Cancer Misdiagnosis & Delayed Diagnosis

Understanding the Tumor Doubling Defense (continued)

One novel and unscientific defense advocated by Ostrum and others is to argue from the size of tumor at the time of diagnosis that the tumor at the time that the earlier diagnosis should have been made would have been of such a size as would have already metastasized. This argument depends upon the earlier false premise that growth of a given tumor is exponential and predictable. However, it is important to remember that this argument also depends upon accurate measurement of the tumor at diagnosis. The measurement of tumor size on a mammogram is often impossible. In addition, when tumors are examined carefully under the microscope there is sometimes much more inflammatory tissue than malignant cells and assessment of tumor cell density is therefore an important factor in understanding this defense. The fewer malignant cells present within the measured tumor mass the later the critical metastatic event(s).

Prolonged survival, whether or not the patient has been cured, is hardly an insignificant benefit of early diagnosis. Disease-free survival prolonged to the point of a person reaching their normal life expectancy certainly represents a cure in any layman's definition. The possibility of such survival exists for all forms of the cancer when early diagnosis is provided. The chances of prolonging survival with early diagnosis and treatment is virtually certain. Even if one assumes that metastasis has already occurred at the time that a primary tumor is removed, it cannot be seriously questioned that the primary tumor contributed to the overall tumor burden. New tumor needs time to grow sufficiently to replace the cells that have been removed. How quickly depends not only on tumor-doubling time, but also on the impact upon the residual tumor burden of the body's immune defenses and on the success of any adjuvant therapy that may be employed in the patient's care. Adjuvant chemotherapy is successful even where it only wipes out 95% to 99.9% of residual cancer cells in a patient's body. Presumably, in those patients who are not cured by adjuvant therapy, the remaining tumor cells are resistant to chemotherapy. Yet, even applying Spratt's median doubling time of 260 days where reduction of the metastatic tumor from 1,000,000 to 10,000 cells has occurred, 6-2/3 cell generations are required for the tumor to grow back to 1,000,000 cells. With a doubling time of 260 days, a patient wouldn't reach his/her lethal tumor burden for many years (lethal tumor burden of 10¹² is reached after 40 to 45 tumor doublings).

3. Moreover, if adjuvant therapy can destroy 99.9% of residual tumor burden at some point and if chemotherapy is more effective at smaller tumor burdens, one can reasonably conclude that at some point, even after metastasis, 100% of metastatic cells can be eliminated. Consider the patient with recurrent cancer who is administered chemotherapy and enjoys visible shrinkage of tumor mass. Given the limitations of cumulative chemotherapeutic dose (only so much can be given), the only way to eliminate the recurrent cancer is to reduce the tumor burden at the outset. Even if the tumor cannot be eliminated, the benefit of that time required for the tumor to resume its pre-treatment volume cannot be ignored. It is not for the wrongdoer to raise conjecture concerning the magnitude of those chances that he has by his wrongful conduct placed beyond the possibility of realization.

4. The assumption that in all cancers there exists the possibility that metastasis has occurred before diagnosis and removal of the primary tumor is the basis for adjuvant chemotherapy. But even those who believe that metastasis has occurred prior to diagnosis and removal must concede that the size of occult metastases at the time of treatment of the primary tumor and before adjuvant chemotherapy is significant. Adjuvant chemotherapy is known to be less effective when tumor burdens are high.

5. Prior to the development of a surgical treatment for cancer in the 1800's, women died of breast cancer because of hemorrhage within the primary breast tumor and/or infections. Now effective treatment exists for most forms of cancer if treated early. When a medical malpractice defendant attempts to prove otherwise, it is our responsibility to recognize and expose the invalidity of such arguments. By so doing, we free juries to use their collective common sense and intuition and reach the same conclusions that are the basis of 21st century medical practice in the diagnosis and treatment of cancer.

¹ Friberg, S., Mattson, S., On the Growth Rates of Human Malignant Tumor, Implications for Medical Decision Making, J. Surg. Oncol. 1997 Aug; 65(4): 284-97.

² Spratt, J.S., The Relationship Between Rates of Growth of Cancers and The Intervals Between the Screening Exams Necessary for Detection, Cancer Detection Prev., 1981:4(1-4).

³ Friberg, supra.

⁴ Hamil v. Bashline, 481 Pa 256, 392 A2d 1280 (1978).

⁵ Steel, G.G., Cell Loss As a Factor in the Growth Rate of Human Tumours, Eur J. Cancer, 1967; 3: 381-7.

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