Court Opinion

ID: 9555970
Source: CourtListenerOpinion
Date Created: 2023-08-15 18:11:56.639941+00
Date Added: 2024-06-11T15:34:55.708899
License: Public Domain

J-A16044-23

NON-PRECEDENTIAL DECISION - SEE SUPERIOR COURT OP 65.37

    KELLY A. VELESARIS & DEMETRIOS             :   IN THE SUPERIOR COURT OF
    C. VELESARIS                               :        PENNSYLVANIA
                                               :
                       Appellants              :
                                               :
                                               :
                v.                             :
                                               :
                                               :   No. 1602 MDA 2022
    OLEG LEONTIEV, M.D., LEBANON               :
    IMAGING ASSOCIATES, P.C., THE              :
    GOOD SAMARITAN HOSPITAL OF                 :
    LEBANON, PENNSYLVANIA D/B/A                :
    WELLSPAN GOOD SAMARITAN                    :
    HOSPITAL, AND WELLSPAN HEALTH              :

                Appeal from the Order Entered October 12, 2022
    In the Court of Common Pleas of Lebanon County Civil Division at No(s):
                                 2018-02094

BEFORE: PANELLA, P.J., BENDER, P.J.E., and McCAFFERY, J.

MEMORANDUM BY McCAFFERY, J.:                   FILED: AUGUST 15, 2023

       In this medical malpractice action, Kelly A. Velesaris and her husband,

Demetrios C. Velesaris (collectively, Appellants) take this appeal from the

order entered in the Lebanon County Court of Common Pleas, granting

summary judgment in favor of Oleg Leontiev, M.D., and Lebanon Imaging

Associates, P.C.1 (collectively, Dr. Leontiev).2 Appellants aver the trial court

____________________________________________

1 Appellants named Lebanon Imaging Associates, P.C. based on a claim of
vicarious liability. See Appellants’ Complaint, 8/9/18, at ¶ 3.

2 Appellants voluntarily sought to enter final judgment in favor of Dr. Leontiev

to pursue the present appeal. See Final Order, 10/12/22, at 1-2.
J-A16044-23

erred in determining that two of their expert witnesses were not qualified and

competent to render opinions on causation. Based on the following, we affirm.

       The underlying facts and procedural history are as follows. Kelly had

several “routine bilateral mammogram[s]” performed in 2007, 2008, and

2013 at Tristan Radiology. See Appellants’ Complaint at ¶¶ 13-15. All three

studies “showed heterogeneously dense breast tissue with no evidence of

malignancy.” Id.

       On October 25, 2014, she presented to Good Samaritan Hospital for an

annual mammogram screening and Dr. Leontiev was the reviewing physician.3

See Appellants’ Complaint at ¶ 16.

       The study was compared to the prior three previous studies
       performed at Tristan. The results of this study, as interpreted by
       [Dr. Leontiev], revealed “scattered fibroglandular densities” with
       “no dominant masses, suspicious microcalcifications or areas of
       architectural distortion observed to suggest malignancy. [There
       were n]o significant changes when compared to prior studies.” Dr.
       Leontiev assessed [Kelly] as Birads[4] Category 1-Negative.”

Id.

       Kelly returned to Good Samaritan on October 27, 2015, for her annual

mammogram screening, which was again interpreted by Dr. Leontiev. This

____________________________________________

3 Dr. Leontiev is a board certified radiologist.
                                               See Dr. Leontiev’s Answer and
New Matter, 6/24/19, at ¶ 2. Kelly testified she never met Dr. Leontiev. See
Dr. Leontiev’s Brief in Support of Supplemental Omnibus Motion in Limine,
9/16/22, at Exhibit “B” (Oral Deposition of Kelly A. Velesaris, 9/9/19, at 27).

4 “Birads” is the acronym for “Breast Imaging Reporting & Data System.”

                                           -2-
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study was compared to the October 25, 2014, and the March 21, 2013,

studies, and the results were substantially similar to the 2014 screening. See

Appellants’ Complaint at ¶ 17.

      Kelly next returned to Good Samaritan on November 14, 2016, for a

mammogram screening. This time, Jennifer Kegel, M.D. interpreted the study

and compared it with the five previous studies.         She “noted ‘scattered

fibroglandular densities.     Focal asymmetry/architectural distortion, upper

quadrant left breast.’      Dr. Kegel assessed [Kelly] as Birads Category 0-

Incomplete, and recommended [she] undergo further imaging and ultrasound

in light of the findings.” Appellants’ Complaint at ¶ 18.

      Kelly then went to the Milton S. Hershey Medical Center (Hershey) on

November 17, 2016, for additional diagnostic testing. Appellants’ Complaint

at ¶ 19. “Results of the tests confirmed that a ‘solid mass in the left breast

[was] highly suggestive of malignancy.” Id. Kelly was then “assessed as a

Birads Category 5-Highly Suggestive of Malignancy.” Id. A biopsy of Kelly’s

left breast was taken, “confirming a diagnosis of invasive left breast

carcinoma.”   Id. at ¶ 20.     “A breast [magnetic resonance imaging (MRI)]

performed on November 23, 2016, at [Hershey] confirmed the presence of

multiple additional suspicious masses, thereby precluding any option of

breast-conserving surgery.” Id. at ¶ 21.

      On January 2, 2017, Kelly “underwent a bilateral mastectomy and a left

axillary sentinel lymph node biopsy” at Hershey. Appellants’ Complaint at ¶

                                      -3-
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22. “The results of the lymph node biopsy revealed left multifocal invasive

breast carcinoma with ductal and lobular features, and extensive high nuclear

grade ductal carcinoma in-situ, as well as micrometastic carcinoma in sentinel

lymph nodes.” Id. at ¶ 23. Kelly also underwent chemotherapy six weeks

later.    See Oral Deposition of Kelly A. Velesaris at 60.      Additionally, she

decided to undergo postmastectomy radiation. Id. at 90. Subsequently, she

sought numerous breast reconstruction procedures.5 Post treatment, Kelly

has not been diagnosed with any recurrence of her breast cancer. Id. at 94-

95.

