Cancer and its treatment
The medical specialty of oncology (or cancer medicine) takes its name from the Greek word oncus, a tumour. Cancer is, of course, not one disease, but a variety of different malignant diseases.
The treatment of cancer involves essentially a combination of three different disciplines:
Hence three groups of specialists play their part in managing most cancer patients: surgical oncologists, clinical oncologists and medical oncologists, also known as chemotherapists.
The term ‘clinical’ oncologist was developed to describe doctors specialising in radiotherapy because many of these doctors also give chemotherapy within specific areas of expertise. Hence the American term ‘radiation oncologist’ was not sufficiently comprehensive.
Broadly speaking, the widest experience of cancer medicine probably lies with these clinical oncologists because most cancer patients up to now have received irradiation at some stage in their disease. This may sound a rather depressing unpleasant specialty. But there is in fact enormous intellectual interest in the challenge of good cancer control, and great personal satisfaction in caring for these patients.
The surgeons play an important role by removing many primary cancers such as bowel cancers or a tumour in the breast. Alternatively, diseases best treated by drugs or irradiation still need a surgical biopsy taken to define the type and degree of aggression of each individual tumour.
Once the diagnosis is made, there is a need to find out how far the cancer has spread. This process is called cancer ‘staging’ and usually involves blood tests, X-rays, mammograms, computed tomography (CT) or magnetic resonance imaging (MRI). Tumour stage is largely classified using the TNM staging information. (TNM refers to Tumour, Nodes, Metastasis.)
Radiotherapy is often used to ‘sterilise’ the site of a previous tumour after surgery or can be the treatment of choice in some tumours such as early cancer of the voice box (larynx) or small skin cancers. In addition, radiotherapy is very effective in reducing the size of a lump or treating painful bone deposits (metastases).
Chemotherapy has an increasing role in reducing tumour size, eradicating diseases such as lymphomas (malignant disease of lymph-node tissue) and, most notably, destroying small deposits (micro-metastases) anywhere in the body. This effective treatment, often given first, can eradicate cancer cells and prolong many thousands of lives, for example in breast cancer.
Scope of litigation
Oncologists are relatively rarely targets of litigation themselves. But they are very often involved as experts in medico-legal disputes where the allegation of negligence is
- failure by a general practitioner to refer the patient for proper assessment or
- failure by a clinician in another specialty to diagnose the tumour.
Oncologists often then give important evidence about the causal significance of the allegations and the loss of life expectancy.
Information concerning the proportion of negligence cases that involve oncology can be obtained from the Medical Defence Union (MDU) and the National Health Service Litigation Authority (NHSLA).
The MDU reported 620 cancer-related claims in a recent 5 year period. Of these claims, 148 or 24% related to delayed diagnosis in malignancy. The most common malignant diagnoses involved in these settled claims were breast (21%), cervix (14.5%) and bowel cancer (13.5%).
Among cases recorded in hospital medicine by the NHSLA between 2002 and 2006, 1032 concerned patients with a diagnosis of cancer. The most frequent cause of complaint was also delay in diagnosis, which amounted to 53% of all cancer claims.
Most common sources of claim in oncology
1. Delay in diagnosis
2. Toxicity of treatment (surgery, irradiation or chemotherapy)
Other issues of possible dispute
- Cancer wrongly diagnosed or wrong communication of diagnosis of cancer
- Problems of consent or failure of communication
- Chemotherapy mistakes
- Underlying issues, inability to come to terms with diagnosis
Delay in diagnosis
Unnecessary delay in the diagnosis of any cancer can deprive a patient of the opportunity of cure or lead to the need for more aggressive treatment than would otherwise have been necessary. These delays can occur at any stage of care and leave a patient feeling angry, cheated and powerless.
- A general practitioner fails to examine someone adequately, so depriving the patient of the opportunity for referral to an appropriate assessment centre.
- A surgeon accepts the evidence of a benign biopsy and an apparently benign mammogram, leaving a breast lump which ultimately proves to be malignant. Again the opportunity for timely diagnosis is missed.
- Faults in the referral process may equally lead to delay.
However, underlying a complaint about delay in diagnosis there occasionally lies a patient’s inability to come to terms with the fact of a diagnosis of cancer. This failure to come to terms with the situation creates a sense of agitation and injustice. The patient may feel ‘it must be someone’s fault’ and pursue a claim in negligence as a result.
Toxicity of treatment
Damage caused by treatment (toxicity) may follow surgery, irradiation or chemotherapy. Often it is the combination of two or more of these treatments which together cause unpleasant complications.
Examples of radiotherapy damage which has led to legal action include...
- damage to the nerves in the arm and to the lymphatic drainage of the arm resulting in gross swelling after irradiation for breast cancer, and these problems are more likely after surgery to the armpit as well.
- long-term effects of irradiation of the pelvis, usually for cervical cancer. The late effects of this treatment, such as bowel and bladder damage, have been devastating for some patients.
Diagnostic negligence usually concerns either the faulty interpretation of cervical smears or the missed diagnosis of breast cancer at mammography.
Choice of expert
Who can usefully advise you when things have gone wrong for a cancer patient? It is probably wise to consult experts who have experience of working in multidisciplinary teams in the relevant area of cancer. Wider experience results from the opportunity for regular discussion with colleagues in this setting. Furthermore, fellowship of the appropriate College is a good guide to clinical ability.
- Surgery: FRCS, Royal College of Surgeons
- Clinical Oncologist: FRCR, Royal College of Radiologists
- Medical Oncologist: FRCP, Royal College of Physicians