Missed or delayed lung cancer diagnosis

The National Cancer Institute’s patient summary on non-small cell lung cancer, one of the two main types (opens in a new tab), says it sometimes causes no symptoms and may be found during a chest X-ray done for another condition (opens in a new tab). It says signs such as a cough that does not go away may be caused by lung cancer or by other conditions (opens in a new tab).

It is usually diagnosed with tests that make pictures of the lung (opens in a new tab), and if cancer is suspected, a biopsy follows (opens in a new tab).

Screening is for people without symptoms. Since March 9, 2021 the U.S. Preventive Services Task Force has recommended yearly low-dose CT for adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years (opens in a new tab). A pack-year is a pack of cigarettes a day for a year.

The Task Force gives that a B grade, one of the two grades it uses for services it recommends (opens in a new tab). A recommendation is not a legal duty. The Task Force also says screening does not prevent most lung cancer deaths (opens in a new tab), and that its benefit depends in part on scans being read as accurately as in the trials.

The Task Force points to Lung-RADS, the American College of Radiology’s reporting system, which it says provides guidance on the suggested management of lung nodules (opens in a new tab), meaning small spots on a scan.

The version released in November 2022, linked from the College’s Lung-RADS page (opens in a new tab), attaches a suggested next step to each category: a repeat low-dose scan in 12 months after a negative screen, in 6 months for a finding rated probably benign and in 3 months for one rated suspicious, and further work-up such as a diagnostic CT, a PET scan or a tissue sample for one rated very suspicious. The same document says a negative screen does not mean that a person does not have lung cancer.

These are professional bodies’ documents, and they recommend rather than require. What careful practice required for a particular patient is for a qualified physician to explain.

A 2010 study of the records of 587 lung cancer patients at two tertiary care centers identified what its reviewers called missed opportunities in 222, or 37.8% (opens in a new tab). The clue most often left without documented follow-up within 7 days (opens in a new tab) was an abnormal chest X-ray. Patient adherence contributed in 44% of those cases (opens in a new tab), and the abstract gives no result on whether the delay changed the outcome.

In a 1992 study of lung cancers visible in hindsight on chest X-rays, six radiologists who knew the cases were missed cancers each still missed a mean of 26% of the lesions (opens in a new tab), which shows how hard some are to see. A 1996 report on 14 patients whose cancers were overlooked on CT found that unrelated major abnormalities on the scan may have contributed to the failure to diagnose the tumor (opens in a new tab).

In a 2019 study of primary care malpractice claims over diagnostic error, missed cancer diagnoses made up 980 cases, or 46% (opens in a new tab), lung cancer among them.

That figure counts malpractice claims. It says nothing about how often lung cancer is diagnosed late among patients.

A cancer found after a normal scan is not, for that reason alone, a missed cancer. In the first round of a screening trial of people at high risk, reported in 2013, low-dose CT flagged 93.8% of the cancers present and chest X-ray 73.5% (opens in a new tab).

The published figures describe groups of patients. For cancers of the lung and bronchus diagnosed from 2016 to 2022, the National Cancer Institute reports five-year relative survival of 65.5% for cancer confined to where it started, 38.2% once it had spread to nearby lymph nodes and 10.5% once it had spread to distant parts of the body (opens in a new tab).

They are estimates from registries that do not include Illinois, and the Institute says they cannot be used to predict exactly what will happen to an individual patient (opens in a new tab). The difference between two stages does not measure what a delay cost anyone.

A 2015 review of studies of time to diagnosis in patients with symptoms reported that differences among the studies precluded definitive findings (opens in a new tab), and lung cancer was not among the cancers with more reports linking a shorter time to diagnosis with better outcomes.

In Illinois a patient has to prove that the care was negligent and that the negligence more probably than not caused the harm, which can be a lost chance of a better outcome. That takes expert proof in each case.

The record is mostly images and reports: each chest X-ray and CT scan, with the radiologist’s report.

Illinois requires a hospital to keep X-ray films made at a physician’s request for 5 years (opens in a new tab) and its medical records for not less than 10 years (opens in a new tab). Both laws apply to hospitals. The second does not cover hospitals run by the federal government or by a state university (opens in a new tab), and how the first applies to a CT scan is a question for a lawyer.

You can ask for copies, and how to request them under Illinois law is on our law page. It helps to write down the dates of visits and tests, and what you were told after each.