Chapter 19

### The Patient's Story

Ms M is an 83-year-old, nulliparous woman who lives in her own home with a friend of 50 years' duration. She presented to Dr D with a list of concerns, one of which was a new set of skin lesions on her abdomen. Dr D immediately suspected metastatic cancer and scheduled a fine needle aspiration for that day. The pathological finding was an unusual lipoma.

A couple of weeks later Ms M saw a nurse practitioner who works with Dr D for evaluation of abdominal discomfort; the physical examination findings were normal other than the skin lesions. Three weeks later, she was admitted to the hospital with abdominal pain, nausea, and vomiting and was found to have an infiltrative narrowing of the colon, from the cecum to the midtransverse colon. Biopsy results showed adenocarcinoma in a single-cell infiltrative pattern suggestive of gastric origin. The partial bowel obstruction resolved clinically, and she went home with a plan to keep stools loose to prevent recurrence of obstruction. The patient and physician had a thorough discussion of chemotherapy vs comfort-oriented therapy. The patient was inclined toward comfort care, but she felt she should "do something" because she feared her many caring relatives would "have regrets" if she did not. On a hunch, Dr D asked the pathologist to look for estrogen receptors in the biopsy specimen given the uncertainty of the primary tumor (even though the findings of the breast examination and mammogram were both normal). Interestingly, the cells were 40% estrogen receptor positive, so, as an alternative to chemotherapy, Dr D offered her an empirical trial of tamoxifen, which Ms M accepted with some relief at escaping chemotherapy. At that time, Dr D told Ms M that she thought her prognosis was on the order of months; she estimated that Ms M would probably die within 3 months. To Dr D's surprise, Ms M stabilized despite some initial weight loss, and the lesions on her abdomen shrank and disappeared.

### Perspectives

Ms M and Dr D were interviewed by a Perspectives editor 33 months after the 3-month prognosis was delivered.

DR D: Ms M was first admitted with a bowel obstruction, and it became apparent that she had metastatic cancer. I'd suspected this at a previous visit because of some skin lesions. What I told her at the time was that I thought [her life-expectancy] was on the order of months. The pathologists were telling me that it was probably a gastric primary, which has an even worse prognosis. I expected her to go downhill quickly…At the time, I didn't think there was a whole lot of doubt about the prognosis, frankly.

Her reaction to the news was shock and that surprised me. It was a shock to her that at the age of 83 she might die sometime, which really surprised me because at that age, ...

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