PROSTATIC CANCER TREATMENT (WITHOUT BIOPSY):

PROSTATIC CANCER TREATMENT (WITHOUT BIOPSY):

Dear Sumner:

Mr. Y., an 86 year old man, came to my office last week complaining of progressive slowing of his urinary stream along with rather severe lower back pains. The back pains lessened with the use of Tylenol, local heat and bed rest. He is a bit “fragile,” having had a heart attack about 3 years previously and is generally quite weak. He is currently on prophylactic low dose aspirin. On rectal examination I found his prostate to be hard and bumpy. I obtained a PSA level, which the lab reported as 32 (normal level for that lab is <4). style=""> Where should we go from here? Do we need a tissue diagnosis prior to starting hormonal therapy?

Dear Bob:

I certainly agree with you about the high probability of your patient having prostate cancer. The question arises as to the best way of handling the current situation. I had a long discussion with both Mr. Y and his family about the “statistics” of prostatic cancer with increasing age: i.e. after the age of 70, there is approximately a 70% chance of there being a focus of cancer in the prostate, over the age of 80, an 80% incidence, and after 90, almost all men will have a focus of cancer in the prostate. The message is: if you live long enough, you will die with, but not from, prostate cancer. (Of course, in this case, he could, indeed, die from metastatic disease.).

Re the question you brought up about the necessity of obtaining a tissue diagnosis prior to initiating treatment, under the best of circumstances, prostatic biopsies run the risk, albeit very low, of possible complications such as bleeding or infection, not to mention the discomfort. And taking into account your patient’s age, his past medical history, the fact that he is on prophylactic aspirin, and the clinical picture of probable prostatic cancer (PSA of 32 with an underlying firm and irregular prostate), I would opt for starting him on anti-androgen therapy without having a tissue diagnosis.

TERMINALLY ILL PATIENT:

TERMINALLY ILL PATIENT:

Dear Sumner:

I would like you to see Harry, a 68 year old patient of mine who was diagnosed with renal cancer about 5 years ago. He underwent a radical nephrectomy shortly after the lesion was discovered. He has had no recent weight loss and currently has no symptoms suggestive of recurrent tumor. However, a routine chest X-ray done a few days ago revealed obvious metastatic lesions. Blood chemistries are consistent with spread of the tumor into the liver. These came as quite a shock to both him and his family, since they had been reassured by his previous urologist that the tumor had been completely removed. Needless to say, some active steps should be taken to handle this very distressing situation. Although Harry, himself, is currently in no dire distress, given the radiological and serological findings, we are likely dealing with a non-curable process that will likely manifest itself clinically in the very near future. I and the family will be most grateful for your input.

Dear Bill:

I had a very frank discussion with Harry and his family about the various aspects of kidney tumors. It was interesting to note Harry’s attitude shift from one of anger and total dismay to one of relative calm as he gradually came to grips with his own disease process. (Of course, it would have been a better situation if Harry as well as his family would have already anticipated the possible happenstance of metastatic/terminal disease before this state actually occurred, but unfortunately, this was not the case here.) Harry asked some very thoughtful and practical questions about possible scenarios involving metastatic disease. We spoke quite openly about the potential conflicts involving the issues of quality versus quantity of life and the fact that medical technology today has awesome capabilities of prolonging life. Harry expressed his preferences regarding the future management of his care, stating quite emphatically that he wanted neither to have his life prolonged by artificial means, nor to suffer with severe pains. I think it was also very helpful for Harry to have his family in on the discussion as he came to grips with his current condition.( This can really help avoid future feelings of guilt if family members feel that insufficient steps are being taken to prolong the patient’s life.) Harry and his family agreed that as his physical condition deteriorated, Hospice care would be initiated.

TERMINALLY ILL PATIENT (FAMILY DEMANDS):

TERMINALLY ILL PATIENT (FAMILY DEMANDS):

Dear Sumner:

I am faced with a very difficult situation. It involves a 79 year old man who was diagnosed with bladder cancer about 4 years ago. He has since had a stroke, which has left him with left sided weakness as well as aphasia. He has had many episodes of hematuria, necessitating readmission to the hospital for multiple blood transfusions and local cauterization to try to control the bleeding. Earlier in his care, he had expressed the desire that, should the situation arise when he would be considered “incurable”, he did not wish to have his life prolonged by artificial measures. (He had expressed these wishes in a living will.) Because of the aphasia, he is currently unable to communicate with either me or his family, He continues to have bleeding, and since his family has been unable to handle the problems at home , I have had to admit him to the hospital many times in the past few months for both catheter irrigations as well as for blood transfusions. While I personally think that it is futile to continue to give him blood transfusions since the underlying tumor remains his son demands that we continue with active treatment. Would you be willing to see this patient (and his son)?

Dear Percy:

I certainly share your, and the family’s distress. This is, indeed, a very difficult situation. My first effort was directed to his son. I listened as he explained that even though his father had previously signed a living will requesting that no undue measures be taken to prolong his life, there was no way of knowing if, indeed, his father had since changed his mind. (Of course, given his father’s current aphasic state, this presumption is only conjectural). I discussed the very practical considerations involving the utilization of limited resources, e.g. blood, nursing time, time taken up by the surgical and nursing staff and the expense of the supplies as well as the repeated catheter irrigations and bladder cauterizations causing trauma to his father. His son counter-argued that he has paid into the insurance company for many years, and his father is entitled to this care. Quite frankly, Percy, I believe that the son has strong feelings of guilt that he, the son, is not fulfilling his filial duties if he permits the cessation of active therapy on his father. After a lengthy with the son, I suggested that his father’s case be presented to the Ethics Committee of our local hospital, which is made up of medical staff as well as clergy and lawyers. When all members of the committee agreed that cessation of active therapy would be the wisest course here, the son accepted this suggestion with apparent relief, since it seemed to take the burden of this decision off of him personally.

Learning to Manage Some Urological Probems: a Case-Based Approach

EPILOGUE I feel very privileged to have practiced medicine for so many years. Gratifying, satisfying, rewarding are words which describe my experience. I have found over the years that injecting some humor into my letters was much appreciated by the physicians and perhaps even more so by their office staff. Indeed, very often I received referrals directly from the staff, who confessed to me later that their primary motivation for the referral (with tongue in cheek?) was to get my referral letter. Involving the students in the physician-patient relationship is a critical part of the learning process. Having the students play the role of patients can be a very effective teaching tool. The students must be able to empathize with the patients and must recognize the inherent risks of any diagnostic or therapeutic measures. These must be weighed against the natural course of the disease. Medical Students must remain open to the individual needs of the patients as they guide them in their medical dilemmas. I have attempted to present this material in an instructive yet informal style often using storytelling as a device to engage the readers’ attention. I hope that the above material will serve as a productive resource for medical students and educators.