Real-Life Decision Making
Dr. Joanna Chon, a urologist, loves her job. But she admits that there are tough decisions to be made regularly in her profession.
"The most common thing that arises in urology is prostate cancer. It is one of the major illnesses we deal with. Even if prostate cancer is diagnosed early, there's a lot of options for treatment -- surgery, radiation therapy, or just waiting and watching, symptomatic treatment. So the toughest thing I think is the dilemma of helping patients choose which therapy is best for them," she explains.
"You look at the percentages to see which treatments are likely to work the best and at the statistical outcomes of real patients in the past, and you look at the biopsy results. But not every patient falls neatly into one classification or another."
You are a urologist. A white male in his mid-30s named Kevin Clark has made an appointment to see you. He is complaining of urinary problems. He also has abdominal pain, lower back pain, fatigue, shortness of breath and loss of appetite.
You give Mr. Clark a physical examination. You know that his symptoms may point to testicular cancer. This kind of cancer is the most common type of cancer in men between the ages of 15 and 35.
You also know testicular cancer is much more common in Caucasians than in African-Americans and that it is usually diagnosed when a man is in his mid-30s. Looking at Mr. Clark's medical history, you also notice that his father had testicular cancer.
An examination of Mr. Clark's testicles reveals that his left testicle is swollen and that there seems to be a painless hard lump inside. Normally, you would first prescribe a course of antibiotics to Mr. Clark to see if this makes the mass in his testicle go away. Success by the antibiotics would rule out cancer.
Mr. Clark's other symptoms worry you, however, so you decide to order some tests right away. Mr. Clark undergoes ultrasound imaging and chemical analysis of his urine and blood. The results of these tests make you suspect that your patient may indeed have a cancerous growth.
You tell Mr. Clark that the next step is to remove the testicle that has the lump in order to perform a biopsy, which is a test on the actual tissue that is suspected to be cancerous. You explain that removal of the testicle is unavoidable because it is the only way to get a clear diagnosis.
Mr. Clark is very hesitant to undergo surgery. You explain that if he does have cancer and they find it right away, his chances of a full recovery are very good. If not treated, testicular cancer can spread to the lungs, the liver, the bones and possibly the brain. If the cancer has already spread to nearby organs, Mr. Clark would have an excellent chance of surviving for five years, but after five years there would be no guarantees.
You also explain to Mr. Clark that the removal of one testicle usually does not cause infertility. But because further treatment may cause infertility, you do advise him to bank some of his sperm for future use.
Mr. Clark, it turns out, is not a fan of surgery or traditional medicine. He believes in alternative medicine, such as acupuncture, herbs and positive imaging. He also doesn't like to take drugs, but he would be willing to take something for the urinary problems and other symptoms.
You explain again to Mr. Clark that the only way to be certain that he has cancer is to remove the testicle and perform a biopsy. Finding the cancer and being aggressive about its treatment will give him an excellent chance of being cured. Nearly all testicular cancer patients achieve remission when treated aggressively. Also, in most cases only one testicle is affected.
You believe from all the evidence that Mr. Clark does have testicular cancer and that it may have already spread to other areas of his body, but he wants to know if you can just treat him for his symptoms. He is very insistent that he is not a candidate for surgery.
If Mr. Clark really wants to fight his physical problems using alternative medicine, then doesn't he have a right to do that? This is not the first time you have dealt with this type of situation. How hard should you push the patient to follow your recommendations?
What do you do?