FAILURE TO DIAGNOSE

CANCER
 In the most basic terms, What Is Cancer?
cancer refers to cells that grow
out-of-control and invade other
tissues. Cells may become
cancerous due to the
accumulation of defects, or
mutations, in their DNA.
Most of the time, cells are
able to detect and repair DNA
damage. If a cell is severely
damaged and cannot repair itself,
it usually undergoes so-called
programmed cell death or
apoptosis. Cancer occurs when
damaged cells grow, divide, and
spread abnormally instead of
self-destructing as they should.
Cancer Facts:

• Cancer is the second most common cause of death after heart disease.
• A significant percentage of newly diagnosed cancers can be cured.
• Cancer is more curable when detected early. Although some cancers
develop completely without symptoms, the disease can be particularly
devastating if you ignore symptoms because you do not think that these
symptoms might represent cancer.
Top 10 Common Cancers in the Philippines

1. Breast Cancer
2. Lung Cancer
3. Liver Cancer
4. Cervical Cancer
5. Colon Cancer
6. Thyroid Cancer
7. Rectal Cancer
8. Ovarian Cancer
9. Prostate Cancer
10. Non-Hodgkin’s Lymphoma
What Are the Common Signs and Symptoms of Cancer?
There are more than 100 different types of cancer. Every cancer and every
individual is unique. Cancer symptoms and signs depends on the size and
location of the cancer as well as the presence or absence of metastasis. Some
general signs and symptoms associated with, but not specific to, cancer, include:
• Lumps or tumors (mass) • Fever
• Difficulty in swallowing • Pain
• Changes or difficulties with bowel or • Fatigue
bladder function • Skin changes (redness, sores that
• Persistent cough or hoarseness won’t heal, jaundice, darkening)
• Short of breath • Unintended weight loss or weigh
• Chest pain gain
• Unexplained bleeding or discharge.
Cancer Metastasis
Metastasis is the process
whereby cancer cells break free
from a malignant tumor and
travel to and invade other tissues
in the body. Cancer cells
metastasize to other sites via the
lymphatic system and the
bloodstream. Cancer cells from
the original—or primary—tumor
can travel to other sites such as
the lungs, bones, liver, brain, and
other areas. These metastatic
tumors are "secondary cancers"
because they arise from the
primary tumor.
 What Causes Cancer?
Certain genes control the life cycle—the growth, function, division, and death—of a
cell. When these genes are damaged, the balance between normal cell growth and
death is lost. Cancer cells are caused by DNA damage and out-of-control cell growth.
The following is a partial list of factors known to damage DNA and increase the risk of
cancer:
Mutations Cause

Environment Cause

Microbes Cause

Lifestyle and Diet Causes

Treatment
Risk Factors:
While doctors have an idea of what may increase your risk of cancer, the
majority of cancers occur in people who don't have any known risk factors.
Factors known to increase your risk of cancer include:
• Your age
• Your habits
• Your family history
• Your health conditions
• Your environment
 6 Types of Cancer
Cancer can occur anywhere in the body. Broadly, cancers are classified as either solid (for
example breast, lung, or prostate cancers) or liquid (blood cancers). Cancer is further classified
according to the tissue in which it arises.
What Is Sarcoma Cancer?
What Is Carcinoma?
Sarcomas occur in
Carcinomas are cancers that occur in epithelial tissues in
connective tissue like the
the body. They comprise 80% to 90% of all cancers. Most
bones, cartilage, fat, blood
breast, lung, colon, skin, and prostate cancers are
vessels, and muscles. This
carcinomas. This class includes the two most common skin
class of cancers includes
cancers, basal cell carcinoma and squamous cell
the bone cancers
carcinoma. Also in this class is the glandular cancer
osteosarcoma and Ewing
adenocarcinoma.
sarcoma, Kaposi sarcoma
What Is Leukemia? (which causes skin lesions),
Leukemias are a group of different blood cancers of the and the muscle cancers
bone marrow. They cause large numbers of abnormal blood rhabdomyosarcoma and
cells to enter the bloodstream. leiomyosarcoma.
 6 Types of Cancer
What Is Lymphoma Cancer?
Lymphomas are cancers of the immune system cells. These
include the rare but serious Hodgkin lymphoma (Hodgkin’s
lymphoma, also Hodgkin’s disease) and a large group of white
blood cell cancers known collectively as non-Hodgkin lymphoma
(non-Hodgkin’s lymphoma).

What Is Myeloma Cancer?

