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Pathologist wrong in 137 cases, review finds

Failed to warn 2 cancer patients

By: Jenny Ford

Posted: 02/18/2012 1:00 AM | Comments: 0

A provincial pathology probe found more than 130 Manitobans were given the wrong medical prognoses -- including two patients who were told they didn't have cancer when in fact, they did.

The Diagnostic Services of Manitoba review investigated the work of one Manitoba pathologist, revisiting more than 3,000 of his cases from October 2010 to June 2011. The pathologist, whom the review is not naming, is no longer practising.

Other cases

This isn't the first time pathologists have come under fire in Manitoba.

In July 2010, two women undergoing breast cancer treatments had their tissue samples switched by DSM. One had an unnecessary breast surgery while the other had her breast cancer treatment delayed by 10 weeks. Both were patients at the Breast Health Centre in Winnipeg. A review was inconclusive eight months later about why the switch happened. At the time, Kabani said the biopsy samples were likely inadvertently swapped by a pathologist assistant.

A Freedom of Information request revealed in March 2010 that there were 22 cases of critical incidents at Manitoba labs between July 2007 and November 2009. This included several cases where there were delays in processing at the labs and also cases where there was a misdiagnosis because tissue samples were not interpreted properly. Tory health critic Myrna Driedger, who obtained the Freedom of Information request, said heavy work loads and staff shortages contributed to the delays and misdiagnoses.

Veteran pathologist Dr. Robert Stark had 822 of his cases put under review in 2008. Stark had been practicing for 40 years. The cases went back as far as March 2007. He retired from his post at St. Boniface Hospital in June 2008 after a review found he made 42 errors including two cases where patients were diagnosed with the wrong cancer.

"As soon as we knew there was a problem, we stopped him from doing any cases immediately," Dr. Amin Kabani, DSM's chief medical officer, said Friday.

"We made sure to review all the cases, to do it quickly, but most importantly to actually inform the patients as soon as we knew there was an error."

The 137 patients whose prognoses were affected were informed throughout the review as soon as DSM found discrepancies, Kabani added. None of the patients can be named due to privacy rules. DSM is a not-for-profit corporation that runs 77 labs in the province.

Out of the 137 cases under review, five were determined to be "critical incidents," meaning the amended prognosis affected their treatment.

The review found two patients were initially told they did not have cancer, when in fact DSM subsequently found they did have cancer.

The three other critical cases were incidents where the new prognosis found the cancer was at a different stage than previously diagnosed, meaning, for instance, the tumour had grown or the cancer had spread, said Kabani.

Kabani could not give specific details about the cases in question.

He said in the two incidents where the cancer was misdiagnosed as benign, the late prognoses did not affect their treatment as the cancer had not advanced significantly.

"The good news within that bad news is that the review happened very quickly so the delay did not impact the prognosis. Obviously it did impact the patients' stress," he said.

The other 132 cases where the prognoses changed did not affect the treatment. For instance, a patient was too ill for treatment no matter the stage of cancer, or the patient was already undergoing treatment.

"It has been an extremely difficult time for everyone involved in the review process. Especially for the patients whose cases were reviewed and where discrepancies occurred," said Jim Slater, DSM's chief executive officer.

The review was given to the College of Physicians and Surgeons of Manitoba, which is investigating the pathologist, DSM said.

"Obviously we take this very seriously," said Dr. Bill Pope, registrar for the college.

Pope said he couldn't talk about what the investigation will look at, but said they will review the cases DSM identified.

"What we will review is the issues they (DSM) have sent us and then determine if there is anything we should do," he said.

It's unknown how long the investigation will take. Pope added it may take a while, especially since the pathologist is no longer practising and therefore no longer a risk to patients.

Pathologists are physicians who examine tissues, blood and other bodily fluids to help doctors diagnose diseases such as cancer, blood disorders and infections.

The pathologist in question practised in Manitoba for about eight months. He had attended medical school in the United States before coming to Manitoba, where Kabani said he had participated in a mentorship program and completed a probation period when he started practising with DSM.

"He had been in very prestigious institutions. We had interviewed his references," Kabani said.

The pathologist first came under scrutiny after DSM conducted a routine internal audit in April, reviewing 20 of his cases. It expanded the probe to 100 cases after finding discrepancies and put him under the supervision of a senior pathologist. The pathologist was suspended in June while DSM went over all his cases.

jennifer.ford@freepress.mb.ca

Republished from the Winnipeg Free Press print edition February 18, 2012 A11

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