The man was a smoker in his 50s when he developed a lump in his neck that wouldn't go away. A doctor missed two opportunities to diagnose cancer. Photo / Getty Images
The man was a smoker in his 50s when he developed a lump in his neck that wouldn't go away. A doctor missed two opportunities to diagnose cancer. Photo / Getty Images
A man who went to a GP twice complaining of a lump on his neck was eventually diagnosed overseas with a rare cancer that had spread, requiring aggressive surgeries to remove his teeth and half a lung.
Now the man, who was in his 50s in 2021 when the cancer was missed, has less than five years to live.
If the adenoid cystic carcinoma, a rare cancer of the salivary gland, had been diagnosed and treated earlier the man could have avoided the loss of his teeth and part of his lung, he told the Health and Disability Commissioner [HDC].
Instead, he couldn’t work for nine months, is likely to need to undergo further surgery, and his prognosis is a much-reduced life expectancy.
The man, identified only as Mr A in an HDC investigation into the case released publicly today, told the watchdog he did not want any other patient to experience what he had gone through.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell found the GP in breach of the Code of Health and Disability Services Consumers’ Rights [the Code] for not immediately referring the patient to a specialist or further investigating when he first presented with the lump in February 2021.
On the day the man saw the overseas-trained GP, she had only been in New Zealand three weeks and was at the end of her first week working at the unnamed medical centre.
The man told the GP, identified Dr B in the HDC decision, the lump had been on his neck for about a year but it was increasing in size and had become tender during the past three months. He was also having trouble swallowing liquids.
Dr B documented that on examination Mr A’s head, eyes, ears, nose and throat were normal with no signs of trauma.
She noted he was a smoker and had poor arrangement of teeth but had no active abscesses.
Mr A’s neck lump was recorded as being “1.5 x 1cm tender, movable submandibular gland with no overlying skin changes”.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell found the GP should have urgently referred the patient to a specialist. Photo / Supplied
Dr B diagnosed an “enlarged lymph node that was likely reactive”, which she told the HDC was not uncommon in adults due to dental concerns, sinus or ear drainage.
She prescribed anti-inflammatory medication for two to four weeks, asked the patient to notify her if his symptoms worsened and to return in four weeks’ time for review.
The man did not return in four weeks and there was no record of the doctor or the medical centre attempting to recall him.
He returned in August that year complaining of a sore tooth which Dr B diagnosed as an abscess and prescribed antibiotics. She recommended the patient also see his dentist.
The GP noted the lump was “still there” and “unchanged”.
In April the next year the man was diagnosed overseas with the rare cancer and the following month he complained to the medical centre, and later to the HDC.
In June last year he was advised he had three to five years to live.
The HDC sought an expert opinion from GP Dr David Maplesden, who said although it was a rare cancer it should be considered when a patient presented with a painless swelling in the head or neck region, because the cancer had a high tendency to spread.
He said a number of aspects of Mr A’s initial presentation indicated that his neck lump required investigation.
The HealthPathways guidance was that “a neck lump that has been present for more than three weeks needs investigation unless it is shrinking”.
Lumps less than three weeks in duration were usually due to infection.
The fact that Mr A presented with a neck or salivary mass that had no obvious explanation, that it had been a lump for 12 months, it was bigger than 1cm and was slowly growing, and was associated with a new symptom, should have given rise to a high suspicion of cancer, the guidance stated.
Dr B apologised to the man and told the HDC in hindsight she should have arranged an urgent consultation with an ear, nose and throat specialist for the patient after both appointments.
However, she said she did not recall if she had learned about HealthPathways guidance for the management of neck lumps at an orientation two days before the first appointment.
She said Mr A’s dental infection distracted her at the second appointment.
Dr B stated that at her practice in her home country she had no mentor “so most times [she] had to figure it out [herself]”.
She was still in that mindset when she first saw Mr A, she told the HDC, and since then she had come to value the importance of asking for help.
She said she was “truly sorry” for Mr A’s delayed diagnosis and pain and suffering, and now had a heightened awareness of these issues and a lower threshold for suspicion of cancer.
Caldwell found the doctor breached Right 4(1) of the Code; the right to have services provided with reasonable care and skill.
“Although the man’s cancer is a rare, slow-growing type, which often hinders early diagnosis, his neck lump was persistent and significant in size, with no clear cause at either appointment.
“There were two missed opportunities to diagnose his cancer at an earlier stage.”
Caldwell said while the GP had only recently arrived in New Zealand before the first appointment, the doctor accepted there did not appear to be substantial differences between neck lump guidance in her home jurisdiction, and the relevant guidance in New Zealand.
The deputy commissioner concluded the medical centre did not breach the Code, and there was no failure by it in respect of the GP’s induction, orientation, and initial supervision.
The GP has made several changes to her practice, will be undertaking an audit, and had provided a written apology to the man.
Natalie Akoorie is the Open Justice deputy editor, based in Waikato and covering crime and justice nationally. Natalie first joined the Herald in 2011 and has been a journalist in New Zealand and overseas for 27 years recently covering health, social issues, local government, and the regions.
