Sunday, June 7, 2020


     The famous line from Hamlet, is not uncommonly experienced or can be applied in medicine, by both physicians and patients. Sometimes it is very easy to make decision and sometimes it is not so easy. If I see a patient with Asthma ,who has shortness of breath and wheezes, I have very easy decision. I must start him on certain treatment . The patient also has not much difficult decision . Sometimes I do see patients who do not like to take medicines  and feel if they avoid allergens or take allergy medicines, then they will not need prescription drugs. But majority of patients who have symptoms , it is very easy to start medications. But then we see patients where the decisions are not that simple,the question arises as to which path one should take it.Say I see some one with a mass or a spot on the lungs  and I feel we should do open lung biopsy or do surgery to take it out and find out if it is cancer. So for me this is easy if I think the chance of cancer is high. But for patient it may be not that easy . This is a major decision as it involves major surgery and it may not turn out to be cancer after surgery.So in some cases decision is simple for physician and and patients  and in some cases easy for physician and not so for patient . The third possibility is where it is difficult for patient and physician also.So that brings me to the case for today.
     I had seen this 69 years old patient with spot on the lung . As usual we did the work up. The bronchoscopy was negative to get the diagnosis  and the PET SCAN did show that the spot was hot or had increased uptake suggestion cancer. The Pulmonary Function Test or the breathing test did show that she had good reserve to cut out out part of the lung. So I suggested seeing surgeon and she did see one  and he also told her to do the surgery and so she had surgery and indeed it was cancer of the lung. So as one can see I  suggested surgery - easy for me , the patient did agree for the surgery - some what easy -may be not as easy for her as was for me , but not very difficult. The surgery though did show that some of the lymph nodes were positive for spread of cancer. So I suggested doing radiation . The cancer spread to lymph nodes increases the chance of recurrence  and so I suggested it  and it was easy for me based on the data that I know. She did see the radiation doctor  and she got radiation . Again somewhat easy for patient to accept or make the decision. I had also told her to see medical oncologist.I wanted to know if in addition to giving radiation to kill some cancer cells that may have been left in some of the lymph nodes,if there was a need for chemotherapy. Here comes the difficult decision. The oncologist saw her  and suggested her to get in a TRIAL'She called me . The trial of new drugs is done when we do not have 100% evidence of benefit of using the drug . So this is a investigation to see if the medicine will help to reduce incidence or recurrence. In this trial, some patients will get the new medicine that is being tested to see if it works  and other patients will get NO MEDICINE OR SO CALLED PLACEBO . So the patient called me to know what she should do. In this case the decision is very - very difficult for me  and also for the patient as we will not know if patient is getting the drug or placebo I am not sure if the oncologist will know it or not - as is the case in some of the double blind studies (where both patient and physicians do not know to avoid having any bias).
     I don't know . WHAT DO YOU THINK YOU WOULD DO ?

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