Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, January 04, 2007

More Hard Conversations

Having garnered considerable praise for my handling of these cancer conversations (thank you) I would now like to go out on a limb and describe another, more recent, interaction for which I make no apologies, but which may very well evoke more criticism than praise.

I got a phone call last week from a guy in his 50s: "I'm peeing blood." I told him to come right over and sure enough, the specimen cup contained pure merlot instead of nice clear ale.

Here's the thing: gross hematuria (blood in the urine; lots of blood in the urine) although also caused by kidney stones or really bad bladder infections, has to be considered cancer until proven otherwise. Kidney cancer and bladder cancer, which can both present this way, are the "drop dead" diagnoses for gross hematuria and have to be ruled out definitively.

So in addition to a history, exam and urine culture, this guy was going to need a CT scan of his abdomen and pelvis, and a cystoscopy by a urologist. I was not going to stop until I was certain he didsn't have cancer. (Maybe someday I'll tell you about the last patient who peed blood whose initial CT was read as negative.)

To my way of thinking, I have to tell him this up front. Look at it this way: which is more alarming? Being told from the git go that I'm looking for cancer, or being sent all over kingdom come for rests and referrals and more tests without being told why? I trust my ability to tell the truth while remaining supportive, and so I opt for full disclosure.

I sat down with him (known him for over ten years) and his fiancee (whom I'd just met) and laid it out. It could be just a bad bladder infection (less likely in a male, though) or kidney stones (even though he didn't have any renal colic or kidney stone-type pain) but I was worried because cancer can cause that kind of blood in the urine, and we needed to rule it out.

He got a little teary but the fiancee was a tower of strength. I called the urology office and got him an appointment in less than a week, and pulled strings at CT to get him in the day after next (including getting a pre-cert all by myself; no staff that week.)

But here's what happened:

On exam, his temp was 100.1. He had no CVA tenderness and a benign abdominal exam, but a giant, non-tender prostate on rectal exam. I had actually documented it (huge; asymptomatic; normal PSA of 1.7) a few months back on a routine physical. He had to run to the bathroom four times during the visit, meaning he had what would be called "significant lower tract symptoms." The urine was filled with blood, to the naked eye as well as on dipstick and microscopic (meaning there was no way to tell if there were excess white cells with all those red ones, which would point to infection.)

I gave him generic trimethoprim-sulfa (cheap; great bacterial coverage and tissue penetration for both kidney and prostate; all infectious bases covered pretty well) and by the next day his fever was gone, the bleeding had stopped and he was feeling "100% better." His PSA was still less than 2 (low likelihood for prostate cancer) and his renal function and blood count were fine. The kicker was that his urine culture grew out a pan-sensitive E. Coli. Yesterday I got the CT report: no renal masses. I haven't yet heard from Urology, but I'm optimistic (1. That they did a cysto; 2. That it was normal; 3. That I will hear from them.) So the whole thing is looking more like a hemorrhagic cystitis with or without a superimposed prostatitis, probably all secondary to subclinical urinary retention from his enormous prostate, with no cancer at all.

Here's the question: Did I do the right thing by trotting out the C-word at the start?

It's a real one, and I don't know the answer yet. I will be talking to the patient in the next few days, and (assuming everything is fine) I shall ask him how he felt about it. I'll report back here, and we can all compare notes.

Whaddya think?


At Thu Jan 04, 08:29:00 AM, Anonymous Anonymous said...

Personally, I would rather know up-front, but explained thoroughly to reduce anxiety. I would be suspicious, however, if my doctor ordered a bunch of tests without an explanation if I assumed that I just had a UTI. Some people, however, might totally freak out. That's a hard one . . .

At Thu Jan 04, 08:30:00 AM, Blogger Dr Dork said...

I think you did well by this chap.

Honesty is the best policy unless primum non nocere is at gross risk.

At Thu Jan 04, 08:42:00 AM, Anonymous Anonymous said...

I'm a little on the fence about it. I'm not a doctor but I do like the med blogs. I've had experience with the gyno trade and their cancer screenings; I feel like they are all too willing to overtest.

In this situation though, especially if you have personally seen a lot of cancer diagnoses based on this symptom, it made sense to lay your cards on the table--if only to get the patient's buy in on having the testing done in a timely fashion. A cystoscopy is not a fun experience for anyone.

