We Need To Talk About Your PET Scan

This is not funny, so if you’re not in the mood for some serious, come back later.

Yesterday was my last day of inpatient medicine for the entire year. I have two weeks of outpatient clinic left and a shelf, but for all practical purposes we’ve completed our clinical year. It’s terrifying to think that in a typical curriculum, I’d be applying for residencies right now. Oh god.

The night before my last day, my team admitted a gentleman, whom we’ll call Mr. P. He came in after hours with a months-long history of difficulty peeing and some blood in his urine. Why he chose to address this in the ER in the middle of the night, I have no idea.

(I have, of course, changed many details here for privacy reasons.)

Mr. P, like many 75-year-olds who regularly visit a tertiary care center, had multiple medical problems. Chief among them were a prostate cancer many years ago. He was treated with brachytherapy, a procedure where a urologist implants small radioactive beads into the prostate, irradiating the tumor from the inside out. It’s safe and works well, with excellent long-term survival rates. Mr. P, unfortunately, had some complications from the procedure: his ureters, the tubes leading from the kidneys to the bladder, were slightly damaged and required stents to prop them open so urine could continue to flow.

I know, medicine is gross.

The ER doctors were originally concerned that he had a recurrent block of his ureters. They ordered a CT scan, which incidentally showed nodules in his lungs that hadn’t been there before, but no block of his ureters.  When we assumed care of Mr. P that morning, the overnight resident was mildly concerned for cancer but not all that worried. The lung nodules were probably inflammatory, or histoplasmosis, or nothing at all.

Just to be safe, we ordered a PET scan.

A positron emission tomography scan is a marvel of modern medicine. A technologist injects a special solution of glucose – sugar – into the patient’s vein before the scan. The glucose itself has been modified, adding on a radioactive isotope of fluorine. It’s a little like putting a bumper sticker on a car. The radiation isn’t enough to be damaging, but the PET scanner can pick it up. Cells can’t even tell the difference between the fluorinated sugar and the regular kind.

All cells use sugar, but highly metabolic cells – like brain tissue – take up more sugar than their neighbors. Tumors in particular suck up glucose like yours truly in front of an unlimited supply of Reese’s peanut butter cups. Combined with a CT scan, a PET scan can show you where clusters of sugar-gobbling, greedy cells – possibly tumors – are located.

While Mr. P was in line for his scan, we went to visit and chat. We found a sinewy man with a neatly trimmed white beard, wispy hair, and rheumy blue eyes. He looked tired but alert, wearing a tube in his nose for oxygen. I remember his grip when I shook his hand.

We explained that we thought he probably had a blockage of his ureter again that we just couldn’t see on the CT, and that we were going to rule out any “badness” – my attending physician’s words – before talking to the urologists about going back in to re-stent his pipes.

When we were leaving, Mr. P’s son stopped us at the door. “I don’t know if you know this, but he didn’t just work at a tire processing plant like he told you. He also spent some time working around radioactive waste…” he trailed off, worry lines creasing his forehead.

My attending thanked him for telling us. There was nothing really more to say at that point.

Out in the hallway, my attending looked at the resident and said, “I don’t think this sounds very good.” We just looked grimly at each other before moving on to finish rounds.

After rounds, I sat down in the workroom to see that the scan had been performed but had yet to be read by a radiologist. We pulled it up on the screen.

You didn’t need to be a radiologist, or even a doctor, to see that there were all sorts of spots where there shouldn’t be any. He had clusters of “high avidity” in his lungs, kidney, and in lymph nodes all over his body. He even had one in a spinal vertebrae, right near the nerve that controls urination. That explained his difficulty going to the bathroom.

I showed my resident, who just sighed and said, “that’s unfortunate.”

With the diagnosis presumably made, I set about writing my notes for the day and forgot about Mr. P. (It’s a reality of hospital medicine that cancer is commonplace and you never have time to dwell on a new one. The story, up until now, is sadly typical.)

After a morning class, the resident got a page from radiology that the “official read” was up from them and asked me to pull it up.

The report was littered with phrases like “innumerable masses” and “highly suspicious for malignancy.” No surprise there.  I put on my Interested Medical Student Face as we discussed whether this was a recurrence and spread of his prostate cancer or a new lung cancer from his radioactivity exposure. It would be impossible to tell without a biopsy, so we scheduled him for a visit with the oncologists. Since he was peeing better on some medication, we decided to send him home until that appointment.

“Nate, will you go down and talk to Mr. P about his PET scan?” the resident asked.

