Monday, October 30, 2006

The Philosophy of Disclosure

From AK:

I'm sure most of us have seen some close variation on this clinical theme: a smoker has a suspicious lung mass with evidence of metastasis elsewhere, and you're consulted to help get tissue. The patient hasn't seen the scans, doesn't know the overwhelming odds that they have metastatic lung cancer. As a consultant, how much should you tell the patient before you have path results? If they ask about the possibility of surgical resection, is it right to put off an answer you know is highly likely to be correct?

2 comments - CLICK HERE to read & add your own!:

Jennings said...

For me it's relatively easy; I show them the scans, point to the mass and tell them that there is a very high likelihood that this is cancer. If there is some uncertainty, based on the radiographic appearance, I tell them that. For example "although cancer is the most likely diagnosis, infection is still on the list", or "I suspect that this is a chronic infection, but I cannot rule out a cancer so we need to biopsy it (or repeat CT or whatever the case may be)...
I think it is very important to have the patient know of the odds of cancer BEFORE the biopsy is done, so they know what to expect and can also make an informed decision about how to proceed in the diagnostic workup.

Arenberg said...

Jeff, I completely agree with your approach. I think its very important that the patient hears up front what to expect. Its OK to asay you are not sure, if you aren't.

But...if you believe there is cancer, and you believe its unresectable, you are doing the biopsy only to prove its unresectable. There is NO good to be had from biopsying resectable cancer (i.e. just take it out), and I always tell my patients that the best news I can give them after a biopsy is "no news".

Frankly most of the time a patient is sent to me to get tissue, they have already been told, or at least have assumed, that they likely have cancer. I view my job to help them interpret the road map of tests and possible treatments in front of them.