I'm glad it all turned out all right and I think that your instinct to discuss the issue with your patient is what will make all the difference. Mostly I think that he will be so glad to be better and verified uncancerous that he will not hold it against you. I also predict that if he ever pees blood again, he will be on the phone to you pronto.

Looking on the bright side a little more, it sounds like he's got the right woman by his side. :o)

At Thu Jan 04, 11:21:00 AM, Blogger Pieces of Mind said...

You laid out all the possibilities, cancer and otherwise.

You were careful to explain you didn't know for sure but wanted to rule it out.

You've known the patient for 10 years, so clearly there is some sort of established relationship, which is always a plus.

I'd say you made the right call.

Realistically, the patient must have been rather frightened by his symptoms. And most people would probably have wondered, "Is this cancer?" So the possibility was more than likely in the back of his mind anyway, even before you brought it up.

A couple of years ago I had to be evaluated for chronic hoarseness. As I had radiation to the neck and chest back in 1995, the possibility of a secondary cancer was kind of obvious. I did not mind that the physician said it might be cancer; in fact I was grateful for his honesty.

It's not a lot of fun for patients to be run through a battery of tests without being told why. When you leave people guessing, they often come up with imaginary scenarios of the worst kind.

Even if this did turn out to be cancer (which thankfully does not seem likely), consider what has been accomplished: The possibility has been put on the table and the patient and fiancee have some time to start wrapping their minds around it before the axe falls.

I blogged a couple of months ago about cancer survivorship and how the discussion about potential late and long-term effects of tx needs to start early, preferably while treatment decisions are being made. I see the "C" conversation as somewhat similar: These are not conversations that you hold at one single point in time; they are both part of a process that may unfold across days, weeks, or months.

All right, I'm done talking now. ;)

At Thu Jan 04, 11:29:00 AM, Blogger Artemis said...

I think you did the right thing -- the odds in this case are much lower for a simple UTI than for a possible malignancy; it's my guess that the guy was a bit concerned about that "c" possibility, which is why you met the fiancee. (How many men come to the doctor's office for a routine check-up with support system in tow?)
Keep up the great work!

At Thu Jan 04, 11:41:00 AM, Blogger Sid Schwab said...

I'm no judge, so of course I'll give an answer: it's similar to (but also quite different from) (how am I doing so far?) BRB per rectum. Clearly cancer is always on the list, but the context is important. It's most likely hemorrhoids; but hemorrhoids are common and many is the person in whom they've been seen and treated, only to ignore the cancer higher up. But still, I didn't always order a full workup when, in context, cancer was a real zebra and the person responded as expected. I suppose in a young woman you'd have tested for and treated UTI before going full-bore... Since bureaucrats always look retrospectively, I also suppose some of them could wonder about the extensive workup for a UTI. But they don't have to face the patient with the missed cancer....

At Thu Jan 04, 11:55:00 AM, Blogger Dr Dork said...

Damn surgeons and their rectums...

At Thu Jan 04, 12:47:00 PM, Anonymous Anonymous said...

I am not a doctor, but I think you did it correctly - you explained that it could be something else but that you need to rule out the cancer.
The way information is presented is really important. Some months ago during a routine physical, my father's doctor pointed out at a suspicious leision on his face and told him "it is probably cancer" before sending him to the dermatologist. No "it could be", no explanation as to the different types of skin cancer and that even if it is, it isn't necessarily life-threatening. Even the dermatologist was surprised - she said "how could he know, did he do the biopsy?". The biopsy came back negative - it was just a sore my father scratched too much, but for 3 weeks my father was worried sick. Considering that my 78-year old father has a history of heart desease, it doesn't seem a reasonable way to handle the conversation.

At Thu Jan 04, 05:03:00 PM, Blogger Richard A Schoor MD FACS said...

It's not like you asked him if his personal effects were in order or suggested that he should take that trip of a lifetime. You did the right thing.

At Thu Jan 04, 05:34:00 PM, Anonymous Anonymous said...

My parents (60ish) are alarmists - everything is CANCER! So 10 years ago when my father had blood in his urine my mother fell to pieces and promptly called me to start planning his funeral.

