When doctors disagree

SINGAPORE - What doctors do is as much an art as it is a science. I feel this strongly when there is disagreement among colleagues.

It was a Friday afternoon when Danielle walked into my consultation room, with a warm smile despite the long wait.

She came to see me to confirm that she was on the right track. The 40-year-old had been scheduled for an operation for stomach cancer on Tuesday.

I tried to put her at ease with friendly banter as it is important not to be rushed and to get the full story.

Danielle's story dates back to last November when she started experiencing pain in the epigastrium (upper part of the abdomen).

She did not think much of it initially, but decided to see a doctor when the symptoms persisted despite taking anti-gastric medicine.

In January, using a simple breath test, the doctor diagnosed her with a stomach infection caused by a fairly common bacterium called Helicobacter pylori.

In the majority of patients, a one-week course of triple therapy (so called because it employs a combination of three drugs) is adequate in eradicating the bacteria.

Up to 20 per cent of patients will develop gastric ulcers in their lifetime. Of greater concern is the 1 to 2 per cent who develop stomach cancer or lymphoma of the stomach.

Danielle's infection failed to clear, despite her completing the triple therapy.

In April, she underwent gastroscopy. A fibre-optic scope is inserted through the mouth, down the gullet and into the stomach. This allows the doctor to look directly at the inner lining of the passage to see if there are abnormalities such as bleeding, ulcerations or tumours.

The gastroscopy confirmed that she had cancer of the stomach.

By then, she had lost 3kg or about 5 per cent of her normal weight.

Difference of opinions

Difference of opinions

A computed tomography (CT) scan of the chest and abdomen was carried out. The radiologist found some enlarged nodes around the stomach and that the stomach wall was thickened. These are common findings in stomach cancer patients.

What was rather unexpected were findings of enlarged lymph nodes in the left lung and some streaky shadows in both lungs, raising the possibility of metastatic disease, or cancer spread.

Danielle was referred to a general surgeon with an interest in stomach cancer and a medical oncologist.

Both felt that the cancer was localised and that she should have surgery to remove part of the stomach with the cancer.

Although almost convinced, she wanted to be absolutely certain by seeing another surgeon and medical oncologist.

She located another general surgeon who specialises in stomach cancer. After reviewing the medical records, he too agreed that surgery was the appropriate treatment.

"So, what do you think?" she asked.

I paused and thought carefully before I advised her to go for a positron emission tomography-CT (PET-CT) scan before the planned surgery on Tuesday.

It was obvious from the expression on her face that this was not the answer she was expecting.

Three other doctors had advised her to undergo surgery and she had mentally prepared herself for it.

"Are you saying that the three doctors are wrong?" she asked incredulously.

I explained that medical advice is dispensed based on clinical judgment.

The judgment of the three doctors was that the CT findings in the chest were unlikely to be of clinical significance.

I had the highest regard for these doctors, but I had a niggling feeling that we should not ignore the radiologist's report.

"After all, what is there to lose by doing a PET-CT scan? Surely the cost and morbidity of unnecessary surgery far outweigh the cost of a negative PET-CT?" I asked.

She could be scheduled for the scan on Monday morning and would have her results in the afternoon.

If the scan did not find any metastases, she could still go for the scheduled operation on Tuesday.

Unnecessary surgery

Unnecessary surgery

Danielle agreed to the PET-CT scan.

It showed metastatic disease in the lymph nodes in the chest as well as in many bones all over her body.

I explained to her that surgery was no longer justifiable because of the widespread disease and the absence of significant symptoms from the primary tumour.

Danielle saw another surgeon, who agreed that the operation was unnecessary. She has since been started on palliative chemotherapy.

Other patients sometimes do go through unnecessary surgery.

I recall an Indonesian woman who was referred to me by a gynaecologist after he had removed her uterus and both ovaries for cancer of the uterus.

After the surgery, he carried out a PET-CT scan which showed that the cancer was stage 4, as it had spread to distant lymph nodes and the liver.

I had an awkward time explaining to her that the surgery had been unnecessary.

Difference of opinions is not uncommon in medicine.

Doctors are sometimes put in the uncomfortable position of disagreeing with their colleagues.

In many cases, there is no outright correct answer. In others, the right answer may come a little too late.

With better scanning technology and diagnostic tools, hopefully these cases will soon be few and far between.

angpt@pcc.sg

Dr Ang Peng Tiam is the medical director of Parkway Cancer Centre. He has been in practice for 30 years. In 1996, he was awarded Singapore's National Science Award for outstanding contributions to medical research.


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