         On August 9, 2018, Appellants filed a complaint against Dr. Leontiev,

and other entities,6 alleging that the doctor’s failure to timely detect and report

radiologic mammographic evidence of cancer in Kelly’s left breast based on

____________________________________________

5 Kelly acknowledges she has had five breast revision surgeries. See
Appellants’ Pretrial Statement, 2/28/22, at 1; see also Appellants’ Brief at 6.
Her treating radiation oncologist, Jennifer C. Rosenberg, M.D., stated that
when a patient that has breast reconstruction, they can develop scar tissue
after radiation. See Omnibus Motion in Limine of Defendants, Oleg Keontiev,
M.D. and Lebanon Imaging Associates, P.C., Challenging Expert Evidence,
9/8/22, at Exhibit “A” (Oral Deposition of Jennifer C. Rosenberg, M.D.,
2/21/20, at 32).

6  Appellants also named The Good Samaritan Hospital of Lebanon,
Pennsylvania d/b/a WellSpan Good Samaritan Hospital (Good Samaritan), and
WellSpan Health (WellSpan) as defendants. Good Samaritan and WellSpan
were dismissed from the underlying litigation pursuant to the trial court’s
October 5, 2022. Appellants do not challenge that portion of the trial court’s
order on appeal.

                                           -4-
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studies he reviewed on October 25, 2014, and October 27, 2015.7 Moreover,

Appellants averred:

       27. As a consequence of the delayed diagnosis of left breast
       cancer, [Kelly] required more aggressive, invasive treatment
       and lost any possibility of pursuing any breast-conserving,
       less radical options. The delayed diagnosis also diminished
       [Kelly]’s chances of achieving a complete cure.

       28. As consequence of the delayed diagnosis of left breast cancer,
       [Kelly] sustained permanent and irreversible loss of both
       breasts.

Appellants’ Complaint at ¶¶ 27-28 (emphases added).

       The parties exchanged numerous pleadings and motions. The matter

was scheduled for trial on October 10, 2022.        In their pretrial statement,

Appellants identified two experts — a radiologist expert, Reni S. Butler, M.D.,

and a psychiatrist expert, Howard L. Forman, M.D. — who would testify that

the delayed diagnosis caused the progression of Kelly’s breast cancer, which

necessitated the treatment chosen by Kelly.              See Appellant’s Pretrial

Statement at 6 (unpaginated).

       Dr. Butler’s report provided, in relevant part:

             It is my opinion, to a reasonable degree of medical certainty,
       that the standard of care was breached at the time of
       interpretation of the 10/25/2014 and 10/27/2015 mammograms,
       due to a failure to identify interval development of new or
       increasing suspicious findings; a failure to recommend further
       evaluation with diagnostic mammography and ultrasound; and a
____________________________________________

7 Appellants originally filed their complaint in the Philadelphia Court of
Common Pleas. The matter was subsequently transferred to the Lebanon
County Court of Common Pleas pursuant to a stipulation by the parties.

                                           -5-
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      failure to perform biopsy for histologic diagnosis.         The
      misinterpretation of the mammograms from 10/25/2014 and
      10/27/2015 fell outside the standards of acceptable professional
      practice and resulted in a delay of [Kelly]’s breast cancer
      diagnosis.

             It is also my opinion, to a reasonable degree of medical
      certainty, that had a biopsy been performed after the 10/25/2014
      or 10/27/2015 mammograms, [Kelly’s] cancer would have been
      diagnosed earlier when she could have been treated less
      aggressively with breast conserving surgery. In this case as well
      as any other oncologic case, it is a well-accepted medical concept
      that the earlier the stage at which a malignancy is diagnosed, the
      better the prognosis for treatment and eventual outcome. The
      delay in diagnosis of [Kelly’s] invasive breast carcinoma due to
      the failure to identify suspicious mammographic findings on
      10/25/2014 or 10/27/2015 allowed her cancer to progress, led to
      more aggressive surgical treatment, and diminished her chances
      of [a] cure.

Dr. Leontiev’s Motion in Limine at Exhibit “B” (Dr. Butler’s Report re Kelly

Velesaris, 5/18/18, at 3-4 (unpaginated)).

      Additionally, Dr. Forman’s expert report stated, in part:

      [Kelly]’s decision-making throughout the treatment of her breast
      cancer was not influenced by any mental illness.

                              *    *     *

      When [Kelly] was finally diagnosed, her physicians provided her a
      menu of treatment options. She chose from that menu. If the
      cancer had been diagnosed earlier, it is reasonable to conclude
      that menu would not have included as many of the disfiguring and
      systemic treatments [Kelly] received.

Dr. Leontiev’s Motion in Limine at Exhibit “C” (Dr. Forman Report re Kelly

Velesaris, 6/7/21, at 8-9).

      On September 8, 2022, Dr. Leontiev filed a motion in limine, asserting

Appellants’ proposed experts, Dr. Butler and Dr. Forman, were “not qualified

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to present opinions on causation in this matter where the specific care at issue

is based in various disciplines of oncology.” Dr. Leontiev’s Motion in Limine at

7 (capitalization and emphasis omitted). Dr. Leontiev alleged that Dr. Butler’s

curriculum vitae did “not reflect any education, experience or training in

oncology or the assessment and treatment of cancer.” Id. Moreover, Dr.

