had suggested that earlier involvement of a surgeon should have been sought.

He said he agreed with the testimony of expert witnesses “that [pancreatic cancer] diagnosis was sought serially and repetitively with appropriate investigations. When those tests failed to show that cause, the doctors continued to arrange follow up despite negative tests, as is appropriate.”

The judge said he also accepted the evidence of medical oncologist Dr Matthew Burge, who specialises in treating pancreatic cancer, when he said an earlier diagnosis was unlikely to have changed the prognosis of the cancer in this case. He noted the patient had a rare, NTRK fusion pancreatic tumour, present in only 1 in 250 – 300 cases of pancreas adenocarcinoma.

“Therefore, with such unique biology, he could not be certain of the impact of surgery or adjuvant chemotherapy on prognosis as there is no data looking at this very rare subtype. This clouded his ability to state with any certainty what impact earlier treatment may have had,” the judge noted.

The plaintiff’s action against the hospital was therefore refused.

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