Yesterday I saw a 90-year old woman in consultation. She presented to the emergency room in September with abdominal pain, and in the process of working her up, a chest x-ray was taken which showed an infiltrate in her lingula, part of the left lower lobe of her lung.
As it turned out, there was nothing wrong with her belly, but a follow up CT scan of her chest showed this strange fluffy area in the left lung—not quite a tumor, but not quite a pneumonia either. She had smoked for years but quit in 1980 and she had no symptoms of cough or shortness of breath. The decision was made jointly between the patient and her primary care physician to just “watch it”.
A repeat scan was done two months later, in November, which showed that the area had “slightly” enlarged. She was seen by a pulmonary specialist who recommended that she have a biopsy and she was referred to interventional radiologists who were asked to put a needle in it and withdraw cells for analysis. They declined, unfortunately, citing that the risk of causing a lung collapse or bleeding was too great in this elderly woman. The pulmonologist could have tried to reach it with a bronchoscope, but he doubted that he could—it was a little too far in. So two months later, she was referred to me for consideration of radiation therapy, still entirely well, with no lung symptoms whatsoever–and no diagnosis of cancer.
Yesterday she and her equally intact and otherwise healthy 90-year old husband sat in my exam room as I explained to them that, while there is a high likelihood that this abnormality in her chest is indeed a cancer, to operate to remove it could be fraught with complications, even fatality, and to give her radiation without a diagnosis was equally unconscionable, given the fact that the area was very near her heart and that radiation itself can cause serious inflammation in the lung. She looked at me without a trace of irony and said, “Doctor, all I want is another ten years.”
And there we have it. Next week she will have a PET-CT scan to see if the abnormality is positive on PET (a clearer indication of cancer than a plain CT scan), and to rule out cancer elsewhere in her body. If it is larger now, and PET avid, she will be referred to a tertiary care center for a specialized bronchoscopy which can reach the lesion for biopsy. If the biopsy is positive for cancer, she will be treated with whatever modality is deemed most appropriate for her type of tumor, be it surgery, radiation therapy, or chemotherapy. It is what she wants, and what her husband wants for her and they clearly understand the risks. She is ninety.
People say to me all the time, “What would YOU do if this was your parent?” The answer, honestly, is I do not know.
Miranda Fielding is a radiation oncologist who blogs at The Crab Diaries.