Sunday, October 27, 2019


      The phrase of 'back to the square one' is very commonly used when we do something as a plan  and that does not work . This probably came from one of the board games  may be chutes  and ladder  when we are going to the higher squares  and suddenly we find our-self going down due to chute. The same things happen when someone is trying to solve the criminal case and the clues lead us to dead end  and then we are back to original level. The same thing happens in medicine , but not often. This brings me to the present story.
      I saw this lady for shortness of the breath. She had smoked  and had diagnosis of COPD  and in past she had lung cancer diagnosed  and she had treatment for it She also had breast cancer  and she had surgery and she was cured. I saw her  and did  act scan  and also breathing test and started her on oxygen. She was started on medicines for the COPD  and then the CT scan showed tiny nodule. I told her that we will need to do the follow up fort the nodule  and it was too small for the further work up to know the diagnosis. Doing bronchoscopy , or doing needle biopsy or doing PET  scan or asking surgeon open biopsy were not options as they would not have given the diagnosis. So we decided to do the follow up . I continued to see her for next year and we did couple of CT scans  and they did not show any any change or growth . She did not come to me for follow up a year. Then she  had shortness of breath and she was hospitalized.I was asked to see her . She was very sick and she had to be in ICU for short time  and even after getting out of ICU. She had new CT scan done  and that was abnormal . The nodule that we had seen was same but she had new 'mass' in rt middle part . She was not in very good shape for biopsy and so we did PET scan  and that did show that the mass was likely to be cancerous -had increased uptake of the glucose.She was never a candidate for the resection  as she had advanced COPD and the location was such that she could not have had resection or entire lung and then also she would not have been cured. I did do bronchoscopy  and I had to get help from anesthesiologist and she did OK . I did see narrowing of the middle part of the right lung and i though that she may have external pressure from cancer or it may be narrowed due to cancer itself. I did do the biopsy and other things  and they came back with 'atypical cells but not conclusive for cancer.
      She was getting better  and i told her that we need new biopsy but she needs to be better  and so after 2 weeks i had do EBUS - biopsy with help of ultrasound , This was done and they came showing no cancer . I knew the CT scan , I knew the PET SCAN  and i also knew her history. She had 2 different cancers  and she also had OXYGEN dependent COPD.So now what I can I do to get to the diagnosis? As you can see every time we did a test thinking that we will get the diagnosis we were back to the square one.
     So I had a surgeon to review her scans  and he called me stating that the situation was very difficult, but he felt that he could do some biopsies  and get the diagnosis. He saw her and did a procedure called Mediastinoscopy  and biopsies came back showing no cancer. So he did see her again and did biopsies through chest  and they also came OK. So she came back to me  and she was hurting from the surgery and we had no diagnosis. I asked radiation doctor to see her and see if they can do radiation WITHOUT the tissue diagnosis of cancer. They were not very happy to do such a treatment without the proof for cancer . This is not like giving antibiotics.
     So I decided to do new CT scan in 3 mo this The month before she was to have new CT scan done she was in hospital  and I saw her . She had developed fluid collection around the lung - same side as was the mass. I did new CT scan  and that did show the fluid  and also that the mass has increased. So there was no question that she had cancer . But we had no proof. So I called the same surgeon  and told him the situation . I was concerned that she had fluid due to cancer and just taking it out once may not be enough.She was also on blood thinner . So I asked the surgeon to do the  catheter insertion to drain the fluid  and do some additional biopsies.
    He did do the catheter and did  not do he biopsies .The fluid was sent for cancer cells  and they came back as No cancer . So we were back to square one - same place that we started after  5 procedures to get the answer. So now I  again called the radiation doctor and asked if they could do radiation without the diagnosis OF CANCER..
   This time they agreed  and she got the radiation therapy without tissue diagnose of the CANCER . 

