Monday, 2 March 2015

Be clear on cancer!

Be clear on cancer. Well my patient was: 'Three weeks of heartburn? See your doctor', so they did.
I wish I was that clear!
No risk factors, no drinking, no smoking.
No red flags, no vomiting; eating, swallowing and appetite fine.  Put on a bit of weight. Typical mild but annoying symptoms on lying and bending, eased by a simple antacid. And on examination no nodes, no lumps, no anaemia, looks as well as I've ever seen them. No sign of cancer at all.
And when you dig a bit: well yes I've always been a bit prone to it, so not just three weeks, but worse in last year since starting the aspirin for the silent ischaemic heart disease based on the abnormal ECG and since stopping the PPI (anti-stomach acid drug) you gave to cover the NSAID (gut-rotting anti-inflammatory drug) course for the arthritis flare.
But there you have it, the big C genie is out of bottle or is it ogre out of his lair: could it be cancer? Well it might be and really only your age is against you but weight gain, aspirin and medication changes are actually much more likely causes.
Be clear on cancer: your GP estimates your risk at less than 2% given the above but a) he might be wrong and the risk is actually higher and b) if he isn't you could still be in the 2% anyway (you might have asymptomatic cancer and your symptoms are coincidentally due to the weight, aspirin and medication changes and I'm about to blow your luck - he said with a smile on his face)!
You always cheer me up, doctor!
It's called explaining risk to the patient - you are 98% OK. OK?
Oh... so you're not 100% sure....
Be clear on cancer because your GP is not wholly non-anxious about his conclusion about the best course of action here and saying 'You're the Doc' is not much help when I ask 'What do you think?'
Am I mistakenly colluding with your desire to avoid endoscopy to your disadvantage, or are you just being nice to me in my uncertainty, giving me an excuse not to refer?
And if we refer you all something else will have to go - causing longer waiting times for the 2% who do turn out to have cancer whose prognosis will worsen as a result.
So we're clear on (symptoms that have <5% chance of) cancer, just unclear on what to do about it.
Decision! Stop aspirin (and increase your heart attack risk - he smiles again) and restart a PPI and I'll review you in two weeks.
It'll either be another totally unsung, well-judged piece of risk management that saves enough cash to allow the NHS to fight another day, avoids delaying the diagnosis of those we hope will be less fortunate than you and avoids your small endoscopy associated risk and your inevitable anxiety or I'll be thrown to the dogs as another cancer-missing-GP. Watch this space!

Well that was two weeks ago and on telephone review (What it is to be an early adopter of new technology!) my patient is absolutely fine. Will now stop PPI and see. Still no certainty of course - I've either slightly saved the NHS from financial self-harm from a miss-targeted ad campaign or I've missed a cancer and covered up the symptoms - useless GPs...
As a Reader in the good old C of E I could go on a funeral course and then I could legally bury my mistakes. Mmm better not mention that to my appraiser.

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