In life we often say that each one of us has opinion and sometimes we have 2 opinion especially if we are talking about politicians. But even normal people have different opinions and the same hold true in medicine. Most of the time we all have same opinion -may be because we all read the same book or have seen same study. No one will argue about treating high blood pressure or high blood sugars. But then we it comes to certain other conditions in elderly , we have different opinion. No one can state that his way is the only correct way. Take for example HBA1C , the indicator of diabetic control. In younger patients we like it around 6 or may be even less-close to as normal as it could be. But in elderly such a tight control is not good or could be detrimental. In elderly patient who may be living alone or who may be living with spouse who also may be elderly, it is more dangerous to have low blood sugar than high sugar . The low sugar can lead to unconsciousness and brain damage , while high blood sugar -not extremely high sugar is not that bad. This kind of thinking brings me to case for today.
I had seen this 80 years old patient in office . He had diagnosis of lung cancer and then we had surgery and he did well and did not need any additional chemotherapy of radiation and did ok .He did have some shortness of breath and I saw him and the work up was ok .He came to me for few months and then stopped . After a gap of 3 years he came to me and had some shortness of breath and we did do new CT scan and that showed density next to suture line. In past we had seen that density and followed it and it was stable for couple of years. This time it looked like it had increased. So, I saw him . By now he was elderly , fragile and had some dementia. He had reduced activity partly related to shortness of breath and partly related to aging , dementia etc. I did order new PET scan and new breathing test. The wife was a nurse and she wanted everything done and wanted to see thoracic surgery - the same one who had done surgery 3-4 years ago . I ordered the tests and she saw him. He ordered a biopsy of the mass. I did PET scan and that showed very high uptake in the mass -suggesting that it is cancer . Certainly we did not know the exact diagnosis or what type. The physician who was to do the biopsy is in the same group as the surgeon. I had suggested asking radiation doctor to see him as I did not feel he would do well with surgery cutting out part of the lung and also he would do well with chemo. The wife wanted surgery as 'that is the BEST treatment for the cancer'. But the surgeon agreed with me and told her that doing surgery was too risky. I had suggested not doing any biopsy but just based on PET scan treat with radiation . But the surgeon wanted his group doctor to do lung biopsy. I asked them - if biopsy is positive - would you take chemo the answer was NO. I asked if the biopsy is negative for the cancer would consider radiation treatment based on PET scan? the answer was YES . So my question is why do a test that does not change the course of treatment in this elderly fragile patient.
There is no answer and he will have the biopsy and radiation treatment !! RIGHT OR WRONG.
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