Leontiev stated Dr. Butler “does not diagnose cancer, recommend treatment

plans, manage treatment plans, coordinate oncological specialties or generally

follow an oncology patient.” Id. Rather, the radiologist “interpret[s] studies

and develop[s] impressions which recorded in reports then utilized by

oncology providers.”   Id.   Moreover, he stated that while “radiology is a

necessary and integral step in the diagnosing and sizing of cancer, it can only

disclose, at most, the existence of a tumor and sometimes, the size and extent

of the disease.” Id. Dr. Leontiev further asserted:

      The issues of causation in this matter relate solely to whether
      [Kelly] required more aggressive oncology treatment resulting
      from the alleged failure to detect. However, the size of the tumor
      alone is insufficient, as explained by each of [Kelly]’s treating
      providers, to perform this analysis even though that is the extent
      of information that can be offered by a radiologist.

Id. at 7-8.

      As for Dr. Forman, Dr. Leontiev alleged that “it is difficult to find two

medical specialties more unrelated to one another than psychiatry and

oncology and there simply does not appear to be any basis for Dr. Forman to

render causation opinions.” Dr. Leontiev’s Motion in Limine at 8. Dr. Leontiev

                                     -7-
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concluded that “neither of these individuals are qualified to render causation

opinions in this matter.”8 Id. at 9 (footnote omitted).

       On October 5, 2022, the trial court entered an order, which addressed

multiple motions, including Dr. Leontiev’s motion in limine regarding

Appellants’ experts. The order stated, in pertinent part:

       4. The Omnibus Motion in Limine of [Dr. Leontiev] Challenging
       Expert Evidence is GRANTED, in part, and DENIED, in part, as
       follows:

          (a.) Dr. Reni Butler and Dr. Howard L. Forman are prohibited
          from expressing an expert opinion as to causation, i.e.,
          whether [Kelly] would have had a more favorable prognosis
          for treatment and eventual outcome if the diagnosis of
          cancer had been made at the earlier date(s) suggested by
          the evidence adduced at trial.

          (b.) Dr. Forman is prohibited from expressing an opinion as
          to whether any mental illness interfered with the decision-
          making process of [Kelly] regarding her cancer treatment.

Order, 10/5/22, at 3.

       Upon receipt of the court’s order, Appellants’ counsel “notified the [trial

c]ourt that they would not be able to make out a prima facie case of negligence

____________________________________________

8 Dr. Leontiev also made the following comment:

       Dr. Leontiev is not suggesting that Dr. Forman is unqualified to
       render a causation opinion relating to any alleged emotion injuries
       or disorders resulting from the alleged delay to detect. However,
       this issue is separate and distinct from the issue of whether the
       alleged delay to detect require more aggressive treatment or
       actually resulted in harm to [Kelly].

Dr. Leontiev’s Motion in Limine at 9 n.1.

                                           -8-
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due to [its] ruling on the Omnibus Motion in Limine.” Trial Ct. Op., 12/23/22,

at 4.    Consequently, the court entered a final order on October 12, 2022,

which granted summary judgment in favor of Dr. Leontiev and directed the

prothonotary to enter final judgment in this matter.           See Final Order,

10/12/22, at 1-2. Appellants filed a timely notice of appeal.9

        Appellants present the following issues for review:

        A. Whether [Appellants]’ expert, Dr. Reni Butler, is qualified and
           competent to render opinions regarding causation[?]

        B. Whether [Appellants]’ expert, Dr. Howard Forman, is qualified
           and competent to render opinions regarding causation[?]

Appellants’ Brief at 5.

        Because both of Appellants’ claims concern the court’s grant of summary

judgment in favor of Dr. Leontiev, which stemmed from the court’s grant of

Dr. Leontiev’s motion in limine on the basis that Appellants were precluded

from offering expert opinions regarding medical causation and an increased

risk of harm,10 we are guided by the following standards and principles.

        In reviewing a challenge to the entry of summary judgment, we may

disturb the trial court’s order “only where it is established that the court

____________________________________________

9 Appellants complied with the trial court’s directive to file a Pa.R.A.P. 1925(b)

concise statement of errors complained of on appeal. See Appellants’ Concise
Statement of Errors Complained of on Appeal, 11/14/22, at 1-2. The trial
court issued a Pa.R.A.P. 1925(a) on December 23, 2022.

10 See Final Order, 10/12/22, at 1.

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committed an error of law or abused its discretion. As with all questions of

law, our review is plenary.” Pass v. Palmiero Auto. of Butler, Inc., 229

A.3d 1, 5 (Pa. Super. 2020) (citation omitted).11

       Moreover, our standard of review of a ruling on a motion in limine is

well-settled:

       A motion in limine is used before trial to obtain a ruling on the
       admissibility of evidence. It gives the trial judge the opportunity
       to weigh potentially prejudicial and harmful evidence before the
       trial occurs, thus preventing the evidence from ever reaching the
       jury. A trial court's decision to grant or deny a motion in limine is
       subject to an evidentiary abuse of discretion standard of review.

Parr v. Ford Motor Co., 109 A.3d 682, 690 (Pa. Super. 2014) (en banc)

(citations & quotation marks omitted).

             When we review a ruling on the admission or exclusion of
       evidence, including the testimony of an expert witness, our
       standard is well-established and very narrow. These matters are
       within the sound discretion of the trial court, and we may reverse
____________________________________________

11 Furthermore, we note Pennsylvania Rule of Civil Procedure 1035.2 provides:

       that where there is no genuine issue of material fact and the
       moving party is entitled to relief as a matter of law, summary
       judgment may be entered. Where the nonmoving party bears the
       burden of proof on an issue, he may not merely rely on his
       pleadings or answers in order to survive summary judgment.
       Failure of a non-moving party to adduce sufficient evidence on an
       issue essential to his case and on which he bears the burden of
       proof establishes the entitlement of the moving party to judgment
       as a matter of law. Lastly, we will review the record in the light
       most favorable to the nonmoving party, and all doubts as to the
       existence of a genuine issue of material fact must be resolved
       against the moving party.

