Saturday, September 21, 2019


    I was talking to a friend om mine . We were talking about SAT examination. He stated that that that is very important examination . I made a statement that at a particular time in our life ,things that appear to be very important , do not appear to be that important when we look back at it after several years. The SAT examination does determine which college we can get in . But many a times the college that we join may or may not  and in most instances does not make difference in our future. . When my son graduated from college and went to medical school, one of the guest made a comment that even the graduate of the medical college who stood LAST in the class is called MD. One my patent's son who was with GOOGLE and making ton of money -over a million dollars a year , was graduate of UCF  and his major was physics ! So sometimes we worry and get concerned  and get upset over things that on long term does not matter.That brings me to my today's story.
    I saw this patient about 71 years of age who had moved to Florida from some other state . She was diagnosed to have lung cancer  and had treatment for it  and was 'cured' . She was a smoker  and then she also had history of breast cancer and she had surgery and she was 'cured' of that too. She had smoked for several years  and had COPD. She was compromised  and had shortness of breath  and also had reduced lung capacity. I treated her and she was going better. She had  a CT scan of the chest  and it showed some changes related to COPD   and related to previous cancer but was thought to have them related to her previously treated cancer rather than new cancer. She continued to come for follow up for 6-8 months  and then did not come - very common now  a days since HMO have taken over health care  and 'RISK ' contracts  are becoming common and big business are 'buying the medical offices  and run them . They can not make money unless they cut the cost  and doing so they reduce follow up by consultants and do less testing .
     Then one day - about 1 year down the road,I was called to see her in the hospital as she was admitted for shortness of breath  and pneumonia. I saw her  and when I asked her questions I came to know that she had CT scan done as out patient (No one had bothered to  ask her and she had new CT scan in hospital and that was abnormal . So I wanted to do further work up .) She told me that she had routine chest X- ray and then it was abnormal  and so she had CT scan  and since that was also abnormal she had PET SCAN . So I got hold of the scan  and she clearly had very abnormal CT scan and also the PET SCAN . It looked like she had NEW LUNG CANCER  and the way in which the scans were , she would not be a surgical candidate for resection. Certainly her condition was bad  and from COPD stand point also she was not surgical candidate, She was on oxygen  and was very short of breath. After I treated her with medications , she did seem to improve and one day I did do bronchoscopy to get some tissue . She had hard time with the procedure  and the biopsy came by showing some abnormal cells but not conclusive for cancer.The daughter was not very happy as the PET SCAN was done 3 weeks before the hospitalization and now 10 more days were gone  and we still did not know the diagnosis of the cancer  and so no treatment was started.
     I told them that the condition was such that doing more invasive procedure at that time would put her in worst state  and she will be on ventilate and than we will not be in position to treat. So the best option was to treat her  and allow her to recover her from present illness and then in 4 weeks when she is better then do some additional procedure like doing biopsy of enlarged  and abnormal lymph nodes as reported on the PET SCAN There appear to be tumor wrapping around the  right bronchus  and that appear to be out side the main bronchus . So I asked a another physician to see her to that biopsy  and there were  problem with referrals  and the appointments got cancelled due to physician having emergency  and the primary not giving referral at right time . The daughter walked in my office twice  and asked me to help and was not happy .I called the both the offices  and made arrangements  and then she  had procedure by another physician as the the one that saw her in office was not available. This added to the frustrations  and then she came to see me. The biopsy done by this MD did not show any cancer and so we were at square one . She was not any better  and she was on oxygen  and the daughter was not happy that we did not have the diagnosis  and so there was no treatment started for CANCER. Our conclusion that she had cancer was based on PET SCAN which is almost 88% accurate. So I was convinced that she had cancer , but the biopsies were not showing . One thought that I had was to sent her for Radiation therapy  and asked them to see if they felt they could treat her WITHOUT THE DIAGNOSIS based on PET scan findings . But I decided to call a surgeon. He was very prompt  and he saw her  and did  2 different biopsies from 2 different sites on 2 different occasions.
     So the frustrations that patient and the daughter  and I had about not getting diagnosis IN TIME  and worried about the delayed treatment was real and now looking back at it not very important.
I am still not sure that she has or does not have cancer and I think only time will tell us.