This case involves a male patient who was under the care of a hematologist for a diagnosis of a slow growing cancer of the bone marrow in New Hampshire. Over the course of two years, he developed progressively worsening knee pain and deformity. He relayed this concern to his hematologist, but was not referred to an oncologist. For more than 2 years, he was treated with a knee brace, a number of drugs, and physical therapy. He eventually transferred care to another facility where a flow cytometry test aided in diagnosing him with a soft tissue and bone sarcoma of the knee. He underwent an above the knee amputation, but was later found to have metastatic disease. His cancer was identified as advanced (stage 4) and was too advanced for tumor cryoablation; the only potential treatment was palliative chemotherapy. It was alleged that the delay in diagnosis and treatment worsened the patient’s outcome.
Question(s) For Expert Witness
- 1. How often do you treat patients with this sort of cancer?
- 2. What is the standard of care regarding patients who present with bone pain and deformity? Should these patients be worked up/referred?
Expert Witness Response E-007690
I currently have 5 patients with this sort of blood cancer. In a case like this, I would refer to orthopedics and probably order an MRI. Patients should be worked up and referred. Interestingly, the American Cancer Society makes the following statement: An injury is not a risk factor for developing sarcomas. But this issue has caused some confusion in the past. One reason is that an injured area might swell. That swelling could resemble a tumor but is not a true tumor. Also, when you are injured, the pain may draw your attention to the injured area. The area may be examined closely, and x-rays or other imaging studies may be obtained. This can make it more likely that any sarcoma that is present will be discovered, even though it may have been present for some time. This suggests there should have been additional follow up.
Expert Witness Response E-008039
I am board certified in hematology and previously treated patients with this type of bone cancer. However, in the past 15 years I have only practiced medical oncology with an emphasis on lung cancer, head and neck cancer, melanoma and sarcoma. Clearly a 2 year delay in diagnosis would be sufficient for causation with the specifics depending on the histopathologic type of sarcoma.