Pass, 229 A.3d at 5 (citation omitted).

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      only upon a showing of abuse of discretion or error of law. An
      abuse of discretion may not be found merely because an appellate
      court might have reached a different conclusion, but requires a
      result of manifest unreasonableness, or partiality, prejudice, bias,
      or ill-will, or such lack of support so as to be clearly erroneous. In
      addition, [t]o constitute reversible error, an evidentiary ruling
      must not only be erroneous, but also harmful or prejudicial to the
      complaining party.

Freed v. Geisinger Med. Ctr., 910 A.2d 68, 72 (Pa. Super. 2006) (citations

& quotation marks omitted).

      Pursuant to Pennsylvania Rule of Evidence 702:

      A witness who is qualified as an expert by knowledge, skill,
      experience, training, or education may testify in the form of an
      opinion or otherwise if:

      (a) the expert’s scientific, technical, or other specialized
      knowledge is beyond that possessed by the average layperson;

      (b) the expert’s scientific, technical, or other specialized
      knowledge will help the trier of fact to understand the evidence or
      to determine a fact in issue; and

      (c) the expert’s methodology is generally accepted in the relevant
      field.

Pa.R.E. 702(a)-(c).

      The Medical Care Availability and Reduction of Error Act, 40 P.S. §

1303.101 et seq. (MCARE), sets forth additional requirements for expert

testimony in medical professional liability actions.        Specifically, MCARE

provides, in relevant part:

      (a) GENERAL RULE. — No person shall be competent to offer an
      expert medical opinion in a medical professional liability action
      against a physician unless that person possesses sufficient
      education, training, knowledge and experience to provide

                                     - 11 -
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     credible, competent testimony and fulfills the            additional
     qualifications set forth in this section as applicable.

     (b) MEDICAL TESTIMONY.— An expert testifying on a medical
     matter, including the standard of care, risks and alternatives,
     causation and the nature and extent of the injury, must meet the
     following qualifications:

        (1) Possess an unrestricted physician’s license to practice
        medicine in any state or the District of Columbia.

        (2) Be engaged in or retired within the previous five years
        from active clinical practice or teaching.

     Provided, however, the court may waive the requirements of this
     subsection for an expert on a matter other than the standard of
     care if the court determines that the expert is otherwise
     competent to testify about medical or scientific issues by virtue of
     education, training or experience.

40 P.S. § 1303.512(a)-(b).

           To prevail in any negligence action, the plaintiff must
     establish the following elements: the defendant owed him or her
     a duty, the defendant breached the duty, the plaintiff suffered
     actual harm, and a causal relationship existed between the breach
     of duty and the harm. When the alleged negligence is rooted in
     professional malpractice, the determination of whether there was
     a breach of duty comprises two steps: first, a determination of the
     relevant standard of care, and second, a determination of whether
     the defendant’s conduct met that standard. Furthermore, to
     establish the causation element in a professional malpractice
     action, the plaintiff must show that the defendant’s failure
     to exercise the proper standard of care caused the
     plaintiff’s injury. Expert testimony is generally required in
     a medical malpractice action to establish several of elements: the
     proper standard of care, the defendant’s failure to exercise that
     standard of care, and the causal relationship between the
     failure to exercise the standard of care and the plaintiff’s
     injury.

Freed, 910 A.2d at 72-73 (citations omitted; emphases added). “[M]edical

opinion need only demonstrate, with a reasonable degree of medical certainty,

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that a defendant’s conduct increased the risk that the harm sustained by

plaintiff would occur.” Gradel v. Inouye, 421 A.2d 674, 679 (Pa. 1980).12

       Lastly, we note:

             In Hamil v. Bashline, our Supreme Court adopted the
       relaxed “increased-risk-of-harm” standard for use in certain
       medical malpractice claims. 392 A.2d 1280, 1288 (Pa. 1978). In
       adopting this principle, the Hamil Court reasoned:

          In light of our interpretation of [subs]ection 323(a) [of
          Restatement of Torts 2d,13] it follows that where medical
          causation is a factor in a case coming within that Section, it
____________________________________________

12 Furthermore, it merits mention:

       [A]lthough it is preferable that the expert be in the same specialty
       as the defendant, that is not what the law requires in every case.
       Rather, “[t]he ‘same subspecialty’ ideal contained in [the MCARE
       Act] includes an express caveat, reflecting the Legislature’s
       decision to afford the trial court discretion to admit testimony from
       a doctor with expertise in another specialty that ‘has a similar
       standard of care for the specific care at issue.’”

Vicari v. Spiegel, 936 A.2d 503, 513-14 (Pa. Super. 2007) (citations &
footnote omitted; emphasis in original).

13 Subsection 323 provides, in part:

       Negligent Performance of Undertaking to Render Services

       One who undertakes, gratuitously or for consideration, to render
       services to another which he should recognize as necessary for
       the protection of the other's person or things, is subject to liability
       to the other for physical harm resulting from his failure to exercise
       reasonable care to perform his undertaking, if

          (a) his failure to exercise such care increases the risk of such
          harm . . . .

Restatement (Second) of Torts § 323(a).

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          is not necessary that the plaintiff introduce medical evidence
          in addition to that already adduced to prove defendant’s
          conduct increased the risk of harm — to establish that the
          negligence asserted resulted in plaintiff’s injury. Rather,
          once the jury is apprised of the likelihood that defendant’s
          conduct resulted in plaintiff’s harm, [subsection 323(a)]
          leaves to the jury, and not the medical expert, the task of
          balancing probabilities.

