Delays in Diagnosis of Bladder Cancer
Approximately 600,000 people globally were diagnosed with bladder cancer in 2020. Bladder cancer is responsible for an estimated 200,000 or more deaths every year worldwide. These numbers are expected to rise for years to come.[i] The success of treatment and long-term survival for patients with bladder cancer depends in large part on diagnosis as early as possible. Unfortunately, the diagnosis of bladder cancer is often delayed, and progression or spread of the disease occurs without treatment.
The most common symptom of bladder cancer is hematuria (blood in the urine). However, doctors may attribute this symptom to less serious conditions like urinary tract infections (UTIs), kidney stones, or benign prostatic hyperplasia (BPH). Because hematuria is “nonspecific” as to its exact cause, some healthcare providers and even patients may initially dismiss hematuria as insignificant, delaying further investigation.
Bladder cancer can also present with symptoms like frequent urination, urgency, and dysuria. These symptoms are common in benign conditions such as UTIs or overactive bladder. This overlap can lead doctors to overlook the significance of hematuria seen only on microscopic evaluation of urine, or attribute microscopic hematuria to one of these often transient, less harmful conditions.
Bladder cancer may also involve the upper urinary tract. The upper urinary tract is composed of the kidneys and left and right ureters. Ureters are the tubes which drain urine from the kidneys to the bladder.
Urologists use a combination of diagnostic tests to identify malignant tumors or cancer cells of the bladder and upper urinary tract. Urologists are expected to know which tests to order and when based on each patient’s unique situation, including their risk factors, symptoms, and the results of the gold standard test for bladder cancer – cystoscopy. Regrettably, a delayed diagnosis of bladder cancer can occur if doctors do not follow the right pathway for evaluating bladder cancer for a particular patient.
Assessing the Risk of Malignancy in Patients with Hematuria
The investigation of a lawsuit involving the delayed diagnosis of bladder cancer begins with identifying the first sign of the disease. Often, hematuria, or blood in the urine, is the first sign of bladder cancer. Hematuria can range from benign to indicative of serious underlying conditions, including malignancies like bladder, kidney, or prostate cancer.
Doctors, especially urologists, are expected to assess the risk of malignancy in patients with hematuria. This clinical assessment guides decisions on whether further testing is warranted. A doctor may violate the standard of care they owe to the patient if they fail to properly consider the risk factors for bladder cancer in the setting of hematuria, and order appropriate testing to look for bladder cancer.
Key Risk Factors for Malignancy
If a doctor fails to consider risk factors for bladder cancer in a patient with concerning symptoms like hematuria, they may never consider diagnostic testing which can identify the cancer at the earliest possible stage. Key risk factors for cancer of the bladder or upper urinary tract include :
- Age: The risk of malignancy increases with age, particularly in patients over 50. Hematuria in older adults often triggers a more aggressive diagnostic approach due to the higher likelihood of cancer.
- Smoking History: Current or former smokers with hematuria are at a considerably higher risk for bladder cancer and should be thoroughly evaluated.
- Occupational Exposure: Patients with a history of exposure to certain chemicals and dyes, particularly in industries like rubber, leather, and textiles, are at elevated risk for bladder cancer.
- Gender: Men are at a higher risk of bladder cancer compared to women.
- Duration and Nature of Hematuria: Persistent or gross hematuria (visible blood in the urine) is more concerning than transient or microscopic hematuria (detected only on lab tests). Gross hematuria is particularly worrisome and often warrants immediate further investigation.
Recommended Diagnostic Tests
It is critical that doctors know which tests should be performed to investigate the underlying cause of hematuria, and how to interpret the test results. As mentioned, depending on the patient and the results of initial testing, additional tests may be necessary to fully work-up the location and extent of any cancer and avoid delays in diagnosis or misdiagnosis of cancer of the bladder and upper urinary tract. The following tests are commonly used to initially diagnose and stage cancer of the bladder and upper urinary tract:
Cystoscopy: This is the gold standard for evaluating the lower urinary tract (bladder and urethra) for tumors, stones, or other abnormalities. It involves inserting a thin tube with a camera into the bladder to directly visualize the area.
Urine Cytology: This non-invasive test examines urine samples for abnormal cells that could indicate cancer. While it has high specificity, it is less sensitive for low-grade tumors, so it is often used in along with other tests designed to detect signs of cancer.
Importantly, doctors who evaluate patients for bladder cancer need to understand some of these tests, especially cystoscopy and urine cytology, can produce false negative results. A false negative result can lure a physician to believe the patient is cancer free, when in fact the cancerous cells or tumors simply evaded detection.
Imaging Studies:
- CT Urography: This is the preferred imaging study for evaluating the upper urinary tract (kidneys and ureters). It provides detailed images and can detect tumors, stones, or other abnormalities.
- Ultrasound: Often used as an initial imaging study, especially in patients for whom radiation exposure from CT scans is a concern. It is less sensitive than CT but can still detect many significant abnormalities suggestive of malignancy.
- Urine-Based Molecular Tests: Tests like NMP22 or UroVysion can detect specific genetic changes associated with bladder cancer. These are generally used as adjuncts to cystoscopy and cytology, especially in patients with a history of bladder cancer or in cases where cystoscopy is negative but clinical suspicion remains high.
Common Reasons for Delayed Diagnosis of Bladder Cancer
Failure to Fully Work-up Hematuria – In some cases, primary care providers may not immediately consider bladder cancer in patients with hematuria. Doctors may ignore their duty to obtain a full medical history which can identify all potential risk factors for bladder cancer and consider the need for cystoscopy. This can lead to a “wait and see” approach, further delaying diagnosis.
