Take-home Message

Treatment of comorbid patient

(Fictional narrative by the doctor)

James Fleck, MD, PhD & João A de Andrade, MD

Anticancerweb 18 (07), 2019

Thirty years ago, Charles suffered a car accident, leading to a ruptured spleen and substantial blood loss. He had to undergo emergency surgery to remove the spleen and required  several units of blood. Unfortunately, at that time, transfused blood was not routinely tested for hepatitis C virus (HCV). He recovered from the surgery and soon thereafter, resumed his life without any limitations or sequelae from the accident. Ten years later, around the turn of the millennium, Charles was diagnosed with chronic HCV – genotype 1. He was then treated with a combination of peginterferon alpha-2b + ribavirin, which was considered the state of the art at the time. After a few months, he achieved a “sustained virologic response (SVR)” and remained very compliant with all his follow ups. He was advised that he had low risk of recurrence or of developing cirrhosis and hepatocellular carcinoma. 

He was a heavy smoker, drank 5 oz of whiskey every day, was overweight, had hyperlipidemia, type 2 diabetes and hypertension. He was hoping to be able to sustain a healthier lifestyle but his life was very stressful making it difficult for him to be able to quit smoking and drinking. Eventually, his poor diet and the drinking led to fatty liver (hepatic steatosis). Fortunately, his liver functional tests were still normal and the HCV viral load remained undetectable.

An abnormal Chest CT prompted his primary care physician to refer him to me. Charles mentioned that he had read the report of a recent chest CT scan and was aware of the presence of a “lump” in his left lung. He mentioned that he did not have any shortness of breath, but that he was losing weight, felt weak and had an uncomfortable constant dull pain in his legs. Charles always dealt well with his medical problems. Aside from smoking and drinking, he was very compliant, and asked pertinent and objective questions. 

Charles never uttered the word cancer, although the radiologist's report explicitly mentioned the hypothesis of a malignant tumor in the lung. Interestingly, throughout the period of the consultation, Charles alternated his gaze between me and his wife, who sat silently, looking at the Renaissance paintings. He chose his words carefully so that our conversation did not upset her.  It was some artful self-censorship and as if he was telling me that he already knew everything, but did not want his wife and his children to be upset.

I understood his feelings and I respected the fact that he was simply trying to protect his family. I suggested that we move to the examination room as I asked my assistant to gently lead his wife back to the waiting room.

Charles had a sudden and substantial weight loss, but his muscle tone was still preserved. He was slightly hypertensive, which could be explained by the stress of being in a doctor’s office. The liver was not enlarged despite his previous medical history. The neurological examination was normal. Examining his hands, I could easily recognize the presence of digital clubbing, which is often found in patients with a number of chronic lung diseases, including lung cancer. He had a lot of pain with percussion of the anterior tibial surfaces. His prostate was slightly enlarged, but he did not have a palpable nodule. It was reassuring  to know that a recent PSA level was normal. His heart and lung examination were normal. There were no palpable masses or lymph nodes in the neck, axillae, chest, or abdomen. He had no skin lesions. Likewise, there were no relevant findings in his eyes, mouth, throat and ears.

The lack of significant findings on physical examination of the lungs did not surprise me. It is not uncommon for lung cancer to have a silent clinical presentation, which is often responsible for its late diagnosis.

Having his wife outside the examination room allowed Charles to express himself more freely and at the end of the exam, he looked at me and lightheartedly asked: Doctor, how long will I live?

Of course, I would not be able to answer that question at this point.  Even when all the necessary clinical data is available, the best we can do is to cite probabilities and populational data. In a way, Charles knew that but his question was his signal that, now that his wife was not present,  we could speak more openly.

I answered frankly that we would talk about his prognosis and treatment options once I completed his evaluation. Along the way, I was committed to keeping him informed, about risks, benefits, and the results of any tests or procedures that might become necessary.

Charles looked at me and said, with a resigned tone: Doctor, I know I have cancer.

At that moment, as he was able to express his main fear, I felt that  we had established a good rapport  and were communicating effectively. His line of questions suggested that he equated a diagnosis of cancer with death.

I explained that the diagnosis was not definitive and that his Chest CT scan suggested only an anatomical abnormality that needed to be further investigated. I asked him if he would like to review the  CT scan of his chest together.

Charles, showing genuine interest and curiosity, nodded at once.

I had already reviewed Charles's CT scan, which revealed not only the tumor in the left upper lobe, but also an enlarged lymph node in the mediastinum, which is  the name given to the anatomical area between the lungs. He had a 2.5 cm lymph node between the aorta and the pulmonary artery. Charles's lung also had evidence of emphysema.

When I suggested to show him the CT scan, my intention was to make the disease explicit. Charles was a very practical man, and visualizing the tumor would help him better understand his disease.

We sat together around the computer and using first a lung window, I showed him the  irregularly shaped 3.5 cm mass in the left upper lobe. Later on, changing to the mediastinal window, I pointed out the enlarged lymph node. 

I explained that the finding in the mediastinum could be an indication that the tumor was spreading into the lymphatic vessels. I mentioned that the next step would be a bronchoscopy when two procedures would be performed in sequence: the first would be a biopsy of the primary tumor, followed by an EBUS (Endobronchial ultrasound-guided) biopsy of the mediastinal lymph node. 

I explained that the fiberoptic bronchoscope is a long and flexible device that allows the examination of his entire bronchial tree. The inspection of the airways would be followed by a biopsy from the primary tumor for histological diagnosis along with immunohistochemistry and testing for the presence of  three different markers (EGFR-mutation, ALK-translocation and PD-L1 expression). The EBUS biopsy of the mediastinal lymph node would then determine if the tumor already spread beyond the lungs into the lymphatic system.

Charles looked closely at the primary tumor image at his left lung and asked me: Can we remove everything?

Charles was already speaking in the plural. This was a great signal that he saw us as a team!

I said that it was too early to tell.

We would have to do other tests to assess whether the disease was restricted to the thorax, but even in this circumstance, we need to know if the mediastinum lymph node was free of metastases to allow proper planning for surgery.

I told him that we would have other meetings before this decision was made and that we would talk frankly about the alternatives, just as we were doing at that particular moment.

Charles realized that I could not go any further and asked me what additional procedures would be needed?

I referred him to a thoracic surgeon and mentioned that I would be present for the procedure, and that I would discuss all the results with him as soon as they became available. 

Charles agreed to follow my recommendations.

I asked him if I should speak to his wife.

Charles replied saying he preferred do it himself, explaining that he knew better how to deal with her.

I nodded and expressed my willingness to address any questions that she might have… 

To be continued in PLOT 3 (conflict): Insecure love

*              Attention: The story 4 will be published sequentially from PLOT 1 to PLOT 6 and you will always see the most recent posting. To read Story 4 from the beginning, just click in the numbered links located at the bottom of the homepage. 

© Copyright 2020 Anticancerweb

 James Fleck, MD, PhD: Full Professor of Clinical Oncology at the Federal University of Rio Grande do Sul, RS, Brazil 2020 (Editor)

Joao A. de Andrade, MD: Professor of Medicine and Chief Medical Officer, Vanderbilt Lung Institute, Vanderbilt University Medical Center, Nashville, TN – USA 2020 (Associate Editor)