       Hamil, 392 A.2d at 1288.                Subsequently, our high court
       explained:

          An example of this type of case is a failure of a physician to
          timely diagnose breast cancer. Although timely detection of
          breast cancer may well reduce the likelihood that the patient
          will have a terminal result, even with timely detection and
          optimal treatment, a certain percentage of patients
          unfortunately will succumb to the disease. This statistical
          factor, however, does not preclude a plaintiff from prevailing
          in a lawsuit. Rather, once there is testimony that there was
          a failure to detect the cancer in a timely fashion, and such
          failure increased the risk that the woman would have either
          a shortened life expectancy or suffered harm, then it is a
          question for the jury whether they believe, by a
          preponderance of the evidence, that the acts or omissions
          of the physician were a substantial factor in bringing about
          the harm. See Jones v. Montefiore Hosp., 431 A.2d 920
          (Pa. 1981).

       Mitzelfelt, 584 A.2d at 892; see Smith v. Grab, 705 A.2d 894,
       899 (Pa. Super. 1997) (stating expert’s testimony demonstrating
       increased risk of harm “furnishes a basis for the fact-finder to go
       further and find that such increased risk of harm was in turn a
       substantial factor in bringing about the resultant harm”) (quoting
       Hamil, supra).

K.H. v. Kumar, 122 A.3d 1080, 1104 (Pa. Super. 2015) (footnotes omitted).14

____________________________________________

14 We acknowledge that we are not concerned with a jury based on the
procedural posture of the case, but we do find the case law discussed K.H.
helpful in our review.

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      In their first argument, Appellants complain the court erred in not

permitting Dr. Butler “to testify as an expert as to increased risk of harm in

that her credentials and experience reasonably and rationally envelop this

issue.” Appellants’ Brief at 16. Moreover, they state:

      Not only the radiologic detection of a tumor or mass, but also its
      growth and potential negative impact if it goes undiscovered, are
      intertwined and often subject to a multi-disciplinary approach in
      diagnosis and treatment. Dr. Butler’s extensive experience and
      knowledge of each of these aspects is well within her purview and
      an appropriate subject for her testimony.

Id.   In support of their argument, they rely on two cases — Tong-

Sommerford v. Abington Memorial Hospital, 190 A.3d 631 (Pa. Super.

2018), and McFeeley v. Shah, 226 A.3d 582 (Pa. Super. 2020).

      Additionally, Appellants contend that the trial court ignored “an excerpt

from Dr. Butler’s report which relates directly to evidence of increased risk of

harm from a radiologic perspective.” Appellants’ Brief at 20. They cite to the

following:

      Careful side-by-side comparison with prior studies, a standard
      practice in mammographic interpretation, is essential for the early
      diagnosis of breast cancer. It is the goal of every reasonable and
      well-trained radiologist to detect new potentially significant
      findings on mammography at the smallest size at which they can
      be perceived. When such findings are allowed to grow, the benefit
      of screening mammography in reducing breast cancer mortality is
      diminished.

Id. (quotation marks omitted). Appellants maintain:

      This one paragraph demonstrates why early detection of
      suspicious findings leads to a better outcome. They go hand-in-
      hand. Thus, the failure of the radiologist to detect a tumor or
      mass in its early stages, by normal progression, gives an increase

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      risk of harm to the patient. This passage authored by Dr. Butler
      constitutes sufficient evidence that [Dr. Leontiev’s] negligence in
      failing to detect a mass at its earliest stages naturally gave rise to
      an increased the risk of harm to [Kelly] from a radiologic or
      mammographic standpoint, about which Dr. Butler is certainly
      qualified to opine.

Id. at 20-21 (emphasis in original).

      Here, the trial court opined the following:

      [Appellants] countered [Dr. Leontiev’s motion in limine argument]
      that Dr. Butler was qualified to render an opinion on causation by
      virtue of her education, training and experience in the detection
      of breast cancer and the effects of delayed diagnosis and as a
      result of her active engagement in the full-time teaching of
      medicine. [Appellants] pointed to Dr. Butler’s Curriculum Vitae
      which revealed that she is an Associate Professor in Diagnostic
      Radiology in the Breast Imaging Section at Yale University and
      Yale New Haven Hospital. She is also involved with a multi-
      disciplinary task group at the Smilow Breast Cancer Center. From
      2013 through 2016, she was the Yale Site Principal Investigator
      and National Co-Principal Investigator for a clinical trial called
      Pivotal Study of Imaging with Opto-acoustics to Diagnose Breast
      Masses Detected by Mammography and/or Clinical Findings.
      [Appellants] point out that Dr. Butler has also co-authored a
      number of publications pertaining to breast imaging and that she
      also has participated in various presentations and lecturers
      regarding breast imaging and treatment. [Appellants] argued that
      her 24 years of experience working as part of a multi-disciplinary
      team of breast cancer specialists, as well as her training,
      education and experience in mammography, qualifies her to
      recognize evidence of breast cancer and to evaluate the effects of
      a delayed diagnosis of breast cancer in general. [Appellants]
      argued that Dr. Butler’s background qualified her to render an
      opinion on causation under Pennsylvania’s liberal standards for
      the qualification of an expert.

            [Appellants] claimed that [Kelly], at age 42, was deprived
      the chance at breast-conserving treatment due to the failure to
      diagnose the cancer, and subsequently underwent a bilateral
      mastectomy and, to date, five breast revision surgeries. Once the
      cancer was detected, [Kelly]’s treatment was determined after
      consultation with oncologists and that treatment plan was

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     managed and followed by oncologists. After reviewing Dr. Butler’s
     Curriculum Vitae and her deposition, we agreed with [Dr.
     Leontiev] that, although Dr. Butler was certainly qualified to
     render an expert opinion regarding the detection and
     progression of [Kelly]’s breast cancer, she was simply not
     qualified to provide an opinion on the management and
     treatment of the breast cancer and whether the delayed
     detection impacted [Kelly]’s prognosis or the treatment
     options available to [Kelly].

