Progress in America: (9) A Non-Cancer Diary? Part III
Those Second Opinions
Of course, we were elated. Took a few days off to celebrate our anniversary and then came back to see the 2 docs. First I got hold of all the scans and radiology reports. And that was an eye opener. On the reports at the very top of the page line one was patient’s name, date of birth. Line 2 was patient’s history. On the early scans this was blank. In the case of the recent scans, it said “Patient History: Prostate Cancer.” And this seemed to make all the difference:
Prescription 2 for the system: FRAMING is a real problem. Diagnosticians must be trained to overcome this. Just because you have a flag of a condition does not imply that what was earlier not problematic is now seen as a leading indicator.
October 28th was a busy day. We planed to see the first doctor (the rheumatologist) in the morning. Then we’d go to Dr. Jim for the bone doc’s take on it all. Finally, I was to do a TV show on justice and Rawls. The day started fabulously: one of my heros, Amartya Sen, got the US medal of arts and humanities from Obama. That augered well.
The rheumatologist, Dr. Jane, refused to look at the scans, only the reports. Jane said she wasn’t well trained to look at scans. After a thorough examination of my vital signs, and an interview she announced that maybe this scare was overblown by the radiologists. Perhaps no biopsies were needed. But to make sure, she wanted to look for blood markers of multiple myeloma, Padgett’s disease and a few other things. But she felt none of these problems were likely. But, since she didn't look at the scans, she felt that Dr. Jim (who she knew) might have an experienced eye to evaluate the case.
Afternoon. It was Doctor Jim’s turn. After a quick greeting, he immediately asked to see the scans. Slipping it into the computer, he mentioned that he had lost both his wife, and his brother to cancer. The scans came up, and he took one look at the bone scan, and said clearly, “This is going to kill you. This is clear sign of metastized cancer.” He then examined the MRI and said there were spots of importance in the left hip. His message was clear and succinct: The fact that the CT scans didn’t change over those years doesn’t change the need for a biopsy. I have to find out what is going on. Quite possibly this is metastisized from the prostate but he wouldn’t rule out other forms of cancer. He thought Dr. Jane’s choice of additional tests were spot on. He said hold off sending the scans to J Hopkins till after the tissue was retrieved and analyzed. He recommended a great person for the biopsy would be Dr. Richard. He was the same as Dr. Lisa had recommended at Suburban. Finally, he wished me luck and said he would like to continue being involved in this case.
Lesson 2 for the Doc and Prescription 3 for the system: Honesty and full disclosure are not the same as lack of sensitivity in communication. Learning how to express oneself should be part of the medical curriculum.
I was a bit shaky at the TV show, but better than I might have expected. (Check it out if you want.) But back to the story: the next day, Wednesday, I called my doctor and made an appointment to see Dr. Richard on Nov. 5. I also called my urologist, Benny, to see him. That appointment was for the 4th of November.
Two days later, on Friday, Dr. Jane called. Tests ruled out multiple mylenoma and most other things (but not metastasized prostate cancer). A few days passed and I saw Benny. He was monitoring my prostate cancer. Hearing all that transpired, he quickly concluded, that he was ‘certain’ this wasn’t metastasized prostate cancer to the bone. He ruled that out on the basis of the Gleason scores, the general biopsies, the PSA tests. He thought it would be unheard of for this to be metastasized prostate cancer. He also was quite sure it wasn’t any form of bone cancer. If I had metastasized bone cancer I’d be in a lot of pain, and would have lost a lot of weight. To him, reading the reports of the CT and MRI scans, they seemed uninteresting. But the bone scan looked very troubling. He felt I should get a biopsy. Best would be by Dr. Richard. He thought Richard had lots of experience, liked puzzles, was very good, might have some ideas.
Lesson 3 for the Doc and Prescription 4 for the system: Don’t let test results drive your diagnostics if you have other mitigating information. So, for example, the lack of pain, illness in my case should have caused doubt re the test results.
November 5 I saw Dr. Richard. The biopsy doc looked at all the scans with us for 45 minutes. His conclusion: He eliminated hot spot after hot spot as coming from broken bones (blame biking in DC traffic) and arthritis (blame living this long and my mother’s family). But two of the “hot spots” remained unexplained. Looking at the CT’s carefully, he showed that these‘hot spots’ were associated with bone deformities and that they have not changed at all in 7 years. Why these deformities would show up as absorbing more of the radio active material in the bone scan was not clear. But it was more of a puzzle than a medical problem. It was very unlikely metastasized anything.
Hint 2 for the Patient: Make sure all the information details of your case are being properly processed.
We could still do a biopsy. It would close the book as to cancer. It would probably show no malignancy and then we could call it quits. If it did show malignancy it certainly would be very slow moving. So a week later, I got the biopsy.