Rad Onc Medical Malpractice Case

[evilbooyaa]

Guys, read the linked website, like in it's entirety. Lot of details people are hypotheticalizing that we have actual info on.

I don’t know… I have a feeling that RP node wasn’t contoured at all, and it wasn’t failure - it was missed.

70 Gy definitive hardly ever leads to blowout.

Patient had 60Gy, then received re-RT within 6 months.

If you look at the imaging that carotid blow out was almost certainly due to the aggressive nature of the residual/progressive disease and not the cumulative RT dose delivered.

At autopsy patient had SCC invading near or into his carotid artery. The payout (at least per the website) wasn't because of the re-RT induced blowout. It was the fact they messed up the diagnosis/hand off between surgeon and rad onc and the staging was incorrect.

I don't blame RO peer review for not catching this. Somebody dropped the ball at communicating that there was gross disease left behind.

This is why I usually don't let other docs (or residents, or NPs, or PAs, or medical students) staging influence what I think about a case. Take a look at the clinic notes, the op report notes, the imaging, the path results, etc. yourself and come up with your own staging. The patient had a pre-op PET/CT that shows obvious infiltration into PPS. Even if surgeon said "he got it all" and the Rad Onc was seeing post-op I'd be quite wary of any path report that suggested GTR with negative margins.

One of the imaging studies is from Yale as pointed out by an astute twitterer.

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[jondunn]

to Dr. Parikh's point, it is not clear whether the RP node was included in the initial 60 Gy volume.

 

[deleted1111261]

Guys, read the linked website, like in it's entirety. Lot of details people are hypotheticalizing that we have actual info on.

Patient had 60Gy, then received re-RT within 6 months.


At autopsy patient had SCC invading near or into his carotid artery. The payout (at least per the website) wasn't because of the re-RT induced blowout. It was the fact they messed up the diagnosis/hand off between surgeon and rad onc and the staging was incorrect.

I don't blame RO peer review for not catching this. Somebody dropped the ball at communicating that there was gross disease left behind.

This is why I usually don't let other docs (or residents, or NPs, or PAs, or medical students) staging influence what I think about a case. Take a look at the clinic notes, the op report notes, the imaging, the path results, etc. yourself and come up with your own staging. The patient had a pre-op PET/CT that shows obvious infiltration into PPS. Even if surgeon said "he got it all" and the Rad Onc was seeing post-op I'd be quite wary of any path report that suggested GTR with negative margins.

One of the imaging studies is from Yale as pointed out by an astute twitterer.

I was referring to another poster saying that 70 Gy can lead to blowout and I think that is highly unusual

 

[evilbooyaa]

I was referring to another poster saying that 70 Gy can lead to blowout and I think that is highly unusual

Ah, OK, may have missed part of the conversation. My b. Carry on.

 

[Haybrant]

you have to be very very thorough and you have to be an attending, residents dont get it, it takes a year in practice to really understand the level of defensiveness and skepticism it takes to approach oncology cases in radiation and another year of practicing that way to gain the confidence. When you dont do any notes yourself you're going to miss alot, the consult note should be used for incredibly thorough review to be sure you know all the ins and outs of the case. Otherwise you can harm people and if you do you should be held accountable. If the info that disease was left behind is not in the op report then the ENT is primarily responsible. In general assume that ENT is leaving disease behind and start with that basis, seen it many times. Esp an ENT that wants to take patients with RP nodes to the OR, do not trust

 

[fiji128]

you have to be very very thorough and you have to be an attending, residents dont get it, it takes a year in practice to really understand the level of defensiveness and skepticism it takes to approach oncology cases in radiation and another year of practicing that way to gain the confidence. When you dont do any notes yourself you're going to miss alot, the consult note should be used for incredibly thorough review to be sure you know all the ins and outs of the case. Otherwise you can harm people and if you do you should be held accountable. If the info that disease was left behind is not in the op report then the ENT is primarily responsible. In general assume that ENT is leaving disease behind and start with that basis, seen it many times. Esp an ENT that wants to take patients with RP nodes to the OR, do not trust

Very spot on. I’m in the community and whenever I get an ENT that does a non tors/non oncologic tonsillectomy in these types of cases I always give 70 Gy. This is apparently Yale, so everything should be better then what I typically deal with in terms of pathology and communication but I guess sometimes not. At the end of day it is always so important to show/document your relevant findings in the HPI and your thought process in the A/P.

