Metastasis, a Result of Limited English Proficiency?

Abstract

Background: The U.S. Department of Justice defines Limited English proficiency (LEP) as individuals who do not speak English as their main language and have limited skills in reading, speaking, writing, or understanding it. LEP introduces an added layer of complexity, widening disparities in clinical care. This case demonstrates the effect LEP can have on patient care. Case: A 68-year-old patient underwent a low-dose CT scan of the chest in 2020 as part of the U.S. Preventive Services Task Force recommendations for cancer screening in individuals with a smoking history of more than 20 pack-years. The scan revealed a right upper lobe pulmonary nodule measuring 2.3 × 1.4 × 1.6 cm. A follow-up in six months was recommended. However, due to inadequate comprehension of medical advice, the patient did not return until June 2023. A CT scan performed at that time showed a spiculated pulmonary nodule in the same location as in 2020, now measuring 2.6 × 1.2 cm. A fine needle aspiration (FNA) was recommended, but once again, due to LEP, the patient did not understand the need for the procedure. This resulted in further delays until August 2023, when a biopsy was performed. The analysis confirmed lung adenocarcinoma, prompting treatment with lobectomy. In May 2024, a follow-up CT scan of the chest revealed two right lower lobe pulmonary nodules, with recommendations for a three-month follow-up. An ultrasound-guided FNA of this mass confirmed dissemination of the lung adenocarcinoma. The patient is currently being treated with a combination of carboplatin, pembrolizumab, and pemetrexed. Discussion: In the United States, 8.4% of households spoke English less than very well in 2022. LEP presents significant challenges for healthcare providers striving to deliver effective and equitable care to an increasing number of LEP patients. Ensuring access to professional interpretation services is essential, and expanding the language proficiency among physicians could greatly enhance medical communication and understanding. This case highlights how LEP can delay diagnosis of life-threatening conditions and possibly lead to worsening scenarios such as metastasis.