The medical oncologist is a physician who has
received specific training in the broad area of cancer management. This
training includes an internship and residency in internal medicine
followed by several years in post-doctoral training in the area of
oncology. This is frequently combined with training in hematology that
requires three years of post-doctoral work.
Cancer is increasingly a multidisciplinary
discipline requiring input from a multiplicity of specialties and it is
the responsibility of the medical oncologist to integrate the numerous
physicians involved and oversee the complete treatment program. The
medical oncologist does not specifically perform surgery or radiation
therapy but should have training in their relative contributions to the
overall treatment of cancer patients.
In evaluating whether a specific case of cancer
diagnosis and treatment is consistent with the accepted standard of care
there are several general principles to be considered. Was the
physician aware of established signs of cancer and was sufficient
attention paid to those signs? An example would be an abnormal lump in
the breast or unexplained bleeding from a body orifice. While the role
of the evaluation of these signs may be important, it is not, in and of
itself sufficient reason to indicate that there is a genuine problem
with the care.
A major consideration is whether or not the cancer
itself is treatable. Would treatment alter the natural course of the
disease? There may be significant errors in the diagnosis of the
cancer. However, for certain types of cancers there are few good
therapies available. A central issue is whether or not a delay in the
diagnosis of cancer would alter the treatment approach. There are
certain malignancies that when diagnosed later in the course of that
cancer require more aggressive treatment. For example colon cancer
diagnosed early would utilize surgery. If diagnosis is made at a later
stage in addition to surgery lengthly chemotherapy would need to be
included with the treatment plan.
Another critical aspect in many cases is whether
the delay in diagnosis is accompanied by documentable change in the
status of the cancer. Paramount is the important role of tumor size as
an independent prognostic factor for curability and eventual outcome.
An example would be a breast lump which is documented either on physical
examination or radiographs to be a certain size, appropriate management
is not initiated and later studies show substantive increase in size.
It is known that this type of delay is accompanied by a subsequent
decrease in curability. The patient who presents with bleeding from the
rectum which was not evaluated until a second episode six to twelve
months later may or may not be in a situation where a medical oncologist
can make a definitive statement regarding decrease in overall
survivability. Since it is not possible to identify the stage of the
tumor at the time of the patient's original symptoms it would not be
possible to make definitive statements regarding tumor progression
during the period of the delay.
There are a small number of cancers which are
potentially curable, even when presenting with disseminated disease such
as testicular cancer, Hodgkin's disease and in some of the non-Hodgkin's
lymphomas. The liability in these cases is substantially greater. Some
cancers unfortunately simply have poor outcomes in the vast majority of
circumstances. Lung cancer being a prime example. Mistakes in
diagnosis and management may not have major clinical implications in
terms of ultimate outcome.
Evaluation of patients with malignancy is complex
and must be reviewed on an individual basis. The medical oncologist is
frequently the ideal specialist to evaluate this type of case. Within
the next four to five years it is predicted that cancer will be the
number one cause of death in the United States and will be the primary
reason for admission to the hospital. Legal professionals can expect an
increase in potential cases related to the care of these patients.
* This article is presented and copyrighted by The 'Lectric Law Library
and Dr. Steven E. Lerner & Associates (www.drlerner.com)