Case 33 Urinary problem in a welder

Reg was a 60-year-old self-employed welder when he consulted Dr Oakley. He had noted that he had had rather poor urinary stream and hesitancy for a year or so. A programme he had seen on the TV caused him to think that he needed to be checked out for prostate cancer.

Dr Oakley checked Reg’s International Prostate Symptom Score and it was 11/35. This suggested symptoms of prostatism of moderate severity. Digital rectal examination showed a large, firm but benign feeling prostate with a central sulcus. A week later Reg had a PSA which was 7.2 ng/ml.

What would you do now?

Reg returned to see Dr Oakley. Reg was very concerned that his PSA was raised. Dr Oakley explained that it was a rather poor test and that many male doctors may not have wanted to have a PSA test done on themselves because it was such a poor test.

They agreed that Reg would have the test repeated in 3 months. At that stage the PSA was 8.1 ng/dl. After discussion they agreed that Reg would have it repeated again in 6 months. Unfortunately Reg forgot to return for the test and it was eventually repeated 22 months later. At this stage the PSA was found to be 16 ng/dl. Dr Oakley referred Reg. He was found to have a locally invasive prostate cancer that had infiltrated the seminal vesicles and he was not suitable for radical prostatectomy.

Reg was angry that he had not been referred initially, when his PSA was only 7.2. He had been told that if he had been referred at that stage he could have had curative surgery. He brought a claim against Dr Oakley.

Do you think his claim will succeed?

Expert comment

This case illustrates a number of difficult areas for general practitioners with regard to PSA tests, adherence to guidelines and the notion of informed consent.

Many general practitioners would probably not have a PSA done on themselves because of the low specificity of the test and the fact that localized prostate can probably be detected in 15% to 30% of 50 year olds (Selley et al., 1997). Yet only 3% of the male population die of prostate cancer and the median age of death for the condition is 80. The difficulty, of course, is knowing who should be left alone and who may come to harm. As the 2002 NHS Prostate Cancer Risk Management Program puts it:

Prostate cancer is not a single disease entity but more a spectrum of diseases ranging from very aggressive to slow growing tumours, which may not cause any symptoms or shorten life. Many men with less aggressive disease tend to die with rather than of their cancer, but it is not always possible to tell at diagnosis which tumours are aggressive and which are slow growing.

An additional difficulty is that 10% of PSAs done in men aged 50 to 60 will be ‘raised’ (Wilt & Thompson, 2006).

Despite this the July 2000 Department of Health (DOH) guidelines for Referral of patients with Suspected Cancer advised urgent referral of all men with an elevated age specific PSA in men with a ten year life expectancy. This comprises 10% of the male population between the age of 50 and 60. The 2005 NICE version of the referral guidelines modified the situation slightly, but also slightly complicated the issue by stating:

If there is doubt about whether to refer an asymptomatic male with a borderline level of PSA, the PSA test should be repeated after an interval of 1 to 3 months. If the second test indicates that the PSA level is rising, the patient should be referred urgently.

Dr Oakley had attended a lecture by his local urologist who had pointed out the difficulties with the DOH guidance and who had expressed personal views about who should and should not be referred urgently. The urologist pointed out that the department were at that time swamped with such referrals and were struggling to see other patients within a reasonable time.

This case illustrates the difficulty for general practitioners when following over-inclusive guidance would swamp local services (and generate large amounts of anxiety), but failure to follow the guidelines may lead to censure. A similar example of such guidance is the ‘7 point’ criteria for urgent referral of pigmented lesions as possible malignant melanomas. The specificity of the rules is so low that general practitioners following the letter of the guidance would refer 60% of pigmented lesions urgently.

However, in this case there were a number of problems. Dr Oakley was not aware that a rising PSA at > 0.75 ng/ml per year (in the US 0.35 ng/ml/yr is taken as significant) probably has a greater predictive value for clinically significant prostate cancer than a single raised reading. He did not communicate this to Reg because he did not know it.

Reg argued that he had not been put in a position to make the decision as to whether he wished to be referred or not because Dr Oakley had not given him the information in the NHS Prostate Cancer Risk Management Program. Reg stated that he had been unaware of the significance of the rising PSA and Dr Oakley had imposed his own views about PSAs on Reg and had not followed national guidelines. Reg had been advised that his chance of having biopsy proven prostate cancer on the first occasion was about 45% and of having ‘high-grade cancer’ was about 10%.

It would certainly not be possible to defend the allegation of breach of duty at the time of the second PSA result because Dr Oakley had not realized the significance of a rising PSA and had not given Reg sufficient information to allow him to make his own decision about referral. However, the guidance as it stands does put general practitioners in a difficult position.

Legal comment

Dr Oakley should have referred Reg after the second PSA. This is a clear breach of duty. Whether Reg will succeed in his claim will depend on the causation evidence of a urologist or an oncologist. Causation in cancer cases is not straightforward. It is generally based on five- or ten-year survival rates and how these change from the time when diagnosis should have been made until it was actually made.

That said, it appears likely that Reg will be able to show that he could have been cured, if Dr Oakley had referred him. The calculation of the damages will not be a straightforward affair, either. Keeping it simple, Reg could be compensated for loss of life expectancy during his lifetime or if he is married, his wife could benefit from damages after his death.

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