In medicine I have said that do not ask for the direction to a place where you do not want to go. As we are seeing aging population, this has become more and more common . Patient having some blood in stool will need work up . But then if the patient is very old - and very old can be determined by family and physician only - and say has dementia , is it worth finding the cause and doing million dollars work up with INVASIVE procedures which have some risk, when we know that we are not doing the treatment which is ideal like surgery. A good doctor may suggest certain work up and treatment and a good doctor will take in account not only the diagnosis , but also other factors. That brings me to story for today.
I saw this 85 years old female . She had pain in abdomen and so she went to walk in clinic and they did Ct scan of the belly - abdomen. (I am not sure as to what was the thought process -or differential diagnosis that they did CT scan -but now a days that is a knee jerk reaction) .The scan showed no abnormality in abdomen or pelvis , but showed a nodule in the lung . She had a CT scan of chest in past - few years ago and that had shown a nodule and she had seen a lung specialist 4 years ago. And he had told them to watch it , rather that doing additional biopsy etc . That had happened 7 years ago . So she was 78 years old . Again I was not the physician and not sure what was taken in to account when the decision was made. The size of the nodule was smaller and now after several years when CT scan of belly was done it appeared to show increase in size. So she was sent to me. She had not done CT scan of chest.
She was older lady but seems to understand very well and was accompanied by caring family. I looked at reports and also tried to find out any old reports that might help. I tried to check 2-3 hospital and radiology centers to see if there was any scan of the chest in last 3 years and could not find any. She had no pulmonary complaints. If the size seen on scan of the belly was correct the spot or the nodule had grown in last few years . So it was likely to be slow growing cancer or a scar cancer - cancer developing in old scar. Either way we needed work up . I often tell patients that we need to answer 3 questions - 1 Is it cancer 2 Has it spread and 3 what kind of treatment we need / can do. The treatment of cancer - if it is - is surgery-radiation-chemo. Here comes the point of making decision as to what kind of work up we should do. If the patient does not want surgery or it is felt that the surgery is too risky then how much should be the work up? Ideally we would do PET scan , Breathing test to assess lung capacity and biopsy. But if patient does not want any treatment like surgery or chemotherapy, how much invasive work up we should do. If we don't want to go a place why should we ask for the direction to that place ? This lady did not want surgery and chemo and the family agreed . Then do we need to do biopsy ? I suggested doing a PET SCAN which can pick up cancer in may be 80-85% of the cases So I decided to do the PET scan and if that is positive , consider radiation treatment without biosy or just do follow up Ct scan in 3 months and see if it grows .
Again I would be curious as to what would AI suggest .
