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Oncologic Emergencies – 8 – Back pain

Oncologic Emergencies PART – 8

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)

Question:  Last time we discussed Back Pain as an emergency. 1. Back pain is a very common symptom in general practice. How to find serious back pain cases among these was discussed, with very practical pointers, and minimal investigations.2.  Many cancers present with back pain due to metastases to spine, and sometimes due to retroperitoneal nodes or mass. Most common cancers to present in this manner include prostate, lung, breast, myeloma. 3. NEW back pain has to be taken seriously in general, especially if moderate to severe. And requires at least minimal work up. 4. Any back pain associated with systemic symptoms signs, or neurological signs requires immediate evaluation. 5. Patient may develop cord compression in a short time, even if no neurological signs at presentation. Hence back pain is a potentially serious symptom. 6. Neurological recovery correlates with severity of paralysis and duration of compression. That is why early diagnosis is so important, to prevent lifelong disability.

But all these patients are stage 4 cancers, right? Hence even if we make an early diagnosis, they are not going to live long.

Ans: ABSOLUTELY WRONG! General perception in public for stage 4 cancers has also changed a lot compared to past. Majority of patients that I see, in stage 4, are not ready to stop treatment, even after they have failed several therapies. A newly diagnosed stage 4 cancer patient, that you are mentioning, almost rarely agrees to not initiate any anticancer therapy. Yes I agree that 100 percent of patients in this stage will not benefit from anticancer therapy. However a large majority will do, to some or more extent. For example, a newly diagnosed prostate cancer with bone metastases will easily live for about one year with excellent quality of life. And in many cases 2-3 years. That too with a simple, cheap, and very well tolerated treatment i.e. bilateral orchidectomy. Add to this so many new options for treatment, life span can be better with a good quality of life.

Also, wrong is the assumption that all these are stage 4 cancers and are incurable. Multiple myeloma also may present in this manner. Or Lymphoma. Lymphoma can be cured in many cases. Myeloma patient can live for about 10 years now in a large number of cases, based on options available today. Similarly Breast cancer has many options and highly variable prognosis, from few months to several years in stage 4. Same is true for lung cancer. And this is with current available options. We don’t know what the future holds!

Que: Sorry for being so negative. I agree that even in my OPD as a general practitioner, I see a definite change in perception. Very few people are now willing to give up without any treatment, compared to when I started practice few decades ago. And yes I do remember patients from my own practice, who have beat the statistics. They are alive after so many years of cancer diagnosis, and doing fairly well. And so many who did not survive years, but lived a very satisfied life for them and family both, after a stage 4 cancer diagnosis. Unfortunately, we see many patients who are very poor, and for them cancer treatment is a big financial burden, especially in palliative setting. But we have to remember that all patients are not poor. In fact, India now has a large middle class, many have mediclaim or reimbursement from their employer. Even for poor patients, there are ESIC, Ayushman Bharat or other schemes etc. And of course government hospitals including specialty cancer hospitals from government or trusts.

Ans: You have summarized problem well. India is no longer a country of mainly poor people. There are many different options for resources. And every patient deserves at least one chance, to make sure we are not ruling them out of treatment based on some assumptions about cost, results…

Additionally, as discussed in last part, neurological recovery is critical for quality of life, even if for few months. For both patient and family. Imagine a patient lying in bed for 9 months of his remaining life with bowel and bladder incontinence and bed sores….Versus same patient walking, independent for his activities of daily living, visiting family and friends for remaining 9 months of his life! What a huge difference! This can be achieved only with early diagnosis and timely treatment. Treatment may be in terms of just steroids initially, radiotherapy, or occasionally surgical decompression. And in certain cases, chemotherapy or other medical options.

Most of the options noted for neurological recovery are fairly low cost, covered by insurance, or available in trust or government hospitals. This initial part can be managed fairly well even in a non cancer hospital.

July 14th 2020.  Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com

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