Tumor is the rumor; tissue is the issue

doi:10.15406/htij.2016.02.00043

eISSN: 2469-2778

Hematology & Transfusion International Journal

Perspective Volume 2 Issue 4

Tumor is the rumor; tissue is the issue

Abdulraheem Qasem,

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Kristen Strasser

University of Missouri-Kansas City School of Medicine, USA

Correspondence: Abdulraheem Qasem, University of Missouri-Kansas City School of Medicine, Richard & Annette Bloch Cancer Center at Truman Medical center, 2310 Holmes St, Kansas City, MO 64108, USA, Tel 816 404 4375, Fax 816 404 4337

Received: July 11, 2016 | Published: July 14, 2016

Citation: Qasem A, Strasser K. Tumor is the rumor; tissue is the issue. Hematol Transfus Int J. 2016;2(4):77. DOI: 10.15406/htij.2016.02.00043

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Perspective

Hematologist and Oncologists face many challenges in their daily practice: delivering bad news, having end of life discussions, and navigating diagnostic challenges. Trying to care for a patient who has no resources for treating their malignancy brings another set of challenges and ethical dilemmas. An uninsured patient would be left with insurmountable medical costs from diagnosis and treatment. Would the treatment even be effective? Is it worth the financial burden?

A 77year old undocumented male with a history of hypertension and osteoarthritis recently presented for care. He initially sought attention in the emergency room for a two-month history of progressive left upper extremity swelling extending from 5cm proximal to the elbow joint to 3 cm distal to it. CT was obtained of the left upper extremity in the emergency room followed by MRI. Findings were consistent with soft tissue sarcoma. For staging, CT chest was ordered and showed multiple pulmonary masses and nodules consistent with metastatic disease.

The patient was discharged from the hospital with instructions to follow up outpatient with orthopedics for biopsy as well as with oncology. Because the patient was undocumented, he did not qualify for any payment assistance programs and required to pay out of pocket for each provider visit. He did, however, present to clinic for consultation. Remarkably, he was doing very well and showed excellent performance status, although he had not received routine health care prior to his emergency room visit. During this visit, the patient expressed concern about finances and feared burdening his surviving family with his medical debt. He felt that if treatment would prolong his life by maybe only a few months or even a year, it would not be worth doing.

Would it be worth it? A lot of questions came to mind. Certainly, this patient had metastatic cancer. His MRI and CT findings showed classic appearance and spread of a soft tissue sarcoma. Even with treatment, his survival benefit may not be great. Certainly, his disease was not resectable. Chemotherapy may prolong his life by several months or perhaps a year. Although he had good performance status, what would his quality of life be during this time? He would be on chemotherapy for the rest of his life. Would that life is worth living if the side effects left him incapacitated? Recently, research in health disparities has highlighted that patients of low socioeconomic status have poorer cancer-related outcomes than patients living in more affluent areas. Should this be considered?

Should I subject this patient to biopsy? If so, how would it change the management of his cancer? No new information may be obtained but a large bill would be amassed. Could any other diagnosis be considered? Given the typical MRI findings and spread of disease, I discounted any other remote possibilities. Even if he had a carcinoma, it would be incurable as well. After discussion with his family and after expressing much hesitation, the patient surrendered to his family’s request for biopsy. I felt relief. Not because I thought it would change the patient’s care, but pathology would allow me to make recommendations with confidence. His family pulled together and was able to provide the upfront payment for his biopsy by interventional radiology.

A few days later, the pathologist called me to discuss the patient’s biopsy results. I was shocked to learn that the patient did not have sarcoma, but in fact, a lymphoma. In a matter of seconds the patient’s dismal prognosis turned to excellent- high likelihood of cure even with distant disease. This was an important learning opportunity to share. We have guidelines to assist us with diagnosing and treating cancer. We learn to treat patients based on years of past research. We study typical patterns of disease to assist us in diagnosis. Sometimes, however, things are not as they seem. It is essential to treat each patient as an individual and as unique. Cancer treatment is reliant on many factors; pathology is essential. Tumor is the rumor, but tissue is always the issue.