            Our review of Dr. Butler’s Curriculum Vitae reveals that she
     does have an impressive background in her field of radiology,
     especially with regard to the detection of breast cancer. She has
     won awards for teaching diagnostic radiology, attains membership
     in various radiology/imaging organizations, has been published on
     topics of breast imaging, and has been involved in lectures on
     breast imaging.     However, there is little information to
     suggest that her experience has extended to knowledge
     and training on the effect a delayed diagnosis has on the
     severity of a patient’s breast cancer and/or the necessity
     of a more aggressive treatment once the cancer has been
     detected.

           [Appellants] have provided Dr. Butler’s Affidavit which was
     attached to [Appellants’] Brief in opposition to the Omnibus Motion
     in Limine. In the Affidavit, Dr. Butler affirms her involvement and
     vast experience in the field of radiology with emphasis on breast
     imaging. In addition, Dr. Butler states:

        9. I have 24 years of experience working with a multi
        disciplinary team of breast cancer specialists. As part of my
        training, education and experience in mammography, I am
        qualified to recognize evidence of breast cancer on
        mammography and to evaluate the effects of a
        delayed diagnosis of breast cancer in general terms.

     Dr. Butler’s Curriculum Vitae describes her participation in the
     multi disciplinary team as follows:

        Ultimate Opinions in Medicine Panelist – national multi-
        disciplinary breast cancer expert opinion group formed to
        provide expert-level education and improve cancer care in
        the medical community at-large through virtual Tumor
        Board-like reviews of anonymized cases.

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J-A16044-23

               While we acknowledge Dr. Butler’s inclusion in a team of
        specialists who deal with cancer treatment, there is no
        indication of what role she has played on the multi-
        disciplinary team beyond the field of imaging, whether she
        is involved in assessing treatment options for a patient,
        and if so, what training and experience she relies upon in
        order to make such assessments. Likewise, there is no
        suggestion that once Dr. Butler determines the presence of
        indicators of breast cancer, she is involved in
        recommendations         and/or     management         of    specific
        treatment plans or with following through with a patient’s
        cancer treatment. We believe the circumstances of this case
        require that such information be provided by an oncologist.
        Moreover, it was [Appellants’] burden to prove that the delay in
        detection impacted [Kelly]’s condition and/or course of treatment.
        We do not believe that Dr. Butler’s opinion, even if admitted at
        trial, would have established this vital part of [Appellants’] case.

Trial Ct. Op. at 6-10 (citations & quotation marks omitted; emphases added).

        We discern no abuse of discretion with the trial court’s conclusion that

Dr. Butler was not competent to render an expert opinion on causation

(including the increased risk of harm) to the requisite degree of medical

certainty.    At issue in this case is Dr. Leontiev’s oncologic treatment and

decision-making following the radiologic detection of Kelly’s early-stage breast

cancer.      Appellants alleged that as a result of Dr. Leontiev’s purported

negligent actions, she had to undergo double mastectomies, chemotherapy,

radiation, and multiple reconstructive surgeries. As such, Appellants’ burden

of proof was to demonstrate that Dr. Leontiev’s alleged failure to timely detect

the cancer increased the risk that such treatment was required and the ability

to obtain less invasive treatment was not possible. See Hamil, 392 A.2d at

1288.

                                       - 18 -
J-A16044-23

       Dr. Butler’s background demonstrates that as a radiologist, she is

concerned with the detection of cancer, not the treatment of detected breast

cancer.    Notably, the doctor averred that while she has experience with

working as part of a team of breast cancer specialists, she was qualified “to

evaluate the effects of delayed diagnosis of breast cancer in general terms.”

Appellants’ Brief in Opposition to Dr. Leontiev’s Motion in Limine Challenging

Appellants’ Expert Evidence, 9/23/22, at Exhibit B (Affidavit of Dr. Butler,

9/13/22, at 1) (unpaginated) (emphasis added). This general averment is

deficient where the law requires an expert’s opinion demonstrate, with a

reasonable degree of medical certainty, that a defendant’s conduct increased

the risk that the harm actually sustained by the plaintiff. Gradel, 421 A.2d

at 679. Moreover, Appellants have not pointed to any part of Dr. Butler’s

education, experience, or skill set that demonstrates to what extent she is

involved in the treatment and course of action following a diagnosis — Dr.

Butler fails to specify whether she is involved in entire treatment program or

just a specific part (meaning detection of the cancer).15

____________________________________________

15 Notably, Appellant would need to demonstrate that the harm suffered by

Kelly necessitated more invasive treatment — such as the radiation and
chemotherapy. We note that at her deposition, Kelly acknowledged some of
her doctors questioned the necessity of these procedures. See i.e. Oral
Deposition of Kelly A. Velesaris at 89-93 (Kelly acknowledging that: (1) Dr.
Kristine Widders, M.D., sent her a letter stating there was no indication for
chemotherapy; (2) Dr. Jennifer Rosenberg, M.D., recommended that radiation
would not provide a benefit in her case; and (3) Dr. Leah VonReyn Cream,
M.D., discussed chemotherapy but advised against it).

                                          - 19 -
J-A16044-23

      We now turn to the cases Appellants relied on, Tong-Sommerford and

McFeeley, in their appellate argument. In Tong-Sommerford, the plaintiff-

decedent died after a feeding tube that was supposed to be inserted into his

stomach was improperly placed into his lung by a hospital radiologist. The

defendant-doctor incorrectly interpreted the x-ray image as “showing

termination of the feeding tube in decedent’s stomach when, in fact, it

terminated in [decedent’s] left lung.” Tong-Summerford, 190 A.3d at 637.

The matter proceeded to a jury trial, where the decedent’s expert was

qualified to testify about increased risk of harm but not causation. Id. at 647.

