This case involves an older male patient with a medical history of prostate cancer, who injured his back while at work and began treatment with an orthopedist. He underwent an MRI which revealed an abnormal signal on one of the bones of the man’s back, which was suspected to represent a benign growth. A follow-up scan revealed additional signals on the patient’s back and ribs, however, the treating physician elected not to perform any additional testing. The orthopedist continued to treat the patient for musculoskeletal complaints without further investigation. Despite treatment, the patient suffered worsening back pain and ultimately presented to his primary care physician, who ordered an MRI of the lumbar spine. The MRI revealed metastatic disease involving a number of the bones in the man’s spine, and ultimately produced a diagnosis of stage 4 metastatic cancer. By the time of the diagnosis, the tumors had become too advanced for a standard cryoablation treatment.
Question(s) For Expert Witness
- 1. Do you routinely treat patients like the one described in this case?
Expert Witness Response E-032539
Prostate cancer can be very aggressive in a small group of patients (5%), which seems to have been the case here. That being said, aggressive prostate cancer presents in younger patients. This patient would be considered young for prostate cancer, since the median age for diagnosis in the 70s. One would have to look at the history over a long term, not just a single snapshot to ascertain a change in pain pattern that would produce clinical suspicion for cancer. Arthritis is very common and can be confused on a standard bone scan. There is no foul to not ordering an MRI as an initial screening test for chronic or even semi-acute bone scan. However, there is a foul for not doing a digital rectal exam on a routine exam or, if the patient has urinary symptoms, doing a prostate-specific antigen test. However, in this instance there is no foul in not doing a screening prostate-specific antigen test, as these have been proven to be overdiagnosis in population-based studies.