Oil and Water (Sometimes): Guidelines and Real Life
I had another case the other day when I had no choice but to throw well-documented guidelines for the care of diabetes right out the window.
The patient was a man in his forties with a terrible case of diabetes. The main reason it was so terrible was that he was either completely incapable of or unwilling to comply with lifestyle changes such as limiting carbohydrates in his diet and engaging in regular exercise. His hemoglobin A1c was 13% (good diabetes control being considered less than 7%.) He'd come in at irregular intervals through the years and swear he would do better, but never did for more than a few months at a time.
He recently had a colonoscopy for some rectal bleeding, and was found to have a 4 cm. sessile polyp that was too big to remove through the scope, but did contain cancer in the biopsy specimens. The required procedure is an operation to remove the section of colon containing the cancer.
I only found out about this three days prior to the proposed procedure, when the surgeon's office faxed me a form requesting "medical clearance."
What to do?
All surgery carries risk. The risks in diabetics are magnified; both short term risks like infection and the longer term risk of impaired healing. Surgery for immediately life-threatening conditions (ie, appendicitis) trumps these risks, and the patient must be taken to the OR regardless. But the biology of cancer is such that in this particular case, a delay of three to six months -- or even a year -- is not going to realistically affect the clinical course of the patient's malignancy.
This can be counterintuitive to the general public. How is it possible that cancer is not a surgical emergency? Aren't women with breast masses rushed into surgery? Well, yes, but frankly because it is more of a psychologic emergency than a true medical one. The stress of knowing one has cancer is significant, and it would indeed be cruel to prolong the wait for definitive treatment. But when there are other conditions that significantly increase the risk of surgical complications, that risk/benefit ratio becomes a lot trickier to calculate.
In this case, though, the answer was clear. The surgery needed to be delayed at least 3-6 months so that he could get his diabetes under better control. I called the surgeon, who acknowledged that the cancer posed no immediate threat to his health and agreed to cancel the procedure for now. He told me to call him when the patient was ready to be re-scheduled.*
I hadn't seen the guy for two years, so I made him come into the office, mainly so I could explain to him face-to-face why I thought the surgical risk was unacceptably high while his diabetes was so dreadfully out of control. Here were some other things he said to me to try and persuade me to allow him to proceed with the surgery now:
- He had already arranged to take time off from his job for the operation (which had been scheduled for the next day) and
- If he didn't have the surgery now and lost his job in the next few months -- as he was afraid might happen, as his company was planning layoffs -- he wouldn't have health insurance to pay for it.
Here was the biggest problem: the patient absolutely positively could not swallow pills. Any size; any shape; couldn't swallow them. He had tried. He had swallowed one metformin tablet and it had "gotten stuck." He suffered with the sensation of a foreign body at the base of his neck -- the pill -- for days. There was no way he could do it. Even to save his life -- which he recognized was the case; if he didn't have the surgery at some point, the cancer would eventually kill him -- he just could not do it.
On the other hand, he had no problem with insulin. He had given it to his father for years before the father died (of diabetes complications, of course) so he was at ease with measuring and administering it, even to himself. (He later confessed that he had been on it for a short time many years ago with a previous doctor.)
So along with the most explicit, emphatic discussion of diet and exercise ever provided, I gave him a prescription for insulin: long-acting at bedtime, regular for meal coverage, syringes, new strips and lancets for his meter; the works, but with no oral medications.
There's no guideline in the world that recognizes this as a valid approach for the treatment of type 2 diabetes. But I don't have the luxury of treating guidelines; I treat patients, limitations and all.
*(For all you purists out there, what if the patient doesn't come through with improved control in the given time frame? As time goes on, the urgency of removing the cancer will grow and will eventually outpace even the risks from uncontrolled diabetes. Then he'll get his surgery -- as well as a postoperative infection and non-healing wound -- but at least we'll have done everything possible to avoid it in the first place.)