MISSED STEPS ?

   In medicine we often see that the patients  have come symptoms and then the investigation is done and then we end up with dead end .But then tracing back the work up we realize that we should have taken different course of action / work up. It is often stated that 3rd doctor is smarter than first two as the first 2 physicians have done some work up and have ruled out certain diseases. I also often say that your eyes don't see what your mind does not think.'That brings me to the story of today's patient. 

   I saw this patient in office as the care giver was my patient. She had no relatives and this patient of my was taking care of her in her own home. She was relatively young late sixties and had been smoker and had high blood pressure and dementia. She had some cough and then a chest x- ray was done and that showed some abnormality and so the PCP ordered CT scan chest and when that came back abnormal , snt her to oncologist. This is first missed step. When the diagnosis of cancer is not established what is oncologist going to do? The oncologist does treat cancer with chemotherapy or now a days Immunotherapy. But when we don't know if patient has cancer or what type , the oncologist cannot do anything . The oncologist decided to do PET scan. The PET scan shows uptake of glucose in whole body and organs and when the uptake is higher at a particular area which correspond to the abnormality on CT scan , the suspicion for cancer is increased . Again the diagnosis is not yet established and it is only the possibility of cancer that is increased as infection and inflammation also can show increased uptake of glucose. The PET scan was scheduled but not done and the oncologist sent her to Chest or thoracic surgeon. In my estimate this was second missed step. The CT scan findings were indicative of left lung mass and possible SPREAD TO CENTRAL LYMPH NODES . With is findings the patient will not be  candidate for resecting or cutting out cancer. If the central or hilar nodes are involved by cancer, then cutting out primary cancer does not help to improve prognosis  and patient is 'inoperable'. In addition to that ,she was  a smoker and had COPD the lung disease that is caused by smoking and that reduces lung capacity. We did not know if she had enough RESERVE lung capacity to undergo surgery in which part or whole of left may need to be removed. In between someone sent her to radiologist to do biopsy of the mass in the lung and that did confirm the lung cancer. Again this may have been miss step as we still did not know if the lymph node was showing spread or not , and that is a crucial step Then the care giver asked me to see her . We did schedule PET scan and also did breathing test. She was also sent to a interventional lung specialist for the biopsy of that lymph node which was seem to be involved.

    The PET scan did confirm uptake in lung mass and also in various nodes .So essentially she was not operable / resectable. The breathing test did show significant reduction in lung capacity and so she would not do well with surgery. I explained that to patient and the care giver . Patient had some dementia and so I was not sure how much she understood. I spoke to the care giver, but she was told by oncologist that she needs to be seen by chest surgeon and have surgery. So they had mind set on surgery.