Case and Commentary
Jan 2005
Case
Mrs. Scott, a trim, recently retired teacher who has enjoyed relatively good health, visited Dr. Lee, her general internist, for her annual check-up. She had several complaints including back pain, intermittent nausea, loss of appetite, and fatigue for the last several months. She said her back pain usually followed a meal, and her chart disclosed that she had lost 10 pounds since her last check-up. On physical examination, Dr. Lee was unable to draw any firm conclusions as to the cause of these symptoms. He ordered standard diagnostic blood work which showed mild normochromic anemia and low albumin. Because this is a common finding in several chronic diseases, Dr. Lee told Mrs. Scott they would have to set up an appointment at the hospital for more diagnostic tests. Dr. Lee knew that Mrs. Scott's father had died of pancreatic cancer, and, because she was also a regular smoker, she was at increased risk. Since her symptoms were suggestive of pancreatic cancer, he scheduled her for an abdominal CT scan at the local hospital.
The CT scan confirmed that Mrs. Scott did, in fact, have pancreatic cancer. Dr. Lee waited until Mrs. Scott had dressed. When she asked what the test showed, he told her about the diagnosis of pancreatic cancer. Immediately she said, "I want you to get it removed."
"I've already called for a surgery consult to evaluate the possibility of a surgical resection."
Upon consultation, the surgical oncologist, Dr. Parihar, suggested a biopsy to confirm the diagnosis of pancreatic cancer. After evaluating the CT and the biopsy, he informed Dr. Lee who informed Mrs. Scott that the pancreatic cancer was inoperable. Indeed, the spiral CT indicated that the cancer was locally situated in the body and tail of the pancreas, that it had spread substantially—not only were the local lymph nodes involved, but there were distant metastes. Finally, the CT showed local invasion into the vascular structures—specifically, the superior mesenteric and celiac arteries. In Dr. Lee's judgment, Mrs. Scott had no more than 4-6 months to live.
Even after she was informed by Dr. Lee of the uselessness of surgery for her condition, Mrs. Scott continued to demand surgery to remove the tumor.
What should Dr. Lee do? (select an option)
A. Allow Dr. Parihar to assume complete care for Mrs. Scott.
B. Urge Dr. Parihar to acquiesce to Mrs. Scott's request for surgery.
C. Reiterate the reasons that surgery is not indicated.
D. Ask Mrs. Scott to discuss why she wants the surgery.
E. Suggest to Mrs. Scott that she should seek a second opinion or transfer to another hospital.
