the gynecological tract. In sum, the preponderance of the evidence shows that Dr. Sheffery's and Dr. Wilson's failure to obtain a pap smear and their use of Provera as the sole treatment for Mrs. Snead's abnormal bleeding in July, 1979 did not satisfy the standard of care governing board-certified gynecologists at that time. Their breach of the duty of care was compounded by their failure to specifically direct Yen Snead to seek further treatment, regardless of apparent improvement, in light of the possibility that Provera could mask gynecological abnormalities.
Plaintiffs must next prove that the treatment Mrs. Snead received in July, 1979 was the proximate cause of her injuries. See Johnson v. United States, 178 U.S. App. D.C. 391, 547 F.2d 688, 692 (D.C. Cir. 1976). In cases involving alleged medical mismanagement of a patient's existing and potentially fatal condition, the appropriate test for causation is the "substantial factor" test. Under this test, plaintiffs must show that the defendant's deviation from the standard of care was a "substantial factor" bringing about Mrs. Snead's present condition. Daniels v. Hadley Memorial Hospital, 185 U.S. App. D.C. 84, 566 F.2d 749, 757 (D.C. Cir. 1977). In applying the "substantial factor" test the Court "must at least take into account both the patient's chances of survival [had she been properly treated] and the extent to which defendant has interfered with those chances [by departing from the standard of care]." Id. at 758.
The first inquiry in the causation analysis is whether in July 1979 Yen Snead had a discoverable and potentially fatal condition which Drs. Sheffery and Wilson failed to detect. Defendant, supported by the testimony of Dr. Park, argues that even had Drs. Sheffery and Wilson performed diagnostic tests to determine the cause of Yen Snead's bleeding, they could not have prevented the cancer from which she now suffers, because it was not present at that time. Specifically, defendant argues that there is no evidence that Mrs. Snead's specific form of cancer, poorly differentiated glassy-cell adenosquamous carcinoma, passes through a recognizable prolonged preinvasive state which could have been detected by cervical cytology in 1979.
Refuting that contention, a host of credible physicians testified, including Myron R. Melamed, M.D., the Chairman of the Pathology Department at Memorial Sloan-Kettering Cancer Center in New York, Margrit A. David-Nelson, M.D., the pathologist who examined the cervical tumor removed from Yen Snead on July 31, 1980, George Speck, M.D.,
the surgeon who removed that tumor, and Drs. Goldfarb and Singer. The totality of that testimony, as summarized below, establishes that the nature, size and growth rate of the malignancy removed from Yen Snead's cervix is not consistent with the rapidly invasive growth envisioned by Dr. Park.
Dr. David-Nelson testified that her examination of representative samples of the polypoid mass surgically removed in 1980 revealed that it originated in a benign adenomatous endocervical polyp. Tr. Vol. 5, pp. 165-66. Over time, malignant cells replaced the normal tissue of that polyp, transforming it into the adenoepidermoid carcinoma removed by Dr. Speck. Tr. Vol. 5, p. 166. Dr. Speck confirmed the pathologist's testimony as to the size of the mass he removed (approximately three centimeters or 1 1/2 inches in diameter) and further described it as a pedunculated, movable lesion (arising from the surface of the cervix on a stalk) large enough to obscure the opening of the cervix. Tr. Vol. 5, pp. 159-161. Based on the size of the lesion, Dr. Speck testified that "it had been there for some time" before being removed. Id. at 161.
The critical question is how long Yen Snead's polyp had been present, that is, whether it could and should have been discovered in July, 1979. Based on the growth process (staging) and doubling time (rate of growth) of adenoepidermoid tumors, Dr. Goldfarb stated, with reasonable medical certainty, that some sign or symptom of Mrs. Snead's cancer was discoverable in July, 1979. Tr. Vol. 2-A, pp. 24-25. This testimony is consistent with that of Dr. Melamed, that invasive cervical cancer such as Mrs. Snead's exists "in situ" at the surface epithelium for "some period of time" before progressing to invasion of the underlying connective tissue. Melamed Dep. at 16.
This conclusion corroborates the testimony of Dr. Singer, who held the opinion that Yen Snead's cervical carcinoma "certainly was present", at least in situ, in June of 1979. Tr. Vol. 2-A at 51.
Other relevant testimony as to the growth rate of Yen Snead's cancer supports plaintiffs' case as well. Defendants do not contest (and in fact their own expert witness agrees) that the growth rates of Mrs. Snead's primary and metastatic adenoepidermoid carcinoma would be roughly equivalent, and evidence indicates that the tumor cells which metastasized from Yen Snead's cervix to her lung and mediastinum did not display rapid growth: as late as April, 1982, 20 months after removal of the primary cervical cancer, the metastatic tumors were still too small to appear on a chest x-ray. See PX-1, p. 148 and Report of E. Grant, M.D. contained in PX-1. Those facts simply do not support Dr. Park's conclusion that Mrs. Snead's polyp transformed from an undiscoverable benign polyp to an enlarged and invasive adenoepidermoid carcinoma in less than a single year.
Finally, Dr. Park's reliance on literature from the American College of Obstetrics and Gynecology to the effect that cervical adenocarcinoma is not preceded by a prolonged preinvasive stage is of no assistance in this matter since Yen Snead's form of cancer is not an adenocarcinoma but rather an adenoepidermoid or adenosquamous variety, bearing traits of squamous cell carcinoma as well. The growth process described by Drs. Melamed and Singer accounts for the nature of that tumor.
The weight of the testimony capsulized above compels the conclusion, through credible and persuasive testimony offered with reasonable medical certainty, that in July, 1979, Yen Snead's cervical carcinoma existed in some preinvasive and discoverable stage. Given that Mrs. Snead already suffered from a potentially fatal condition in July, 1979, the issue is whether the actions and omissions of Drs. Sheffery and Wilson substantially contributed to her present condition. See Daniels v. Hadley Memorial Hospital, 566 F.2d at 757.
We look first to the likely effect of timely proper treatment. Dr. Barry Singer stated unequivocally that
a pap smear properly performed at that time [July, 1979] would have revealed the presence of abnormal cells, leading to a more complete examination of the cervix which would have included curettage or biopsy, to determine the source of the abnormal cells. . . . Within reasonable medical probability, a curettage at that time would have been curative, since the tumor, by definition, would have been smaller at that time. Assuming growth of these tumors to be sequentially over time and metastases to occur after a tumor grows to a certain size, at that time the tumor would have been confined to the cervix, would not have metastasized, and should have been curable by curettage.