The jury returned a verdict in favor of the plaintiff and against the defendant-

doctor and her employer. The defendant-doctor argued the trial court erred

in failing to grant their motion for judgment notwithstanding the verdict

(JNOV) due to the plaintiff’s “failure to present competent evidence to support

[the] negligence claim.” Id. at 640. The defendants

      stress[ed] that while [the radiology expert] testified [the doctor]
      had breached the necessary standard of care when she did not
      order an additional study of the [decedent]’s chest upon realizing
      an abdominal study had been done, he did not testify that there
      had been a breach in the standard of care with regard to [the
      doctor]’s interpretation of the actual study performed.

Id. They further contended:

      the trial court erred and abused its discretion when it only partially
      granted their motion in limine to preclude [the plaintiff]’s expert .
      . . from testifying to causation issues that allegedly exceeded his
      expertise. They maintain that as a radiologist, [the expert] did
      not possess the necessary training and experience to provide
      competent trial testimony pertaining to internal medicine and
      forensic pathology. . . .

                                     - 20 -
J-A16044-23

Id. at 646.

      A panel of this Court determined the trial court “did not abuse its

discretion in permitting [the radiology expert] to opine that the deviations in

the standard of care increased the risk of harm[.]” Tong-Summerford, 190

A.3d at 647. Relying on the trial court’s reasoning, the panel noted: (1) the

radiology expert’s “qualifications as a board certified radiologist with 30 years

of experience in the field of radiology qualified him to provide an expert

opinion that the misplacement of a feeding tube in [the] decedent’s lung

increased the risk of harm to the decedent[;]” (2) the defendants’ “claim of

error is undermined by [the defendant-doctor’s] own acknowledgment that a

misplaced feeding tube into a patient’s lung could increase the risk of harm to

the patient[;]” and (3) “[i]t was within the province of the jury to weigh this

testimony as to [the expert’s] lack of knowledge in this regard which,

arguably, undermined his earlier statements at trial concerning [the

defendant-doctor’s] failure to order another radiology study.” Id. at 648.

      Contrary to Appellants’ argument, Tong-Summerford supports the

trial court’s conclusion in the present matter where the court precluded the

radiology expert from testifying about causation as that issued exceeded the

doctor’s expertise. Appellants indicated that they would be calling Dr. Butler

as a causation expert. As mentioned above, Appellants were relying on Dr.

Butler’s expert opinion to establish that the delayed diagnosis caused the

progression of Kelly’s breast cancer, which necessitated the treatment she

                                     - 21 -
J-A16044-23

chose.    Moreover, unlike in Tong-Summerford, Appellants have only

proffered a generalized statement — via Dr. Butler — concerning the increased

risk of harm. As such, Appellants’ reliance Tong-Summerford is misplaced.

      Next, in McFeeley, the plaintiff-decedent died following complications

from a bowel perforation that stemmed from the delayed diagnosis of ovarian

cancer. McFeeley, 226 A.3d at 586. The plaintiff filed a medical negligence

complaint against the defendant-doctor, alleging the delay in diagnosis and

treatment increased the risk of harm to the plaintiff. Id. One of the plaintiff’s

arguments was a claim that “the trial court erred in concluding that [the

radiologist expert for the defense] qualified as an expert for causation

purposes under the MCARE Act standard.” Id. at 597.

      A panel of this Court concluded “the trial court properly held [the

radiologist] possessed the necessary qualifications to interpret radiology

reports related to the gastrointestinal tract so as to provide competent

testimony related to causation.”     McFeeley, 226 A.3d at 598.        It merits

mention that the panel also “agree[d] with the trial court’s sound reasoning[,

where the expert], a board-certified gastrointestinal radiologist, offered an

opinion as to causation based on his review of CT scans, as well as a barium

enema” and concluded “the trial court did not abuse its discretion in concluding

[the expert] demonstrated that he has a reasonable pretension to specialized

knowledge on the subject matter in question.” Id. at 597 (citation & quotation

marks omitted).

                                     - 22 -
J-A16044-23

      McFeeley is distinguishable from the present matter based on the

following. The radiology defense expert in that case was permitted to offer a

limited expert opinion to what caused the perforation (diverticulitis), not that

a delayed diagnosis of cancer at an earlier stage increased the risk of harm

that the decedent would suffer a perforation. Moreover, we point out that the

plaintiff in McFeeley retained a gynecologist oncologist expert, who

“explained that a staging system is used with regard to cancer in order to give

a prognosis as to a patient’s chances of surviving the cancer.” McFeeley, 226

A.3d at 587. As such, Appellants’ reliance on McFeeley is also misplaced.

      Accordingly, we conclude the trial court did not abuse its discretion in

precluding Dr. Butler from offering expert testimony on causation under the

MCARE Act.

      Regarding Appellants’ second argument, they claim the trial court erred

in failing to admit Dr. Forman as an expert witness regarding damages. See

Appellants’ Brief at 21. Specifically, they state:

            Dr. Forman met with Kelly on two occasions for the purpose
      of evaluating how her delayed breast cancer diagnosis impacted
      her emotionally and psychologically, and influenced her decisions
      regarding her treatment. He is not in any manner opining as to
      whether there was a delayed diagnosis of her cancer, or whether
      there was an increased risk of harm that occurred due to [Dr.]
      Leontiev’s negligence. Rather, assuming these two issues to be
      true, he is evaluating the impact they had on Kelly’s emotional
      state and her decision-making relative to her treatment, as well
      as the effect, in terms of damages, on her emotional health and
      well-being post-diagnosis.

                                     - 23 -
J-A16044-23

Id. at 21-22. Moreover, Appellants assert that because Dr. Leontiev’s defense

focuses on

      whether the aggressive treatment Kelly chose to undergo was
      absolutely necessary[,] Dr. Forman’s role is to explain, from a
      psychiatric point of view, how Kelly’s state of mind, particularly
      with regard to her knowledge that there was a cancerous mass in
      her body for two years before it was discovered, impacted her
      treatment decisions following diagnosis.

