It was a case that would haunt Mr. K for the rest of his life—a case that would cause the premature retirement of his supervising physician. But worst of all, it was a case that would have far-reaching consequences for a young mother and her family.

Mr. K, 29, had been the nurse practitioner in a three-person family practice since his graduation. The pay was good, and the regular hours allowed Mr. K to spend time with his young family. Dr. E, 59, was easy to work with, and the only other staff member was the office manager.

Mrs. C, 24, was an established patient, whose history included only minor, routine complaints. She had not been to the clinic since giving birth to her first child five months before. Doctor, nurse, and manager cooed over the baby pictures before Mrs. C went to the exam room.

The young mother complained of constipation, tenesmus, and recent blood in her stool. “Ah,” said Dr. E, while writing in the chart. “You have hemorrhoids. That's very common after giving birth.”

He suggested she try a stool softener, such as docusate (e.g., Colace), and sent her home.

Four months later, Mrs. C was back. Her symptoms had worsened. This time she saw Mr. K, who performed a digital rectal exam and found a palpable mass within the range of his index finger. “You have an internal hemorrhoid,” he told her and recommended a different laxative.

Over the next three months, Mrs. C returned twice with the same complaints, seeing both Dr. E and Mr. K. Each time she received the same diagnosis: hemorrhoids. On one occasion, she was given an enema. On the other, she was told to use phenylephrine suppositories and take a sitz bath.

While taking the bath, Mrs. C thought she felt a vaginal tumor and went to the emergency department (ED).  After a colonoscopy, she was diagnosed with colorectal cancer. Her treatment included chemotherapy, radiation, and major surgeries to remove her entire colon and uterus.

Dr. E and Mr. K were unaware of Mrs. C's condition until the office manager called to schedule her yearly physical. Both clinicians were shocked and looked at each other in dismay. “It's almost unheard of for someone to develop colorectal cancer at her age,” exclaimed Dr. E. “I would never have suspected it… that poor woman!”

Three years after she first showed off her baby's pictures, Mrs. C died. She was 27 years old.

Shortly thereafter, Dr. E and Mr. K were notified that the widower was suing them for malpractice. They contacted their insurance company, which provided a defense attorney. 

The case slowly moved toward a trial. “I'm obligated to tell you,” the defense lawyer told his clients, “that the plaintiff has offered to settle for $1 million—the limit on your insurance policy. However, I don't advise you to take that deal. Although Mrs. C was young when she died, she worked in retail. If the jury does find for her—and I'm not saying that it will—I don't think the economic damages will be that high.”

Not knowing what else to do, Dr. E and Mr. K followed the lawyer's advice.

The trial was painful for everyone. The plaintiffs' attorney introduced a four-hour video in which Mrs. C talked about how her daughter would soon be without a mother and her husband would lack a wife. Then the widower and Mrs. C's mother took the stand, testifying tearfully about their loss and what it was like to have to watch her die.

The plaintiffs' attorney next called an expert gastroenterologist, who described the symptoms of colorectal cancer. She said that Mrs. C should have been referred to a specialist or sent for a colonoscopy after her first appointment with Dr. E because her cancer was probably stage I or II at that time.

“Had the cancer been diagnosed then, when it was stage I, she would have had a 97% chance of survival,” the expert declared. “But by the time she was finally diagnosed, her odds dropped to 50%.”

On cross-examination, the defense attorney focused on the likelihood that a woman so young would present with such disease.  “The  prevalence in people aged 20-34 is 1%, putting them at low risk,”  the expert explained.

“So would you say that it's very unusual for a 24-year-old woman to have colorectal cancer?” the lawyer pressed.

“Yes, it is unusual. But that doesn't mean it can't happen,” the expert responded.

Later the defense attorney called his own experts to emphasize the point. Then Mr. K described the rectal exam and said he was sure the mass he palpated was hemorrhoids.

“How would you discern between hemorrhoids and cancer?” asked the plaintiffs' attorney on cross-examination.

“I don't know...I never felt cancer before,” Mr. K admitted.

The jury found for the plaintiffs, awarding Mrs. C's estate $2.5 million, and a distraught Dr. E decided to retire.

Legal background

Sometimes settling a case is the best alternative. In this situation, it would have saved everyone a lot of pain, legal costs, and extra damages.

The state where this took place sets a cap on noneconomic damages, which was what the defense lawyer banked on when he refused the settlement offer. Economic damages are based on the income patients would have earned during a normal life span. In this case, Mrs. C had many productive years ahead of her. Even though she held a low-paying job, her earning potential was high because she was so young. 

The jury award consisted of $2 million in economic damages, $250,000 for pain and suffering during Mrs. C's illness, and $250,000 for the family's pain and suffering in the future.

Protecting yourself

As the plaintiffs' expert noted on cross-examination, the prevalence of colorectal cancer in a woman Mrs. C's age is very rare. But it's not unheard of.

When an otherwise healthy young woman presents with Mrs. C's symptoms five months after childbirth, hemorrhoids are the most likely culprit. Only in hindsight can Dr. E or Mr. K be faulted for not immediately considering an improbable alternative.

But when Mrs. C returned the third time without relief, they should have suspected something more serious might be afoot. They could reasonably be expected to have performed an anoscopy to confirm the presence of internal hemorrhoids.

Even if the odds are low, you must expand your differential diagnosis when a patient fails to respond to treatment for the most likely condition. Had Dr. E and Mr. K re-assessed their conclusions, the jury probably would not have held them liable for Mrs. C's death.  They might even have saved her life.

Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.