Thursday, January 30, 2014

Cancer? How Much Time Will You Give Me?

Ben's first symptom was coughing up blood.  The cancer had been silently growing for months, if not a few years.  He had no pain or shortness of breath.  The chest X-Ray showed a "5 cm L hilar mass" and the subsequent CT scan showed enlarged lymph nodes and likely spread to the liver.

"So Doc, what is it?  A cancer?  How much time do you give me?"  All these questions on a first visit when I don't really know Ben, his family, or life situation.  As a pulmonologist, this scenario happened once or twice a week.  The patient was usually a smoker but Ben was not.  At age 49, he'd been a basically healthy guy.

I always found it important to say, "I don't know, but let's find out what's going on and here's the plan I'd suggest".  This usually included blood tests, the CT scan, and a bronchoscopy to find the diagnosis and make further plans.  It was far too soon to jump to Ben's future, but Ben said "Come on Doc, give me your educated guess."  I'd usually say, "My crystal ball is cloudy and I can't read your future but I promise I'll tell you all I know as we go along".

Bronchoscopy (from a pulmonologist's point of view) is a pretty simple outpatient procedure.  With the use of lidocaine to the vocal cords and airway and with very light use of short acting sedatives or narcotics a thin flexible scope is passed through the nose (usually) into the airways and everything is seen on a video monitor.  Ben's tumor was evident in the L mainstem bronchus - red rough angry looking tissue.  Biopsies of the tumor were done - and Ben wanted to see the monitor.  I showed him the findings and explained that we would know the diagnosis the next day.

It was a non-small cell carcinoma of the lung - the most common type.  Again Ben asked, "OK now how long to I have."  Small lung cancers that are near the periphery of the lungs have the best outlook and are often curable.  However Ben's cancer was subsequently proven to Stage 3B.

Again, Ben's question and how should I answer it.  Recently in the New York Times a young Neurosurgical Resident posed the question, "How Long Have I Got Left".  Where is any patient on the statistical curve?  How can we begin to know what the response to treatment will be?  Actually in the last decade there have been some significant improvements in treatments and survival in some patients, but the measured improvements are sometimes in months rather than years.

I would say to Ben, "I don't have the powers of a deity and can't see the future, but these are the broad statistics.  I'm hoping you may not only beat the averages but be an outlier.  You are younger and healthier than many of the patients studied.  You're not a statistic.  I'm sending you to the best cancer treatment and research center available so let's see what they have to say.  But it's going to be one day at a time.  I'd like to see you again once a plan is set in place.

Comment:  "Giving a patient time" can be self-fulfilling so doctors must be careful.  On the other hand, refusing to lay out the realistic outcome of other patients (statistics), is denying the patient of information they often want to know.  Staying connected with the patient provides emotional support as they transition to oncologists or surgeons.  It's the human to human connection that makes medicine the most powerful - and humane.  It's also important not to dodge the issue of death.  When the patient reaches the stage of dying, doctor's often fail to tell the patient that it's time for hospice and comfort care.  We need to be comfortable with mortality and frailty - both our own and the patient's.  We need the judgment and wisdom to guide the dying patient to palliative and comfort care.

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