MIGA’s Claims Committee has noticed a recent increase in allegations that relate to delay in the diagnosis of prostate cancer. The following two case studies demonstrate alleged delays stemming from failure to follow up or to act on Prostate Specific Antigen (PSA) test results.
Case study 1: Who will follow up?
A 54 year old patient presented to his GP with uro-genital problems. His PSA was 3.7 and while slightly above normal his GP was not concerned. He was referred to a urologist for review. The urologist suggested a ‘wait and see’ approach with careful monitoring and repeat investigations.
The GP assumed the urologist would attend to the follow up. The urologist, by reporting his recommendations back to the GP, assumed the GP would undertake the repeat testing. Neither doctor followed up the patient with regard to a repeat PSA.
A repeat PSA was undertaken 2 ½ years later with a result of 9.4. The patient was promptly referred to a urologist. A total prostatectomy was undertaken with the unfortunate recognised complication of severe urinary incontinence.
Case study 2: Rising PSA
A low PSA result of 0.5 in a 61 year old was detected at screening. Further screening occurred 18 months later and the result was still low at 1.3 but the PSA velocity was higher than the recognised significant rate of 0.3 per year. The GP felt reassured as the result was lower than the age related median and the patient had no family history of prostate cancer, nor any symptoms other than mild nocturia.
The patient represented 6 months later complaining of a decreased libido. He was given the reassurance of the previous low result of 1.3 and the PSA was not re-tested.
Eighteen months later the patient had a repeat PSA. This showed a result of 44. An immediate retest showed similar results. The finding was a Gleeson 9 aggressive prostate cancer that had metastasised. The patient was given a life expectancy of approximately 6 months.
Guidelines
There are various guidelines for prostate cancer screening, including the Royal Australian College of General Practitioners, the Royal College of Pathologists of Australasia as well as the Urological Society of Australia and New Zealand. It is recognised that these guidelines do not always concur, although there are areas of agreement. Clinical recommendations are:
- The combination of PSA and DRE remains the most sensitive investigation for prostate cancer detection
- At or over 40, a single test and digital rectal examination (DRE) will place a person in a low or high risk category and PSA testing can then be individualised over the ensuing decade
- If a PSA level is above the age-specific median (0.6 ng/ml for 40 - 49 years and 0.7 ng/ml for 50 - 59 years) they exhibit a 3½ fold increased risk of cancer over 25 years compared with levels below median.
- In particular younger men with serum PSA > 1.5 ng/ml who are at high risk should undergo more intensive monitoring
- Men interested in their prostate health in these younger age groups could have a single PSA test and DRE performed at or beyond age 40 to provide an estimate of their prostate cancer risk over the next 10 - 20 years based on age-specific median PSA values, with the intensity of subsequent monitoring being individualised accordingly
For further information refer to the guidelines for specific reference:
RACGP: http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/TheRedBook/redbook_7th_edition_May_2009.pdf pages 56 - 57
RCPA: http://www.rcpa.edu.au//static/File/Asset%20library/public%20documents/Policy%20Manual/Position%20Statements/PSA%20Statement.pdf
USANZ: http://www.usanz.org.au/usanz-2009-psa-testing-policy/
Risk Management Tips
- Communication is the key to good management –
- PSA screening can be both reassuring and anxiety provoking for the patient. Make clear the timelines for testing and retesting and the likely plan based on results
- Ensure that all health professionals are clear about who has responsibility for what – NEVER assume!
- Have a robust system for recalls and reminders
- Follow up attendance at specialist appointments
- Follow up outstanding tests results
- Inform the patient of test results when they are received and the timing for repeating the PSA
- Ensure that significant abnormal results are communicated in timely manner
- Document all attempts to follow up
- Document the advice given on follow up
- Review your practice to ensure that it is consistent with the current guidelines for prostate cancer screening
- Ability of PSA to predict risk of prostate cancer is enhanced using age-related limits, age related PSA medians, PSA velocity and free to total PSA ratio.
By:
Dr Roger Sexton
and
Gareth Thomas
Clinical Risk Coordinator
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