Wednesday, January 15, 2014


    I often tell patients that do not ask for the direction to the place that you don't want to go . So what do I mean by this . I often see patients that have definite problems , but getting diagnosis without an invasive tests is not always possible . I can probably give you many examples . I have  a patient that has weak heart and has a defibrillator , has bad COPD and still smokes , is on oxygen . He has a nodule , in the lung . I have watched it with follow up CT scans and it was stable for a while , may be a year . But then it grew and the PET scan done showed that the nodule was metabolically active , suggestive of it being cancer . Due to his other problem , he and his family wanted him to be on Hospice . But they agreed for the opinion for radiation . My feeling was that with the given data it was highly likely to be cancer and radiation treatment will give good response and may even cure it . But rest of the people in tumor  board wanted additional biopsy . It would have taken general anesthesia , and in my mind diagnosis may not be established . So if it was cancer confirmed on this special test , the treatment would be radiation and if no diagnosis was established , then the treatment , if we decided to do it would be still the radiation . So why go through the procedure with some risk , definite expense , and no guarantee of the diagnosis ?
     When I see patient with lung cancer, who does not want chemotherapy , I tell them my story . Once I went to a stake house with some friends . I do not eat meat . So when the waiter came to take orders , I asked him if he had anything which is vegetarian . He looked at me , as if I was from mental institution . So I tell the patients , do not go to the oncologist and say tat you want something other than chemotherapy . That is the way they they know how to treat cancer , and that is the only way they know .
      But the story that I started to tell is little different . I saw this older patient , about 87 years , who had history of kidney cancer . Her kidney was taken out and she was doing fine . Her CT scan done by previous doctor had shown stable findings . So when she started seeing me ,I did follow up CT scan , The first one was OK . But the next one in4 or 5 months showed increase in the mass next to trachea . We talked about it , and discussed the work up . After some time we did do the bronchoscopy . It was unable to get the diagnosis . I talked to the patient and her daughter. After the talk they decided to do needle biopsy by the radiologist . The patient did not want chemo , nor did the daughter. Patent's husband had cancer and had chemo and had bad experience . I told them that radiation is option . They were not sure if they would consider it . So we did the biopsy . (we are trying to get the diagnosis , but we don't want treatment , We are asking for the direction to the place that we don't want to go .) The biopsy was limited due to many factors. It was highly suggestive of metastasis from the kidney cancer . But the tissue was small . Again I had discussion and told them that if no treatment is to be done we should do no further tests . There was an option of surgeon doing biopsy was there . So they decided to see the chest surgeon and he told them the same thing . But after 3 weeks the patient decided to do the surgical biopsy . With her age and other medical problems , what could have been one day surgery , she was in the hospital for 10 days , She needed cardiologist , a kidney specialist and many other things , She was also seen by oncologist and a radiation doctor . She also had a blood clot i the lungs and neede to be put on blood thinner . The patient and the daughter decided  that  they did not want any treatment . So my question is why did we ask for the direction to the place that we did not want to go ? 

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