Man missed years of prostate cancer testing, commission finds

By RNZ

• The Health and Disability Commission found a GP failed to recall Mr A for necessary PSA tests.
• Dr B’s clinic had organisational issues affecting the recall system, leading to missed prostate cancer monitoring.
• Mr A’s cancer recurred and spread; the clinic has since improved its recall and testing processes.

The Health and Disability Commission has released its findings into a complaint over cancer treatment by a man, referred to as Mr A in the report.

Deputy Commissioner Dr Vanessa Caldwell said that following a prostate cancer diagnosis and successful treatment in 2012, the man’s urologist advised him to have six-monthly prostate-specific antigen blood tests. The man should be referred back to the urologist should elevated levels be detected.

Prostate cancer - as well as other conditions - could cause prostate-specific antigen (PSA) levels in the blood to increase.

The request from the urologist was noted by Mr A’s GP, referred to in the report as Dr B, but there was no indication that he set up a recall for testing.

Mr A had three further PSA tests through the urologist, who he was still seeing for other issues after his surgery, with the last performed in January 2014.

There appeared to be no PSA testing in 2015, one test completed in 2016, and no PSA testing in 2017, the report said.

Dr B told the commissioner the medical centre’s recall system between January 2014 and March 2018 was not working at optimal performance due to organisational changes.

He said this included the amalgamation of three medical practices, high staff turnover and software system changes.

Mr A was recalled for PSA testing in 2018, and then for annual testing.

The report said that from 2018 onward Mr A’s PSA levels exceeded the level which should have sparked re-referral to the urologist, but no action was taken by the centre.

The GP said the results from the pathologist indicated they were within the normal range.

He said each week he had to review between 400 and 600 documents, so results listed as normal were only given “minimal attention”.

Caldwell said the clinic’s PSA request form did not include any clinical details, so the pathologist did not know of Mr A’s history of prostrate cancer or the urologists’ instructions to be informed of any elevated results.

The results between 2018 and 2021 were considered to be within the normal range of 0 - 3.99 ug/L, but in October 2022 a level of 67 ug/L was returned and Dr B notified Mr A.

Further investigation found Mr A had recurrent prostate cancer which had spread to his bones.

Caldwell said the GP and the clinic did not meet their obligations to provide services with reasonable care and skill.

Dr B said he and the centre have taken a number of steps to avoid the situation happening again.

The clinic had changed its recall system, changed the way laboratory tests were made and reviewed, and hired a retired GP to review and manage laboratory results.

Caldwell recommended the GP and medical centre provide a formal apology to Mr A, and the centre should establish a process for surveillance and recall of ongoing laboratory testing.

She also recommended that Dr B reflect on how in future he could recognise when his workload was reaching a point where it might affect his ability to practise safely.

- RNZ