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Incidental findings

DHANVANTARI by BUDDHA BASNYAT, MD


The legendary founder of Apple Inc, Steve Jobs, died of pancreatic cancer. This diagnosis was an "incidental" finding. Jobs was being investigated for kidney stones several years ago when the radiological scan of his abdomen revealed he had a more sinister problem, a tumor in the pancreas. He had no symptoms or signs of pancreatic cancer, and yet there it was on the scan. Doctors call this kind of unexpected discovery an "incidental finding". With the proliferation of elaborate investigative methods, this kind of a surprising discovery is all too common, which often leads to a dilemma for the physician and the patient. Do we treat the problem or not?

Of course, in Job's case, many cancer doctors would argue to treat the problem. In reality Steve Jobs, possibly because of his life-defining trip to India prior to his stunningly- successful entrepreneurial ventures, decided to eat more fruits, turn into a vegan and pursue acupuncture and alternative medicine after the diagnosis. Only after several months did he undergo pancreatic surgery. In many instances there may be a real confusion about what to do next after an incidental finding.

For example, a patient after a mild head injury was told by his doctor to obtain a CT scan of the head. The scan showed no adverse effects of the injury but revealed a very small benign tumor (an adenoma) in the pituitary gland in the brain. Clearly an incidental finding. What is known in medical literature is that these unsuspected adenomas are commonly present in up to 25 per cent of all autopsies and possibly cause no harm during the lifetime of the patient. Now, does this head injury patient continue to check for the increased growth of this adenoma with expensive, annual CT scans?

Indeed, sophisticated tests these days may lead to more tests, anxiety, and unnecessary surgical procedures with their added risks. A very common finding in Nepal is when doctors order an ultrasound of the abdomen, gall stones may be detected in a patient whose symptoms may not correlate with gall stones problems. Often patients are subjected to needless gall bladder surgery based on ultrasound findings which may not address the patient's main problems. With more sophisticated testing, diagnosis and treatment may not be as clear-cut and precise as both the patients and doctors would like to think. Sometimes the contrary is true.

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1. Nepali Doc

Dr Sab,

There are evidence based guidelines for some "Incidentalomas"-like Adrenal adenomas(http://www.guideline.gov/content.aspx?id=15764). For others,there simply arenot evidence based guidelines but expert conseus do exist to guide physicians.Though good quality evidence based guidelines are desirable,physicians (who have been through several years of medical training )should be able to use their clinical judgement.The most important thing is to have an honest discussion with the patient about lack of robust evidence, then uncertainty of benefit and potential harm with intervention.

Just to clarify things,Steve Jobs had Pancreatic Neuroendocrine tumor(PNET) and not the more common pancreatic adenocarcinoma(which is extremely lethal within a year or two).It is unclear if Jobs lived longer  by having detected PNET sooner as no drug/surgery has been found to prolong survival(even the new ones approved by FDA-affinitor and Sutent).



LATEST ISSUE
638
(11 JAN 2013 - 17 JAN 2013)


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