Uh oh.

“What do you mean, talk about his scan?” I replied, a pit forming in my gut.

“Just go down and tell him what the scan showed, and that we are sending him home until an appointment with the biopsy people next Wednesday,” she said, picking up the phone to call someone about another patient. “John [the intern] is off today and normally I’d have him do it, but you have to learn sometime, right?”

She was referring to learning how to deliver bad news.

You might be interested to hear that we are pseudo-formally trained in Delivering Bad News 101. Part of our first- and second-year coursework includes sessions on empathy, interpersonal communication, and story-sharing about how and when and in under what circumstances we should tell patients that they are going to die. We also see attendings and residents do it firsthand. In truth, medical students are rarely the ones taking on these roles – it’s usually reserved for people with “MD” after their name.

Appropriately so. I’m not sure why I was doing this.

But my resident was right. I was going to have to learn sometime.

I made the walk down to Mr. P’s room trying to think of what to say. Do I just blurt out, “You have cancer, again?” Or do I dance around it and try to defer until the biopsy?

After foaming in I entered the patient’s room. Since seeing him that morning, two younger relatives had both arrived and were perched bolt upright in their chairs, owlishly staring at me.

“Hi, I’m Nate, the med student on the team taking care of Mr. P. And you are?” It was his son and daughter from out of state. They had driven three hours in the early morning to join their dad.

I pulled over the bare metal chair sitting in the corner to the bedside.

“Mr. P… we need to talk about your PET scan.”

He just looked at me, waiting.

I cleared my throat. Now what? I had no plan. There was no right multiple choice answer here. No shelf questions talk about this. I was, in Bill O’Reilly’s classic words, doing it live.

I decided to be blunt. “Your scan was very concerning for cancer in your lungs, spine, and kidney. We can’t be sure that’s what we’re dealing with yet, or what kind of cancer it is, but I have to be honest with you – there isn’t much doubt that it’s metastatic cancer.”

Mr. P and I just stared at each other. “Okay, so what do we do now?” he said, in the same tone of voice you’d use if your car mechanic told you that your ‘driveshaft manipulator luke skywalker converter was operating at 30% capacity.’ He didn’t understand.

“Well, the next step is having our interventional radiology colleagues do a biopsy of one of the lung nodules, but they want to do it on an outpatient basis so you don’t have to stay in the hosp–”

The son interrupted. “So you’re sending us home?”

“Yes,” I said, unsure if this was a good or a bad thing. “They can’t do it today, so we thought it would be better to let you rest at home instead of holding you here. It’s not an emergency, which is a good thing. You have time.”

We all sat in silence for a few seconds. Time.

“Okay,” said Mr. P.

The daughter looked up. “So what now?”

“I’d expect the biopsy appointment sometime next week,” I said. “They’ll call you to make the appointment.”

“No, I mean, with the cancer. What’s the prognosis?”

This was the question I was dreading. I knew what his scan meant.

“Well, it’s hard to say. It depends on what this is. If it’s a recurrence of his prostate, there is some treatment we can do, and if it’s something else…” I stumbled. “Basically, we’d like to wait until we get the biopsy results before deciding on the next step.”

“Cross that bridge when we come to it, right Dad?” said the son.

“Right,” I replied, thankful to be let off the hook.

Mr. P stared at me. “It’s terminal, isn’t it?”

Shit. Yes, it most probably is. I spoke slowly, with much more confidence than I felt.

“I really can’t say for sure just based off the scan. I’m not an oncologist, and I want to be as sure as I can to give you the right information. But I also don’t want to sugarcoat anything. If this is cancer, which we aren’t sure it is… well, our treatments for cancers that have spread to many organ systems like yours are limited, but depending on the kind of cancer you could see results, shrink the cancer, and live many more years before it comes back. But you also might not. I’m sorry that I don’t have the numbers, but at this stage we can’t just cut it out like we did before. There is no cure.”

The last two words hung in the air. No cure. The son, a large bearded man wearing a T-shirt that read, “I PLEAD THE 2ND” next to a picture of an assault rifle, had tears in his eyes. The daughter sat staring at her hands.

I had nothing else to say. “I’m very sorry to have to tell you this. I can only imagine what a shock this must be. What questions do you have?”

Mr. P said nothing for a few seconds until turning his hands up in the universal gesture for “welp,” and said, “I’m 75, at least.”

Silence in the room. The undercurrents were obvious. I didn’t know what else to do, so I shook Mr. P’s hand. His grip was just a little less strong.

Then I left.

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