My faith in healthy lifestyle choices is shaken

This must be my eighth cancer scare. (No, I really don’t undergo excessive testing.) Decades ago, I’d noted a possibly normal finding but dropped it after getting no response at subspecialist visits. Recently, following pertinent CME, I asked again and the physician bit. You can guess the rest.

One night while dodging traffic I accessed on my phone the ultrasound report from the designated cancer center’s (DCC) patient portal, revealing a mass, probably exceedingly rare and benign. I’m an acceptably well-informed primary care provider, but frankly, I couldn’t have given a detailed differential diagnosis of a solid mass in that organ. This didn’t sound that worrisome.

Weeks passed without word from my physician, whom I’d seen yearly for over a decade. Would a lay patient have assumed all was OK — how often have you heard that? Perhaps he thought I’d work it up myself? After weeks of calling, I finally reached him; he insisted he’d obtain the MRI pre-authorization. Over a year later and still no word.

I found a surgeon. No contrast needed meant it’s benign. Was it a health-care-in-July thing, or just an oversight, but later a sheepish radiologist called. They’d overlooked a contralateral mass. Undoubtedly malignant, it was small, without local extension or vessel involvement, so no problem. Yeah, not for him.

Was the second mass seen on ultrasound? (The surgeon hadn’t said anything.) The “impressions” section in the report mentioned only one mass. But bilateral lesions were described in “results;” unbelievably, I had forgotten. How often does a radiologist omit a major finding in “impressions”? Given the need in an EHR for multiple clicks, scrolling down and enlarging pages, might clinicians sometimes only look at “impressions?” Failing to identify the initial lesion as benign on ultrasound bought me an MRI — the omission didn’t matter. But if the DCC had correctly identified the first lesion, I wouldn’t have had the MRI, and a solid, contrast-enhancing mass would have been forgotten.

We know screening’s perils: overdiagnosis, lead-time bias, inferring mortality reduction from stage migration, etc. I hate ads for a pretentious multiphasic testing center that checks you out from head to toe, in contravention of screening guidelines and prudent radiation exposure. There’s no screening for this cancer. It’s been advocated (invoking arguments disputed re prostate cancer). A review article says it’s premature. With modern imaging, most cases are incidental and early-stage, yet mortality has only slightly decreased, and late-stage incidence has increased. What are we finding and treating?

Avoiding a long wait, I found my way to a world-renowned comprehensive cancer center. Invoking Occam’s razor, I anticipated the same benign pathology in both lesions, so I was shocked when the new surgeon casually mentioned, “And if it’s a T3…” I’d read the MRI report. How could that be? Apparently, the MRI had lots of artifacts, yet it was good enough for the other institution. While waiting a week for results of additional imaging, I was jolted when I opened an envelope with a cryptic return address to find “Resources for Life After Cancer.” Geez, can’t they wait for a tissue diagnosis?

That came via a robot. “da Vinci” is one scary-looking dude. Much taller than me and several times as wide. With concentric white layers, he’s a cross between Buddha and a horror movie robot. I’m surprised Hollywood doesn’t cast him more. Entranced, I was rushed to the operating table. Our relationship wasn’t consummated until I was under the influence. Recalling past open procedures, it’s amazing that a robot inserts mechanical paws, partially resecting a very vascular organ with minimal blood loss, no incisional pain, and an immediate recovery. Yet scary potential sequelae remain, like multidrug-resistant organisms, stray electric currents and telogen effluvium.

Waiting for the pathology report, I was paralyzed with indecision while shopping. Superstitious or prudent to buy organic? Organic full-fat or regular low-fat dairy products: which is safest? Decades of a DASH diet, and assiduous — if futile — avoidance of possible carcinogens had failed me.

The phone call came: it wasn’t malignant after all. I should have suspected something; when I said “benign,” the surgeon hesitated — we’d talk at my follow-up visit.

When he uttered the seductive sentence still echoing in my head, “You don’t have cancer.” Then my eye fell on the printed pathology report. “They’re very strict here — anyplace else, they’d call it benign.” Jarring to see “carcinoma,” despite nuances. A few more mitoses than allowed. We think dichotomously, is it really a continuum? My case was reviewed at a consensus conference — did the pathologists disagree? Clinicians who see a lot of slides must have their own opinions, but how frequently do they nullify the pathologist? “You’ll be fine,” he said. I’m grateful to the surgeon for his iconoclasm. Much is unknown about this extremely rare type, other than unpredictability and worse prognosis. “Don’t look it up,” he ordered. As if I already hadn’t.

What to tell other doctors? “Tell them you had a benign tumor.” The surgeon and I share this secret. Only we know SEER is off by one case for 2017. Nevertheless, it’s in the EHR, and I’ll follow surveillance guidelines. Someday, I’ll need to decide which story to tell.

It happened soon. The MRI revealed other incidentalomas. Neither elite institution offered a work-up, although it’s in specialty society guidelines. I got to a third institution. Algorithm paths diverge given the history of malignancy. Which story to divulge — surgeon’s or pathologist’s?

In summary, screening yielded cysts, an adenoma, a very rare benign tumor, either an uncommon benign or exceedingly rare malignant mass (depending on my mood) and another pathologic finding, with unknown significance if asymptomatic. I find it thrillingly (if unwarrantedly) reassuring that numerous other organs look fine.

Favorable cancer risk-factors yield a probability, not an iron-clad contract, but my faith in healthy lifestyle choices is shaken. Did testing save my life? Did I narrowly avoid potentially fatal ultrasound report and MRI-reading errors? Or was the surgery, and labeling, for something that never would have presented clinically? Overdiagnosis, misdiagnosis, or neither?

The author is an anonymous physician.

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