Similarly, if hematuria or urinary symptoms are initially treated with antibiotics for presumed infection without further testing for bladder cancer, the underlying bladder cancer may go undetected. This is especially true if symptoms temporarily improve with treatment, leading to a false sense the problem was merely an infection when in fact an underlying cancer is the true cause of the symptoms.
Failure to Refer for Specialist Evaluation: Many primary care providers will defer the evaluation of bladder cancer to a urologist. Delays can occur if patients are not promptly referred to a urologist for further evaluation of gross hematuria. A primary care provider may have a duty to refer a patient to a urologist to evaluate for bladder cancer in the following situations as well:
- If microscopic hematuria (detected on urinalysis) persists without an identifiable benign cause, particularly in patients with risk factors for bladder cancer.
- If a patient presents with irritative urinary symptoms (e.g., frequency, urgency, dysuria) that persist despite treatment for common conditions like urinary tract infections or overactive bladder, and particularly if these symptoms are accompanied by risk factors for bladder cancer.
- If initial imaging (e.g., ultrasound) or lab tests (e.g., urine cytology) suggest abnormalities that could be consistent with a malignancy, a referral to a urologist should be made for further evaluation, including cystoscopy and more advanced imaging.
- If initial tests (e.g., urine culture, urinalysis, renal function tests) do not reveal a benign cause for hematuria, the patient should be referred to a urologist for further investigation, including cystoscopy and upper tract imaging.
Miscommunication or Misinterpretation of Diagnostic Testing
- Misinterpretation of Radiology Exam: For some patients, pain is the first symptom of bladder cancer due to spread to other structures near the bladder. A radiology exam like ultrasound or CT scan may be ordered to evaluate the cause of the patient’s pain. Expecting common conditions like a kidney stone or ovarian cyst, the radiologist who interprets the radiology study may miss an obvious mass. Or, a radiologist might see a suspicious mass and refer to the mass in the report of their findings, yet the physician who orders the test will fail to read the report or act upon the finding.
- Missed Diagnosis on Cystoscopy: While cystoscopy is the gold standard for bladder cancer diagnosis, it is not full-proof. Small or flat lesions, such as carcinoma in situ (CIS), can sometimes be missed, especially if the procedure is not performed thoroughly or if the cancer is in an early stage.
- Low Sensitivity of Urine Cytology: Urine cytology, commonly used to detect cancerous cells in the urine, has limited sensitivity, particularly for low-grade tumors. A negative cytology result may lead to a false sense of security and delay further diagnostic steps which may be necessary depending on the patient’s symptoms and risk factors.
Case Examples
- A $1.75 million settlement was reached after a delayed diagnosis of bladder cancer led to a patient’s death. The patient initially visited a doctor with symptoms of burning urination and frequent nighttime urination, where blood was found in her urine. Despite multiple visits and continued symptoms, the doctor misdiagnosed her with a urinary tract infection and prescribed ineffective antibiotics without follow-up. Latera, another doctor failed to refer her to a specialist despite finding blood in her urine. A year later, the patient was diagnosed with advanced bladder cancer, which had metastasized due to the delayed diagnosis and treatment. She ultimately died, leaving behind a husband and two young children. https://sfspa.com/verdicts-settlements/case-4053-failure-to-timely-diagnose-bladder-cancer-lead-to-death/
- A $710,000 jury verdict was obtained for the failure to diagnose bladder cancer apparent on radiologic testing. A patient presented to her urologist with difficulty urinating. Despite radiological tests revealing a blockage at the bladder’s opening, the urologist either overlooked or misinterpreted the results. As a result, the undiagnosed bladder cancer metastasized, ultimately leading to the patient’s death. https://www.mwslegal.com/settlements-judgments-and-verdicts/
- A $1 million-dollar settlement was reached on behalf of the family of a patient died who at age 73 from urothelial carcinoma. Over the course of two-years she was treated for recurrent urinary tract infections, hydroureteronephrosis, hydronephrosis, and nephrolithiasis, undergoing multiple tests and procedures, including cystoscopy, ureteroscopy, and stent placements. After regular stent replacements and a negative biopsy for urothelial cancer, the defendant urologist referred her for reconstructive surgery. The plaintiff alleged that the defendant failed to promptly test or monitor for urothelial carcinoma. Later, a CT scan revealed a mass that was diagnosed as poorly differentiated urothelial carcinoma, leading to her death.
The approach to evaluating hematuria and other signs or symptoms of potential bladder cancer should be guided by a careful assessment of risk factors for malignancy, with more aggressive diagnostic testing reserved for those at higher risk. Early and accurate detection is crucial, as it can significantly impact treatment outcomes and overall prognosis for patients with urological malignancies.
If you or a loved one face a diagnosis of bladder cancer, and you feel your physician did not do a full work-up which considers your risk for cancer and concerning symptoms, we encourage you to contact Lupetin & Unatin and speak with one of our Pittsburgh medical malpractice lawyers. Or if you feel signs of cancer had to be missed on an earlier radiology study or other diagnostic test like a cystoscopy, please reach out with your questions. We will evaluate your potential case from every angle, and determine whether a lawsuit to recover compensation for you or your loved ones is warranted.
[i] Zhang, et al., The global landscape of bladder cancer incidence and mortality in 2020 and projections to 2040, J Glob Health. 2023; 13:04109; PMID: 37712386