Myelomas are cancers that occur in plasma cells in the bone
marrow. This class of cancer includes multiple myeloma, also known
as Kahler disease.

What Is Mixed Cancer?

Mixed cancers arise from more than one
type of tissue.
Diagnosing Cancer
Various tests may be performed in order to
confirm a cancer diagnosis. Positron Emission
Tomography and Computed Tomography
(PET-CT) Scans and other similar tests can
highlight “hot spots” of cancer cells with high
metabolic rates.
The most common test and procedures
used to diagnose cancer include:

• Mammogram
• Pap Smear Test
• Tumor Marker Test
• Bone Scan
• MRI
• Tissue Biopsy
• PET-CT Scan
What Are Treatment Options?

The treatment is highly variable depending on the type and stage of a

cancer as well as the overall health of the patient. The most common
treatments are surgery, radiation, and chemotherapy. Other treatments
include targeted/biological therapies, hematopoietic stem cell transplants,
angiogenesis inhibitors, cryosurgery, and photodynamic therapy.

Every treatment has potential risks, benefits, and side effects. The patient
and his or her care team, which may include an internist or other specialist,
surgeon, oncologist, radiation oncologist, and others, will help determine the
best and most appropriate course of treatment.
.
Is There a Cure for Cancer?
Majority of cancers can be cured if they are detected early. However at
present, not all cancers can be detected early enough to be cured. Despite
enormous effort and funding, no cure has been found yet to eliminate cancer.
But at least 1/3 of all cancers can be prevented.

Until a cure can be found, prevention through a healthy lifestyle is the best
way to stop cancer. Some ways to help protect yourself from cancer include
eating plenty of fruits and vegetables, maintaining a healthy weight, abstaining
from tobacco, drinking only in moderation, exercising, avoiding sun damage,
getting immunizations, and getting regular health screenings.
 Bromme v. Pavitt (1992)
Sample Case on Medical Malpractice
Facts of the case:
 Dr. Pavitt was Joan Bromme's physician from 1979 until her death in 1984.
 On June 1980, Bromme complained of abdominal pain, constipation, and “difficulties with food”.
After upper gastrointestinal & gallbladder studies appeared normal, Pavitt made no further effort to
diagnose Bromme’s complaints.
 On February & March 1981, Bromme saw Dr. Pavitt for the removal of a cyst. There is no indication
she complained about abdominal plain or bowel problems during these visits.
Facts of the case:

 She went back to Pavitt on September 1981 and complained about constipation & pencil-thin stool.
Pavitt performed sigmoidoscopy, an obstruction prevented the complete examination which Dr.
Pavitt believe caused by a spasm.
 On that same day, a Dr. Heffernon, performed the barium enema examination & concluded the
obstruction “probably” was a adenocarcinoma (cancer) of the colon.
 On Sept. 17, 1981, sigmoidoscopy was performed twice on Bromme by Dr. Imperato but failed.
Facts of the case:

