Thursday, October 6, 2016


     Now a days it is fashionable  to talk about the targeted treatment or approach in the patient care . I often wonder as to what did the physicians did in the past . Was it not targeted  or was it not patient care ? But in the commercials that I see on the TV , especially on cancer treatment I see the word used frequently. But I do not find any difference or at least not anything better. But I find more often treatment being given per BOOKS rather than targeted to individual patients. So the treatment that is offered is more often determined by COMPUTER medicine rather than by Human being who happens to be physician. So one of the story that I am going to tell is one example of this targeted (?) therapy.
    I have known this 78 years old male patient who was smoker for entire adult life . He had COPD ,related to smoking. He was getting more short of breath and then had to be put on oxygen . He still continued to smoke . The when he was hospitalized he had a CT scan of the chest done and it showed a small nodule . The size was around 1cm. With his given condition and the given size , diagnostic procedures to get the biopsy would have been impossible . We can do bronchoscopy , a PET scan or needle biopsy, or open biopsy . But the given oxygen dependent COPD and small size we could not do any definitive test to get the diagnosis.So I decided to do follow up CT scan . The new Ct scan was done in 3 months and the nodule had grown and it was now 1.5 cm . In between he had developed  swelling of the feet and further work up showed that he had Liver problem . As it turned out  he was drinking 5-8 drinks a day and it had caused cirrhosis of the liver. So now we had to treat it . Medicines did help the swelling. Then he was admitted to hospital with shortness of the breath and the new CT scan done showed clot in the lungs . So now he needed blood thinner.. I spoke to radiologist about doing the biopsy of the nodule. I had done the PET SCAN and it did show increase activity suggesting that this nodule was most likely to be cancerous.. The radiologist felt that it was too risky to do biopsy due to the recent clot and the location . So I talked to the patient and the family and it was determined that we will wait and do follow up on the scan . He was discharged to rehab place . He came to see me in the office . He was still quite weak and short of breath,but felt better. So after discussion we decided to ask RADIATION ONCOLOGIST to consider radiation treatment without the diagnosis of the cancer , but based on PET scan finding and the growth seen on CT scans. So I got a note from him. He wanted a biopsy of the lymph node that was shown to be hot on PET scan but was not enlarged .
       He was readmitted and this time he had fracture of vertebra and needed treatment. So I decided to do new CT scan and it showed the nodule and did not show any enlarged nodes. So in span of 4 months the nodule was bigger and no lymph nodes were seen. So I thought that radiation oncologist would agree to do the radiation treatment without the biopsy . I did not feel that lymph node biopsy would be positive or give any additional information to alter the treatment. But the radiation oncologist insisted on the biopsy . So I called 2 different doctors who do such biopsies. Both of them looked at the CT scan and the PET scan and felt that they could not do the biopsy as the nodes were too small and it was too risky.
      So I have this patient who has oxygen dependent COPD , cirrhosis of liver , clot in the lung and vertebral fracture and had aortic aneurysm. So it would be 'targeted 'therapy if we could give him radiation to the nodule rather than looking at the PET scan and feel that if the lymph nodes are positive , we would need different field of treatment .
    By the way patient for now has decided to go with Hospice 

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