Prostate cancer can be difficult to identify in its early stages, particularly where symptoms are mild, gradual or overlap with common urinary problems. Our Clinical Negligence Team has recently been involved in a case, which highlights how delays can arise when symptoms are not followed through, when intended investigations are not carried out, or when the patient is not given clear advice about what should happen next. It also shows why good communication and careful review are just as important as the initial clinical assessment.

A PSA test is a simple blood test which checks the level of prostate specific antigen in the blood. PSA is a protein made by the prostate. A raised PSA result can be a sign of prostate cancer, but it can also be raised for other reasons, including an enlarged prostate, infection or inflammation. This means the test is useful, but it is not a diagnosis on its own and should be considered alongside symptoms, examination findings and any further investigations.

Background to the case

The Claimant first consulted primary care with mild lower urinary tract symptoms, including urinary frequency and poor stream, alongside back pain. A trainee GP carried out a digital rectal examination, which was recorded as showing a normal-feeling prostate, and the Claimant’s International Prostate Symptom Score was low. No PSA blood test was arranged or discussed at that time. The supervising GP later confirmed they had been the debriefing partner for that consultation and maintained that the management plan did not require any amendment.

Over the following year, the Claimant’s urinary symptoms persisted. He re-attended primary care, provided a urine sample and was started on tamsulosin by a duty GP after a telephone review. The GP intended to request a PSA test, but an adjacent computer tick-box was selected in error, and a heart-failure marker was ordered instead. No in-person examination took place, and when the unintended result came back as normal, the Claimant was not brought back for review. Tamsulosin was later repeated on several occasions without a documented clinical review.

Months later, the Claimant deteriorated with severe difficulty passing urine and pain. He was advised to attend A&E and required catheterisation for urinary retention. A PSA test was then performed in primary care and was markedly raised, prompting an urgent two-week-wait referral. On urology assessment and imaging, he was diagnosed with metastatic prostate cancer with widespread bone involvement. He went on to receive treatment including hormonal therapy, chemotherapy, palliative radiotherapy and symptom control, but sadly later died from metastatic prostate cancer.

The claim alleged that earlier PSA testing at the first GP attendance would probably have identified an elevated PSA level at a stage when the disease may still have been localised, allowing urgent referral and potentially curative treatment. It was also alleged that, even at the later contact when a PSA was intended but not ordered, timely

testing and referral would likely have avoided acute retention, reduced the disease burden at diagnosis, improved treatment options and extended survival with a better quality of life.

Urinary symptoms should not be looked at in isolation

Urinary symptoms such as needing to pass urine more often, getting up at night, poor flow or difficulty emptying the bladder can have many causes. They do not automatically mean prostate cancer, but where symptoms persist or change, there should be a clear plan for review or further investigation.

PSA testing should be clearly discussed and recorded

The PSA test has benefits and limitations. It can help identify possible prostate problems and may lead to earlier investigation, but it is not perfect. A raised result does not always mean cancer, and a normal result does not always rule it out. For that reason, the decision to carry out a PSA test should be discussed clearly, with the patient understanding why it is being offered and what may happen next.

In this case, one of the issues was whether PSA testing should have been discussed or offered earlier. Clear notes of the advice given, the options considered and the reasons for any decision not to test can make a real difference if questions are later raised.

Intended tests need to be checked against the results received

Another important lesson was that the test requested must match the test intended. Here, a PSA test was planned, but the wrong blood test was selected. This meant the Claimant did not receive the investigation needed to assess his PSA level, which would have led to earlier recognition of the prostate cancer.

• There should be systems to check that the correct test has been requested.
• If the wrong test is ordered, this should be identified and corrected quickly.
• Patients can ask what test has been requested, when the result is expected and who to contact if they do not hear back.

Repeat prescriptions should not replace clinical review

Medication may help urinary symptoms, but it should not replace review if symptoms continue. In this case, medication was prescribed and later repeated. The lesson is that ongoing prescriptions should not allow an underlying problem to go unchecked, particularly where no clear diagnosis has been reached.

Safety-netting needs to be clear and practical

Safety-netting means telling the patient what to look out for, when to come back and how urgently to seek help if symptoms change. In prostate cancer cases, this might include worsening difficulty passing urine, blood in the urine, new pain, unexplained weight loss or an acute inability to pass urine, un-explained back pain or severe fatigue.

What patients can take from this

If you have ongoing urinary symptoms, it is reasonable to ask your GP whether a PSA test or prostate examination is appropriate. You can also ask what the plan is if symptoms continue, when results are expected and what to do if you do not hear anything.

How we can help

Delayed diagnosis cases often require a careful review of GP records, hospital records, test results, referral pathways and expert medical evidence. The key question is usually not simply whether the cancer was diagnosed late, but whether earlier action would probably have changed the outcome.

If you or a family member is concerned that there may have been a delay in diagnosing prostate cancer, our clinical negligence team can review the circumstances and advise on the next steps in a clear and sensitive way.