This case involves a female patient who had been treating with a family physician regularly for more than a decade, and had also consulted with a colo-rectal surgeon multiple times for what she was told were hemorrhoids. On one occasion, the colorectal surgeon performed banding procedures in the area of what was discovered soon after to be a large, necrotic tumor. He banded the area several times, but never identified the tumor as such. Some time after this, a colonoscopy was performed by another colorectal surgeon who discovered the presence of a large necrotic mass. A CT scan of the abdomen revealed irregular wall thickening involving proximal rectum with posterior rectal wall mass, as well as other signs that represented regional metastasis. At this time, rectal carcinoma was diagnosed and subsequently treated with chemo-radiotherapy to reduce the size of the tumor before surgery could be undertaken. It was alleged that earlier colonoscopies should have been performed to detect the tumor, and that the patient suffered a worse outcome as a result of this failure to diagnose.
Question(s) For Expert Witness
- 1. Could the patient have had a better outcome if colonoscopies were performed sooner or if the care was rendered differently?
- 2. Is it possible that the trauma and banding in the area of the tumor serve to increase the risk of the metastasis of the tumor?
Expert Witness Response E-008039
I presume the patient had bright red blood per rectum, which would make diagnostic studies imperative. If asymptomatic she should have had either colonoscopies starting at age 50 and every 10 years or proctosisigmoidoscopies every 5 yrs. In either scenario it would seem as if there was a failure to diagnose in a timely manner. Rectal cancer progresses from a locally invasive neoplasm to regional spread to lymph nodes and then metastatic disease. Survival is clearly related to stage as diagnosis and thus earlier diagnosis would more likely than not have been associated with an improved survival. I am unaware if the trauma and bleeding associated with ‘banding” can increase risk of metastasis, as it is certainly is not an area where we have clinical research data. That being said, the delay in diagnosis here definitely had a negative impact on this patient’s outcome.
Expert Witness Response E-008438
It is possible that this patient would have had a better outcome if the diagnosis had been made sooner. From the review above, it is unclear how long of a delay was present. In general, if treatment with band ligation has not stopped the bleeding in two months, a colonoscopy should be done to rule out the possibility of cancer. If the cancer was found sooner, perhaps it would not have spread. I doubt that banding increased metastasis of this tumor. Tumors are often biopsied and traumatized and, to my knowledge, there is little evidence that this leads to metastasis.