Heme/Onc: Bad Medicine

We had one new patient this afternoon: a 44-year-old man with metastatic rectal cancer. He was a "self-referral," which isn't the norm (most new patients are referred by their PCPs or surgeons), but we soon got the whole story. He's originally from Weatherford and was diagnosed with his cancer six weeks ago after experiencing increasing fatigue (among other symptoms), and he was referred to the other cancer center in town (Dr. RP calls them "rivals.") The oncologist he was referred to was relatively young, having finished her fellowship just 2-3 years ago, and she insisted that he get a PET scan in several weeks before seeing her again. Dissatisfied with the slow pace, he went down to MD Anderson for a 2nd opinion, but he didn't like the way he was treated there. And in the meantime, he got no treatment ever since he saw that young oncologist except for the PET scan, and that's a six week delay in treatment. Dr. RP, on the other hand, immediately got the ball rolling and made plans for him to schedule surgery to get a port put in so he could start chemo next week.

I'd read in the PET report that the patient had diffuse mets to the liver, but I had no idea how diffuse until Dr. RP let me palpate his abdomen. His liver was HUGE. It felt so hard that I couldn't tell if I was palpating rib or liver, extending into the LUQ of the abdomen. On top of that, if you ran your finger along the skin above the liver, you could just FEEL the nodular mets on his liver. Amazing. Dr. RP called it a "med student liver" because even a med student could tell that it was abnormal. And his CEA was off the charts: over 22,000 whereas a normal CEA is less than 6. Fortunately the patient was a pretty good sport about the whole thing. He was willing to try chemo if it would give him a shot at living longer, but if there was nothing more to be done, then he was fine with it. He also made no secret of his disgust toward MD Anderson and said that he didn't feel comfortable with his first oncologist, and that's why he brought himself here (where Dr. RP has more experience).

After the patient left and we retired to the physician work room, Dr. RP shook his head. "This is bad medicine," he said. "If he'd seen me six weeks ago, I would have gotten him started on chemo immediately or enrolled him in a clinical trial. Why would you wait to treat someone with metastatic cancer? He probably has WEEKS to live at most now." The scribe asked what the other oncologist was waiting for in delaying treatment, "Someone to tell her what to do?" Again, a jab at her relative inexperience. I asked if the patient's family could file a suit against the other oncologist for delaying treatment, and Dr. RP said something like that would never make it to court. In his dictation, however, Dr. RP made a point of reporting that the patient did not feel comfortable getting treated at "the other place" and even went to MD Anderson for better care (never mind that he got a DVT during the drive to Houston) when all this time he could have just stayed in town. *sigh* The lesson here: if a patient has advanced cancer, don't hesitate to treat.