Saturday, October 19, 2019


   I have been asked many times as to the cause of cancer. We see have seen it in older  and younger people , we have seen it in fat and skinny people , we have seen it in people who have good habits  and bad habits.We have known some risk factors like smoking  and chewing tobacco, and people with exposure to chronic irritants. The sharp tooth has caused oral cancer and KANGRI the heated burner that people in KASHMIR out around their belly to keep warm has caused the cancer of the skin of belly wall.When radium was invented  and people used radium dial wrist watches , there was increase incidence of cancer of the wrist bone.So we know some causes but we do not have any idea as to why some get cancer  and why some don't.This brings me to the story of the patient for today.
     I saw this young women who has some vague chest pain . She was nonsmoker and had no h/o high blood pressure or diabetes or any cardiac problems. She was OK till then . So the family doctors did a chest X- ray. The chest X- ray was abnormal. and so she had CT scan of the chest  and that showed a large mass  and also a smaller mass. She was sent to me . She was very anxious  and was quite concerned . And rightly so as the mass was reported as as most likely as lung cancer in the report, which she had with her and had read it few times . She had noticed the right sided chest pain only 2 weeks ago  and she had no pain before that .She had no shortness of breath or any significant cough, She had not coughed up any blood . Her appetite was good, but she had lost some weight,but she had thought that due to the the problem that she had with eating . I explained it to her and her family that the possibility of lung cancer was high but may not be 100%. We should answer 3 questions -Is it cancer, Has it spread and lastly the choice if treatment if it is cancer.
   To answer these questions we needed the diagnosis of cancer.So we ordered PET SCAN which is good in detecting spread of cancer or presence of cancer - may be 85%of the time. I also ordered the breathing test. and also bronchoscopy. That showed narrowed bronchus  and so I did biopsy  and then the biopsy did come back showing cancer .
   The PET scan was done a day after the biopsy. So when I saw the PET scan report I was not happy. So I called the patient to see me . She had lung cancer and the PET SCAN showed that the cancer had spread to Liver and bones . The chest pain that she had was due to the spread of the cancer to the ribs . So she was not operable. I had called  chest surgeon to see if there was any chance of doing surgery - though it was before the PET SCAN,  and I had done it in spite of knowing that she would not be based on ct scan .
    She had come with her family and they wanted to know the prognosis  and why she had cancer . I had no answer to both the questions. So the nonsmoker,nonalcoholic lady was having lung cancer and that too had spread to other organs such that the prognosis was not very good .

Saturday, October 12, 2019


    In our life and in many a times we see the pendulum of opinion swinging . At one time coffee is bad then someone does research  and then tells us that coffee is good. High fat diet was bad for many years then came low carb is good  and high fat diet is good. I have seen this medicine too . We were told that steroids  are needed to treat COPD   and now it is OK not to use steroid inhaler. We are told that we have epidemic of narcotic use  and addiction .But when we look at it we realize that WE ALL are responsible for it .But then we got to have someone else to be blamed for it - may be then we can collect some money. So blame big pharma . As much as they are  responsible,we all are. I just want to mention that I do not  and did not prescribe these medicines. But with hospitals pushing doctors to get better patient satisfaction, the narcotics were prescribed  and they were more than what was  medically needed. The hospital reimbursement was dependent upon the patent's satisfaction. So we created the dependence  and the addicts . So now the pendulum has gone to another direction and that brings me to the story.
    One my my patient age 90 years plus called me on week end stating that she has chest pain on right side . She was doing weed whacker  and she fell down  and hurt the arm  and the skin -which was thin to begin with tore,She was also badly hurting on right side of the chest after the fall. . She went to ER  and they did chest x- ray  and not sure if they did CT scan. They gave her some medicine and discharged her . She wanted pain medication and the ER MD did not give her any . She was disappointed so she called me .I told her that with weekend , I could not do much ,but she can try some over the counter medications  and if not better then go back to ER again . And she did not feel better and so she went to different ER . The events were repeated . The ER physician gave her muscle relaxer - no pain medications  and discharged .She was having pain 'worse than labor pain' as she described it to me . I told her to come to ER where I can see her and let the ER doctor know that I will come and see her. I did ask her to call her PCP  and she had done it , but now a days no PCP goes to hospital, so that was not an option. She came to ER . I went to see her. The ER physician told me that she would not do any tests  as she told them that the 2 previous Er did all the work up. So I talked to her  and told her that we need to do X- ray of the ribs  and she agreed . We did the X- ray  and she has SIX RIB FRACTURES ! She needed to be admitted.
      The question is why did the ER physicians did not do rib X- ray , why did they not admit her  and lastly WHY DID THEY NOT GIVE HER PAIN MEDICATIONS?This old lady was not addict, she was not going to become addict and she had obviously pain starting after a fall. The answer is in the narcotics fear that we have created  and the hoops that physicians have to jump through to JUSTIFY narcotics prescriptions. So that is what I am calling as pendulum has gone to other side.