The Medical Liability Mutual Insurance Company (MLMIC), one of the largest insurance providers to physicians in New York State, has released it's newest information packet to the doctors containing case studies of the most common negligent acts that physicians make. The highlighted mistake of the issue? Misdiagnosing malignant melanoma, a type of skin cancer. Skin cancer can be missed quite easily in children, as they are less likely to develop the disease.
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Learn What Kind of Cancer Misdiagnosis is on the Rise


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9/23/2010
John Fisher
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The Medical Liability Mutual Insurance Company (MLMIC), one of the largest insurance providers to physicians in New York State, has released it's newest information packet to the doctors containing case studies of the most common negligent acts that physicians make. The highlighted mistake of the issue? Misdiagnosing malignant melanoma, a type of skin cancer. Skin cancer can be missed quite easily in children, as they are less likely to develop the disease.

The information packet contained this case study of an actual malignant melanoma misdiagnosis:

A 5-year old female was seen regularly by a pediatrician for well child check-ups. Her medical course and family history were unremarkable. In January of her fifth year, she was seen for an ear infection. The mother claimed that she showed the pediatrician a pink, pimple-like growth on the child's forearm. He told her not to worry about it. The lesion was not noted in the chart.

The child was seen throughout the year for ear and throat complaints. According to the mother's testimony, the lesion changed in size and color, and she persisted in bringing it to the pediatrician's attention. He continued to assure her that it was nothing. There was no documentation in the medical record concerning the legion.

In September, the pediatrician authorized a referral to a plastic surgeon. He told the mother to make an appointment if she wanted the lesion removed.

In November, the lesion was removed by the plastic surgeon. The pathologist indicated that the child had something known as Spitz Nevus. Spitz Nevus is a non-cancerous type of skin growth. He recommended that a wider portion of skin around the original legion should be removed if the doctor so chose. However, no further treatment was given.

In January, the child was seen by the surgeon for bleeding and bruising around the wound site. The surgeon told the mother to bring the child back in two weeks for a follow-up, and to call the office for an appointment.

Unfortunately, the child was not seen until two months later, when she underwent a surgery to remove a larger portion of skin around the original legion site. The second pathologist also indicated that the child suffered from a benign skin lesion. However, slides of the child's skin cells were sent to a laboratory for testing and it was found that the cells were malignant (cancerous).

The child subsequently underwent numerous surgeries. She also developed a bump on her left elbow that was removed and tested positive for cancer. The child underwent a course of chemotherapy and has been disease free to date. The parents initiated a lawsuit against the pediatrician, the plastic surgeon, and the first pathologist, for failing to diagnose malignant melanoma (skin cancer).

This case study demonstrates the large number of physicians that can be involved in misdiagnosing just one case of skin cancer. Although the child saw numerous physicians, it took two elective surgeries for the mother to receive a proper diagnosis. Skin cancer is the most common type of cancer with over a million cases diagnosed each year. Malignant melanoma-type cancer, although a rarer type, is much more serious and can be deadly when misdiagnosed. In 2000 alone, there were about 47,700 new cases of melanoma and 7,700 deaths attributed to the disease

According to skin cancer expert, dermatologist Mark Lebwohl, MD, professor and chairman in the Department of Dermatology at Mt. Sinai School of Medicine in New York, a physician's decision to send slides to a dermatopathologist instead of a regular pathologist could be the difference between life and death. In a recent speech at the American Academy of Dermatology's Melanoma/Skin Cancer Detection and Prevention Month Press Conference, Dr. Lebwohl passionate advocated for the increased usage of dermatopathologists. According to Dr. Lebwohl, dermatopathologists have a much smaller margin of error than pathologists do when diagnosing skin cancer.

Unfortunately, there are indications that misdiagnosis rates of skin cancer are rising due to the fact that pathologists are interpreting skin biopsies rather than dermatopathologists. This is because pathologists are they are cheaper for managed care companies to employ. According to Dr. Lebwohl, managed care companies "are more concerned with their bottom line than with providing the best possible care for their patients," said Dr. Lebwohl. Furthermore, states Dr. Lebwohl "...under many managed care plans, dermatologists are required to send skin biopsies to a laboratory mandated by the plan's contract rather than to the laboratory of their choice. When this happens, there is no guarantee that a dermatopathologist is interpreting the skin biopsy and any pathologist, regardless of experience, can end up reading these slides." In order to combat this problem, doctors like Lebwohl are dropping out of managed care plans that prohibit them from sending skin biopsies to dermatopathologists

In fact, in a recent joint statement issued by the American Academy of Dermatology and the American Society of Dermatopathology, the lack of appropriate training by pathologists at many managed care companies "subjects the patient to a likelihood of having the skin biopsy specimen misinterpreted".

I am horrified that these managed care companies are more concerned with their bottom line than with providing the best possible care for their patients and hope that more doctors follow in Dr. Lebwohl's footsteps of dropping out of managed care plans. This will hopefully send a message to these companies that their behavior is unacceptable. If you develop any type of skin legion, bring it to your physician's attention. If he simply tells you not to worry about it, you may want to seek a second opinion. If possible, you should also request that any skin samples be sent to a dermatopathologist: a doctor specially trained in clinically diagnosing skin biopsies, instead of a general pathologist. According to Dr. Lebwohl, the decision to do so could save your life.



Category: Delay in Cancer Diagnosis


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