Double problem, double risk

Mr E, a 52-year-old truck driver, visited his GP, Dr G, complaining of a tight chest. Mr E had no significant co-morbidities, but had been suffering with coryzal symptoms for more than a week, which were starting to affect his breathing. He had wanted to attend sooner, but due to his job he had not been able to attend the surgery earlier. During the consultation Mr E mentioned that his throat has been bothering him for a couple of weeks, so he had started to cut down on his usual 20 cigarettes a day.

After examining Mr E’s chest, Dr G was quite concerned about his widespread wheeze. He administered a nebuliser in the surgery, and gave him some smoking cessation advice, but did not investigate Mr E’s throat.

A few weeks later Mr E reattended with similar symptoms of wheeziness and a cough, which again required another nebuliser. He mentioned that one side of his throat was painful and this was documented in the notes, but his throat was not examined.

During the following month, Mr E attended the local ENT department for a previously organised appointment to discuss a “recurrent sinusitis problem”. While he was at the hospital, Mr E mentioned his ongoing right-sided sore throat to Dr W, the ENT junior doctor. Dr W suggested that Mr E “tell his GP to check it”.

A month later at a follow-up appointment at the ENT clinic, Mr E saw Dr S, who immediately examined his throat. It became clear that there was an abnormal mass in his right tonsil and further tests confirmed squamous cell carcinoma of the tonsil with neck nodes. There was a five-month delay in the diagnosis, which required more aggressive treatment and left a poorer prognosis.

The experts were critical of the management of Mr E by both Dr G and Dr W, so the claim was settled for a moderate amount.

Learning points

• Head and neck cancers are relatively rare, especially those arising from the tonsils
  Patients who present with more than one complaint can easily distract a doctor’s attention, particularly if the patient is unwell and the added complaint seems insignificant in comparison. If there is not sufficient time during a consultation to address multiple problems, a record should be made and a follow-up appointment arranged.
• A flexible and open approach can avoid situations like the one in this particular case. Sending a patient to see his GP because the new complaint is not related to the reason for the appointment can leave a patient vulnerable.
• Head and neck cancers are relatively rare, especially those arising from the tonsils. The average GP is likely to encounter only one case every six years (NICE 2004). It is important to be aware of national guidance that advises referral for persistent, particularly unilateral discomfort in the throat, for more than four weeks (SIGN 2006; NICE 2005).
• The most common presenting symptoms of head and neck cancers are also common symptoms of infection, so can be easily dismissed. The key difference is that these symptoms tend to persist; therefore, a patient with unexplained symptoms, who fails to respond to conservative treatment, should be referred for further investigation.

Useful links

• NICE, Improving Outcomes in Head and Neck Cancers – The Manual (2004)
• NICE, Referral for Suspected Cancer (CG27) (2005)
• SIGN, Diagnosis and Management of Head and Neck Cancer (2006)