IS IT EVER SAFE

     In medicine we have many terms used and one of them is 'cure rate' or recurrence rate. This is tru especially in cancer diagnosis. If we have a patient who has say 1 cm lung nodule  and we  do surgery and it is taken out , and we have no evidence of spread of the cancer at the time of surgery, we call it a success. But is it really a cure ?The answer is yes and no - many will be cured and some will have recurrence of the cancer . We usually do  follow up CT scan for 3 years as the majority will recur in 3 years and if there is no recurrence of cancer in 3 years then we are 'safe' and the chance of recurrence is very little. This brings me to the story for today. 

  I saw this lade few years ago. She was a nonsmoker and had kidney cancer taken out several years ago - 5- 6 years ago. She was followed by a cancer specialist and he did CT scan every so often . One of the CT scan showed some nodule - a tiny density . He told her there is not much and wanted to redo new CT scan . She came to me and I reviewed the scan and really she had very tiny nodules . At the given size not much could be done as diagnostic test. The bronchoscopy, of needle biopsy or open biopsy could not have ben done to get tissues diagnosis. The PET scan is good for cancers that are at least 8 mm in size . Sometimes we do get it positive for little smaller but then most of the time it comes back negative and then radiologist states - too small to be picked up on PET scan- and we have spent money and sometimes patients get wrong impression. So we decided to do follow up on CT scan . 

     I continued to do  new scans for 3 more years , which means the renal cancer now was diagnosed 8 years ago. But the last 2 scans were showing some growth - still less than 8 mm. Then the last one was 11 mm -one of the nodules -the one that was growing . I decided that she will need biopsy  She was having difficult time with appointment  for biopsy and she finally was scheduled for the biopsy. 

     AND THE BIOPSY SHOWED KIDNEY CANCER !

So the cancer took all most 9 years to recur in lungs . That is why we should call not a cure , but 'disease free time '. 

THE MESSAGE AND THE MESSEHGER

     We have a saying that don't kill the messenger. But sometimes the message is bad and not easy to accept, then people kill the messenger. In medicine I have seen it personally. In spite of advances in medical science, we have diseases that are simply bad  and no matter what treatment you offer, it is not enough and certainly no cure. I have had that experience in past and I am sure I will have that in future. This brings me to the story for today. 

    I saw this 70 plus years old male patient ,who had some cough and some shortness of breath. He had moved here from near by place and was seen by lung specialist and followed by them for 2-3 years. He was ex smoker and had not smoked for may be 10 plus years. He had breathing test done and CT scan done in past. He was started on inhalers and he was OK. Then he started coming to me . I saw him and then I felt that he did not have much of COPD or obstructive lung disease which is related to smoking, but had FIBROSIS. I did do new CT scan of chest - called NRCT -HIGH RESOLUTION CT scan and also did breathing test. The Ct scan showed fibrosis and that was significant. I got hold of old CT scan reports and he did have FIBROSIS IN OLDER CT SCANS ALSO. We di assessment for need for oxygen and he needed oxygen. So now he was on oxygen and I discussed with him on the diagnosis of fibrosis and told him that he had it in past and seems like he was getting worse ,and so we needed to start him on medicines for fibrosis. The problem with medicines for fibrosis is 3 fold . Number one is that it DOES NOT CURE OR REVERESE the process. It slows down the decline. I tell patient that the reduction in lung function continues and does not stop , but the rate of decline is reduced - it continues rob dollars but instead of $100 , it now takes only $50 or so. Then second issue is it does not reverse anything. So the damage which is there does not get better , And lastly , it is expensive. My be as much as $25000 per year. So we need forms to be completed and get patient approved and then copay and other things that are associated with these orphan medicines. There are 2 medicines for the fibrosis - now for last 3 months 3 . I ordered one and the insurance denied the coverage. I was not sure why and we appealed and went through circle of calls and transfer and did not come to any conclusion. Then I realized  that they covered other medicine and not one that I had asked for.

    In between there was a drug trial going for the medicine - same one but as nebulizer and not a pill and we got him in it . He continued to have cough and continued oxygen . He did not get worse on his breathing test, but he felt he was NOT GETTING BETTER OR CURED. I had to tell him that he is not going to be cured and the disease will continue to get worse INSPITE of medicines . 

   He was not happy and dropped out of the study and decided to seek second opinion.  

   The message was not good and so he did not like it .