A Urologist’s standard of care was questioned in a recent court case where a doctor’s failure to communicate and administer PSA Tests to an elderly patient led him to sue. Though one of the patient’s tests from years prior indicated that his score was on the higher end of acceptability, his doctor had chosen not to order a digital rectal exam or discuss the matter with the patient. Six years later, the patient returned to the Urologist since he had begun to see blood in his urine; his prostate was markedly enlarged, and a bone scan was positive for malignant metastatic lesions. At the time of trial, the patient was in Stage 4 cancer with a statistical 5-year chance of survival of below 30%.
Question(s) For Expert Witness
- 1. What are the guidelines for screening when the PSA is steadily increasing?
- 2. Have you lectured or published on this topic?
Expert Witness Response E-014220
This is a case of delayed diagnosis of prostate cancer. The delay led to progression to metastatic disease at the time of diagnosis. The delay is often a result of errors in prostate cancer and PSA screening-detection. The basic standard of care at the time of the critical PSA test for this patient consisted of the use of PSA or another test to detect prostate cancer. In addition, the use of adjunctive measures were applied to improve both sensitivity and specificity of our basic screening measures, especially PSA. This included variant PSA measures such as PSA kinetics of PSA velocity and doubling time, percentage of free PSA, PSA density, and biomarkers such as urine in the PCA-3 test. This case is an example of failing to adhere to the proper standards for PSA and Prostate cancer screening. The provider in this case failed to appreciate clinically significant PSA elevation and PSA kinetics, specifically PSA velocity, and perform a proper digital rectal exam. If the physician had adhered to accepted standards, they would have led to further evaluation including biopsy and diagnosis at an earlier stage.
Expert Witness Response E-007130
Guidelines for screening are complex, since screening PSA no longer recommended by the United States Preventative Services Task Force since 2011. Even before 2011, there was quite a bit of controversy over who should and should not be screened. In 2010 at the patient’s age, it would have been appropriate for the physician to discuss prostate screening with him, including the risks and benefits, and conclude that no value would come from future screening. The PSA of 4.94 is higher than the upper limit of 4, but physicians may use age adjusted values, especially if the patient has concomitant benign prostatic hyperplasia. Using adjusted values for age, the 4.94 may be considered in the normal range.