 Dr. Imperato discussed Bromme’s fainting episode & unwillingness to

undergo further tests.
 On Nov. 1981 while receiving flu shots for a trip to China from Pavitt, he
thought she had endometriosis and it could wait.
 Bromme returned from China, constipated and vomiting. She was referred
to Dr. Pavitt and he suggested that she may have picked up a “bug” in
China.
 On Dec. 1981, Bromme was admitted to the hospital and had surgery on
Jan. 1982, revealed she had colon cancer. The tumor & a portion of the
colon were removed, colonoscopy was performed.
Facts of the case:
 The pathology report revealed the cancer had invaded the full thickness of the bowel wall and had
spread to surrounding lymph nodes. The report also revealed the surgeons had not removed all of
the cancerous portion of the colon. A second surgery to correct that problem was performed in
February 1982.
 In November 1982, the cancer metastasized to Bromme's right ovary. Both ovaries, the uterus, and
the cancerous mass were removed.
 The cancer later metastasized to Bromme's lungs, causing her death in 1984.
 After Bromme’s death, her husband (Charles Bromme) brought this wrongful death action against
Pavitt.
Issue:
Whether or not the medical negligence of the
defendant is the cause of death of Joan Bromme.
Experts Opinion:
 Dr. Leon Schimmel, an obstetrician and gynecologist, testified defendant's failure to diagnose the
most likely cause of Bromme's abdominal pain in June 1980 was below the standard of care.
Moreover, the failure to record important information on Bromme's chart misled subsequent
physicians to conclude that Bromme had endometriosis.
 Dr. Marfleet, a family practitioner testified defendant's failure to properly evaluate Bromme's
complaints of abdominal pain in 1980 was a likely cause of the failure to timely diagnose the colon
cancer.
Experts Opinion:
 Dr. Melvin Shiffman, who specializes in surgery for cancer and allied diseases, stated it was a
reasonable medical probability Bromme's June 1980 complaints were caused by the colon cancer.
At that time, the tumor probably was confined to the muscle and had not metastasized to the lymph
nodes. Had the tumor been removed then, Bromme would have had a 70 to 75 percent probability of
survival. Sometime between March and June 1981, the cancer spread to the adjacent lymph nodes.
Thereafter, the survival rate dropped to between 35 and 40 percent. Bromme's chances for survival
were further decreased when her bowel became obstructed prior to the January 1982 surgery. By
that point, her chances of survival were as low as 15 to 17 percent.
Experts Opinion:
 According to Dr. Bruce Chosney, a medical oncologist and hematologist who saw Bromme shortly
after her January 1982 surgery, the cure rate for cancers with some lymph node involvement is 40 to
50 percent. Because as many as six lymph nodes were involved by the time of Bromme's surgery,
her cure rate was less than 40 percent. By "cure“, it is meant that the patient will survive for five
years without recurrence.
 Dr. Gregory Graves, a surgical oncologist, testified the medical literature shows the prognosis is
poor for patients with obstructing colon cancers. He estimated that by January 1982 Bromme faced
a surgical cure rate of 30 to 35 percent. He believed the three-month delay of surgery from
September 1981 to January 1982 did not affect Bromme's ultimate prognosis.
What should have been done:
 When Dr. Pavitt’s studies on upper gastrointestinal and gallbladder proved negative, he
should have ordered a stool test and lower gastrointestinal x-ray in 1980, not in 1981. He
should have properly evaluate and record important information on Bromme’s chart.
 At that time, the tumor probably was confined to the muscle and had not metastasized to
the lymph nodes. Had the tumor been removed then, Bromme would have had a 70 to 75
percent chance of survival.
Outcome of the case:
 In order to show Bromme’s death was caused by defendant’s medical negligence,
plaintiff had to establish a reasonable medical probability that the negligence was
sufficient of itself to bring about the death, that is the death was more likely than
not the result of negligence.
 The court held that the physician could not be held liable for wrongful death for
failing to timely diagnose and treat his patient’s cancer unless the plaintiff could
show that there was at least a 50% chance that the patient would have survived
the cancer had it been diagnosed at a time that was within the standard of care.
 The expert witnesses agreed that Bromme’s chance of surviving was less than 50
percent after June 1981, so defendant’s alleged negligence after June 1981 was
not a substantial factor of Bromme’s death. Therefore, the court granted nonsuit
as to the acts that occurred after June 1981, but entered judgment on jury verdict
for physician for negligence occurring before that date.
Loss-of-Chance Doctrine (Increased-Risk-of-Harm
Doctrine
 ) which allows a plaintiff to obtain damages from a defendant for a heightened risk of
a legal principle
death or injury, even if the plaintiff cannot prove by a preponderance of the evidence that the
ultimate injury was caused by the defendant's negligence.

 The vast majority of the cases using a loss of chance measure of

damages have involved medical malpractice.
Case 2: Failure to Diagnose Breast Cancer

• Plaintiff had a mammogram which was highly suspicious for cancer.

• The surgeon performing the biopsy failed to remove the suspicious lump,
and missed the diagnosis of the cancer.
• He reassured the plaintiff that she had no cancer.
• A year later further testing revealed the cancer was still present, and had
spread throughout her body, making the cancer untreatable.
• The doctor attempted to cover his tracks by altering his medical records,
but his deceit was revealed during the discovery phase of the case.
• Result: $1,900,000 settlement.
Case 3: Failure to Prevent Ovarian Cancer.
• The plaintiff came from a family with a strong history of ovarian cancer, and
sought to have her ovaries removed to prevent the possibility of getting the
cancer.
• The doctor dissuaded her.
• Plaintiff developed symptoms consistent with cancer, and the defendant
diagnosed advanced ovarian cancer which would have been prevented
with the treatment the plaintiff had requested.
• The matter was brought to resolution before the plaintiff died, and the
plaintiffs were awarded damages for her pain and suffering, as well as
damages in anticipation of the pending wrongful death.
• Result: $3,000,000 award.