Crazy that this probably very highly regarded rad onc/ENT may have cost Yale more in a lawsuit payout then what they will ever bring in thoughout their careers’ because these basic steps were skipped.

 

[medgator]

you have to be very very thorough and you have to be an attending, residents dont get it, it takes a year in practice to really understand the level of defensiveness and skepticism it takes to approach oncology cases in radiation and another year of practicing that way to gain the confidence. When you dont do any notes yourself you're going to miss alot, the consult note should be used for incredibly thorough review to be sure you know all the ins and outs of the case. Otherwise you can harm people and if you do you should be held accountable. If the info that disease was left behind is not in the op report then the ENT is primarily responsible. In general assume that ENT is leaving disease behind and start with that basis, seen it many times. Esp an ENT that wants to take patients with RP nodes to the OR, do not trust

Honestly i feel like h&n care can actually be better outside some of the larger centers for that very reason. One of the major centers in our region just over an hour away has a group that is very aggressive with TORS and I've definitely seen them operate on pts they shouldn't (including with RP nodes), or pts who will invariably end up needing post op chemo RT, with the radiation ending up taking the blame for trimodality long-term toxicity

 

[Mandelin Rain]

Honestly i feel like h&n care can actually be better outside some of the larger centers for that very reason. One of the major centers in our region just over an hour away has a group that is very aggressive with TORS and I've definitely seen them operate on pts they shouldn't (including with RP nodes), or pts who will invariably end up needing post op chemo RT, with the radiation ending up taking the blame for trimodality long-term toxicity

I forgot where I saw it, but it was something like

TORS alone = Home Run
TORS + 60Gy = Walk
TORS + Chemoradiation = Strike out

Patient selection is paramount. Overly aggressive TORS surgeons do more harm than good for sure.

 

[w00tz]

TORS alone = Home Run
TORS + 60Gy = Walk
TORS + Chemoradiation = Strike out

Definitive chemoradiation somewhere in the middle.

 

[Mandelin Rain]

Definitive chemoradiation somewhere in the middle.

I think it's also a walk. Like a push with TORS + 60 Gy.

 

[kimplera]

Probably by a faculty member who tries to be in clinic no more than 1-2 days a week and tries to cap at 2-3 consults on each of those days so they can spend more time on their "groundbreaking" research figuring out who to omit radiation in, while their residents write the notes, do the volumes, and do the statistical analysis on the research.

I take exception to this. Being a physician scientist is not an excuse for inadequate care. In our institution this patient would not have had surgery given RP node and the location of the carotid very close to the tumor (both contraindications). 60 Gy could be defensible for HPV+ disease although off study i still go to 70.

 

[madchemist89]

No need for TORS after orator trial.

 

[kimplera]

sometimes VIPs are the biggest obstructions in their own care

Joel Tepper used to saw - just because you're a VIP doesn't mean you deserve worse care, we'll treat you just like the rest of our patients

 

[deleted1111261]

I take exception to this. Being a physician scientist is not an excuse for inadequate care. In our institution this patient would not have had surgery given RP node and the location of the carotid very close to the tumor (both contraindications). 60 Gy could be defensible for HPV+ disease although off study i still go to 70.

That’s fair. Cheap shot on my part. There are a lot of people doing great clinical work and lab work. My bad, man.

 

[medgator]

That’s fair. Cheap shot on my part. There are a lot of people doing great clinical work and lab work. My bad, man.

Somewhere, a Holman graduate is letting his resident **** someone up

 

[elementaryschooleconomics]

I take exception to this. Being a physician scientist is not an excuse for inadequate care. In our institution this patient would not have had surgery given RP node and the location of the carotid very close to the tumor (both contraindications). 60 Gy could be defensible for HPV+ disease although off study i still go to 70.

I certainly don't mean to imply that EVERY physician-scientist is clinically weak.

I have personally experienced both flavors. I know physician-scientists who are incredible clinicians. However, I know physician-scientists who do exactly what I described: try their utmost to minimize involvement in patient care, leaning heavily on their residents and support staff to pick up the slack. I have many anecdotes where I was left to my own devices by these folks as a young resident. I know I'm not alone. I assume most of us have those stories.

To be honest, if it were me or a family member who needed care, I would prefer it to be delivered by someone who is not trying to run a lab.