Turns out to be a bladder infection (that was my assumption - but I'm no doc)...but then Dr tells my father it could have contracted sexually.

Thus mom's next phone call (no less tearful) was to tell me that my father had accused her of infidelity! After 20 years of marriage! (I know that doesn't really mean much to some, but...)
At this point I just ignored them and let them work it out.

Were you right to tell him (them)?Yes! I'd rather have worse case scenario every time...with the reassuring words like "probably" or "just to be sure" used liberally.

At Thu Jan 04, 08:35:00 PM, Anonymous Anonymous said...

Were I the patient you're talking about, I would have been happy that you did exactly what you did - whatever the outcome. I once had a Gyn do the same with me - right up front, and I really appreciated the honesty.

At Thu Jan 04, 09:31:00 PM, Blogger Bo... said...

I agree--because I truly believe that patients want the doctor's honest opinion. And if you thought that there was a significant chance for cancer, then you were absolutely correct in doing what you did.

At Fri Jan 05, 11:49:00 AM, Blogger oncRN said...

Absolutely you did the right thing. We all know that cancer = death in the minds of our patients which is why it is so scary. But, as I tend to perseverate on in my own blog, the discussion of health and indeed life, cannot exist independent of discussing death, when pertinent. So, kudos to you for presenting it thoroughly and honestly.

At Fri Jan 05, 02:44:00 PM, Blogger Surgeon In My Dreams said...

I had hematuria visible to the naked eye a few years (in my 30's) ago for 8 weeks.

I was scared to go to the doctor, but one night when I had this pain that started in my back, curled around my side and wound up in front, I gave in. Geeez...I have had two 9+ pound babies with NOTHING for pain but that pain that night was a gazillion times worse!!

Mine turned out to be a stone stuck in the curve of a ureter, but he told me right up fron that since I was a smoker it could be cancer.

I am glad he was honest with me, because I would have just went home and "googled" whatever tests he ordered plus hematuria and come up with the same frightening possibility. Not to mention that "smoker - bladder cancer" thing always did stick in my head.

I have been smoke free for 5 days now...

At Fri Jan 05, 08:02:00 PM, Blogger SeaSpray said...

I think you did the right thing. Sending him for those tests without a good explanation may have given him more cause for concern. Either way, he would probably be thinking CA, but at least you presented a balanced picture.

If he didn't present with gross hematuria, (which had to have alarmed him) you could've possibly given him another valid reason for testing, without giving full disclosure until all results were in. I still think honesty is the best policy, but then there could be some gray area depending on different variables in the patient - doctor relationship.

I feel like I have been tested for everything this year and I am a patient that always wants to know exactly what the doctor is testing for and appreciate that he takes the time with me pre and post procedures, etc.

If I were your patient, I would feel better that you weren't leaving any stone unturned, so that if you did give a good report - it would be based on the fact that you checked "everything".

Imagine all the tests that would have to be done to be tested for EVERYTHING? :)

At Sun Jan 07, 08:04:00 PM, Blogger Judy said...

I don't think you can convince many adults that you want a CT scan and a urology consult for "probably an infection" unless you are honest with them about the other possibilities.

Most people know you're not looking for an infection with a CT scan. In fact, most of the non-medical folks I know presume you're looking for cancer unless you tell them you're looking for something else. Even then, they worry.

At Mon Jan 15, 10:23:00 PM, Blogger Carol said...

Your "merlot" reference made me smile. When my Dad told his cancer story the first part went like this: "I got up one morning and went to the bathroom. My urine was the color of a fine port wine." He was in Moscow at the time. His local doctor said Kidney Stone We'll Fix It! He said hmmmm no thanks. A week later he was on his way home and stopped in London for a few days. He saw his local doctor there. That doctor said Kidney Stone We'll Fix It! Again, no thanks. Another week later, he's at home in Houston where MD Anderson pronounced him the proud father of a huge kidney cancer (they described it as the size of a deflated football).

I say if the pee looks like wine, go with your gut! Good work!

At Sat Jan 27, 08:59:00 PM, Blogger Narya said...

You did the right thing. (There's a bunch of bladder cancer running around in my family right this minute; my dad had the tumors removed Tuesday and will get the path report/prognosis/treatment recommendations Monday.)


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