Id. at 22.   Appellants maintain “Dr. Forman’s testimony is not offered to

improperly boost the credibility of Kelly’s testimony.” Id.

      Keeping our standards of review in mind, we note that in Dr. Forman is

board-certified in general psychiatric medicine with a subspeciality in forensic

psychiatry. See Trial Ct. Op. at 3. In his expert report, Dr. Forman averred

the following, in relevant part: “When [Kelly] was finally diagnosed, her

physicians provided her a menu of treatment options. She chose from that

menu. If the cancer had been diagnosed earlier, it is reasonably to conclude

that menu would not have included as many of the disfiguring and systemic

treatments [Kelly] received.” Dr. Leontiev’s Motion in Limine at Exhibit “C”

(Dr. Forman’s Report re Kelly Velesaris, 6/7/21, at 9).

      The trial court explained its rationale for precluding Dr. Forman as

follows:

      Although [Dr. Forman] was identified as a damages witness, [his]
      report could be construed to refer to the effect the delayed
      diagnosis had on the possible worsening of [Kelly]’s cancer and
      the treatment options which became necessary as a result of the
      delayed diagnosis.    Due to this possibility, [Dr. Leontiev]
      apparently proceeded with caution in including this aspect of Dr.
      Forman’s opinion in the Omnibus Motion in Limine. We agreed

                                     - 24 -
J-A16044-23

      with this assessment, and for that reason included Dr. Forman in
      our [October 5, 2022, order]. A review of Dr. Forman’s report and
      Curriculum Vitae likewise reveals that based on his background in
      the field of psychiatry, he does not have the requisite background
      to render an opinion regarding the effects of the alleged delay in
      detection on [Kelly]’s prognosis and/or the treatment made
      necessary by the delay for her breast cancer. Thus, we precluded
      his testimony on that issue.

Trial Ct. Op. at 10. We agree with the trial court’s rationale while adding these

additional comments.

      As Dr. Leontiev points out, he “never challenged Dr. Forman’s

competency to render causation opinions related to [Kelly]’s alleged emotional

injuries.” Dr. Leontiev’s Brief at 35. Moreover, in his motion in limine, Dr.

Leontiev specifically mentioned that he was not suggesting “Dr. Forman [was]

unqualified to render a causation opinion relating to any alleged emotional

injuries or disorders resulting from the alleged delay to detect.” Dr. Leontiev’s

Motion in Limine at 9 n.1. Rather, he pointed out that that “issue is separate

and distinct from the issue of whether the alleged delay to detect require more

aggressive treatment or actually resulted in harm to” Kelly. Id. As such, Dr.

Leontiev emphasizes that he “never challenged Dr. Forman’s competency to

render an opinion regarding how [Kelly]’s ‘delayed breast cancer diagnosis

impacted her emotionally and psychologically, and influenced her decisions

regarding her treatment.’” Dr. Leontiev’s Brief at 36, quoting Appellants’ Brief

at 21-22.

      Moreover, a review of the record reveals that the trial court’s October

5, 2022, order included a ruling relating to Dr. Forman’s competency. See

                                     - 25 -
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Dr. Leontiev’s Brief at 35. Specifically, the court stated, in relevant part, Dr.

Forman was precluded “from expressing an expert opinion as to causation,

i.e., whether [Kelly] would have had a more favorable prognosis for treatment

and eventual outcome if the diagnosis of cancer had been made at the earlier

date(s) suggested by the evidence adduced at trial.” See Order, 10/5/22, at

3. However, the trial court’s order did not include a finding that Dr. Forman

lacked the competency to offer an expert opinion regarding Kelly’s “delayed

breast cancer diagnosis impacted her emotionally and psychologically, and

influenced her decisions regarding her treatment.” Appellants’ Brief at 21-22.

As such, his argument — that the trial court erred in finding Dr. Forman was

precluded from providing expert testimony regarding the impact of Kelly’s

emotional state and her decision-making relative to her treatment — has no

merit.

      Furthermore, the trial court’s October 5, 2022, order, also provided that

“Dr. Forman is prohibited from expressing an opinion as to whether any

mental illness interfered with the decision-making process of [Kelly] regarding

her cancer treatment.” Order, 10/5/22, at 3. However, a review of Appellants’

concise statement reveals that they did not preserve a claim regarding mental

illness expert testimony. The concise statement provided, in pertinent part:

      2. [T]he trial court erred in entering summary Judgment in favor
      of [Dr. Leontiev], and against [Appellants] because the [court’s]
      October 5, 2022, opinion which prohibited Dr. Howard Forman’s
      testimony is in error. Again, the reason for [the c]ourt’s ruling
      is vague and not discernable from the record. However, Dr.
      Forman is a damages witness only and his testimony would

                                     - 26 -
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     not include his own opinions regarding [Dr. Leontiev’s]
     negligence or causation related thereto. Dr. Forman is
     qualified under subsection (b) of the § 512 of the MCARE Act to
     testify, and to exclude him is in error, again for the reasons set
     forth in [Appellants’] Briefs in Opposition to [Dr. Leontiev’s]
     Motions.

Appellants’ Concise Statement at 2 (emphasis added). Accordingly, any claim

regarding mental illness expert testimony is waived.          See Pa.R.A.P.

1925(b)(4)(vii) (providing that issues not included in the concise statement

are waived); see also Pa.R.A.P. 302(a) (providing that issues not raised in

the lower court are waived and cannot be raised for the first time on appeal).

Therefore, Appellants’ second argument is unavailing.

     Order affirmed.

Judgment Entered.

Joseph D. Seletyn, Esq.
Prothonotary

Date: 8/15/2023

                                    - 27 -