This is absolutely not a comment on you! This is an opinion formed from being an MD-PhD myself and spending the majority of my career to this point in large academic environments. In my experience, my "favorite" type of doc (the kind I'd want to be treated by) is an almost entirely clinical person at an academic site with students and residents. I think having trainees with you, to question everything you're doing and present competing opinions, is ultimately the best for the patient. Some community docs (regardless of specialty) can drift away from standards of care if they are by themselves/in smaller groups where they can just do their own thing, unquestioned (which is another type of "bad" going in a different direction).

I could be wrong about this, I don't know. I don't think there's data about patient outcomes in RadOnc with physician-scientists vs pure clinical.

 

[Mandelin Rain]

At an academic center you never know how much or how little an attending is doing to supervise a resident. I get the feeling that there is pretty minimal oversight by many docs at many programs (potentially most docs, at most programs). Glance at contours, okay plan, move on.

 

[evilbooyaa]

I forgot where I saw it, but it was something like

TORS alone = Home Run
TORS + 60Gy = Walk
TORS + Chemoradiation = Strike out

Patient selection is paramount. Overly aggressive TORS surgeons do more harm than good for sure.

Per E3311 - https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.6500
10% of "eligible" patients get TORS alone.
60% get a walk (and you could do 50Gy)
30% strike out

ChemoRT is worse than a home run and likely equivalent to a walk. Let's call it a single.

Outside of that 10% of patients I see no reason to ever do TORS.

 

[evilbooyaa]

Honestly i feel like h&n care can actually be better outside some of the larger centers for that very reason. One of the major centers in our region just over an hour away has a group that is very aggressive with TORS and I've definitely seen them operate on pts they shouldn't (including with RP nodes), or pts who will invariably end up needing post op chemo RT, with the radiation ending up taking the blame for trimodality long-term toxicity

I went from a very aggressive TORS program to a prevalent but much more selective TORS program and agree that the quality of care is better subjectively, with much less trimodality therapy. Some H&Ns are gonna be just as big of oncologic idiots as more (%-wise) urologists are.

 

[RickyScott]

Per E3311 - https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.6500
10% of "eligible" patients get TORS alone.
60% get a walk (and you could do 50Gy)
30% strike out

ChemoRT is worse than a home run and likely equivalent to a walk. Let's call it a single.

Outside of that 10% of patients I see no reason to ever do TORS.

30 gy with cis in selected pts grand slam/ perfect game

 

[temujim]

No need for TORS after orator trial.

Look at the swallowing data on the orator trial -- not like TORS alone was great. These patients are perhaps better managed with RT alone -- and as we push the de-escalation envelope this may be even more true.

 

[Palex80]

Per E3311 - https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.6500
10% of "eligible" patients get TORS alone.
60% get a walk (and you could do 50Gy)
30% strike out

ChemoRT is worse than a home run and likely equivalent to a walk. Let's call it a single.

Outside of that 10% of patients I see no reason to ever do TORS.

I full agree that E3311 provides valuable information and great results, BUT: This particular patient wasn't eligible for E3311, right?
He had cT3 disease.

 

[medgator]

Fascinating but unfortunate case: Carotid Blowout Syndrome [Oncology]

Patient in late 40s diagnosed with SCC.
Surgical resection incomplete due to bleeding complications (not communicated well).
Pt receives 60Gy over 30 treatment days.

Patient ultimately dies of carotid blowout syndrome.

Sues the hospital, asks for >30 million to settle the case. Patient was highly-paid insurance executive.

Exact settlement is confidential but likely was in the low 8 figure range.

QuadShot mentioned the payout being $34 million


!!!!

 

[brushbeamscanning]

They asked for $34 million in the offer of compromise but it's probably slightly lower when they settled.

 

[evilbooyaa]

I full agree that E3311 provides valuable information and great results, BUT: This particular patient wasn't eligible for E3311, right?
He had cT3 disease.

I meant more in general rather than for this specific case.

That being said... why do you say T3 for this case at initial diagnosis? Doesn't seem > 4cm? CT actually suggests T1 (1.4cm primary)

 

[Palex80]

I meant more in general rather than for this specific case.

That being said... why do you say T3 for this case at initial diagnosis? Doesn't seem > 4cm? CT actually suggests T1 (1.4cm primary)

I thought that was the opinion of the reviewer. Or was he referring to the recurrence?
I am not sure how far that tumor really is from the prevertebral plane, since we do not have an MRI. Any chance, this may have even been a cT4?