OK – this case is for all the GPs and Internal Medicine types out there. This is a relatively common scenario… how do you play it?
Here’s the case.
Bruce is a 53 y.o. accountant. He is a little overweight at 89 kg (BMI 31). He is otherwise relatively well, he cycles to the cafe each morning in lycra and drinks a cappuccino in his helmet… why do they do that?
He has hypertension which is controlled by ramipril 5 mg daily. No other meds or relevant medical history. He is interested in his health and even has annual “Mens’ Health checks”. He was in last month for one – which was unremarkable other than a borderline BP and his prostate screen (post full consent and shared decision-making) revealed a normal DRE and PSA level.
Today he has come to see you with a discharge letter from the local hospital. He was admitted for work-up of “unilateral leg swelling” which occurred spontaneously last Friday.
The letter reads:
Dear Dr Leeuwenburg,
Thanks for following up Bruce who had an unprovoked DVT diagnosed on Doppler. US showed a 5 cm proximal DVT at the Femoral-saphenous junction (L) leg.
He also had a series of tests: FBP, UECr, LFTs, Ca, Mg, PO4, CRP, TFTs, a prothrombotic screen was unhelpful and serum rhubarb – these were all normal. WE did a CXR to be sure and this was also reported as normal.
Bruce was commenced on enoxaparin until his warfarin was therapeutic. He’s on 8 mg nocte with an INR of 2.3 today . Please chase his subsequent INRs
Oh – and – please screen for occult malignancy as we have not found anything yet.
So Bruce is sitting in front of you looking a bit worried. He says that he feels fine, and the leg swelling is improving. He was a bit spooked when the “young-looking” hospital doctor told him that DVTs “like this” are usually due to some underlying problem “like cancer”. He really wants to know what to do next. Does he have cancer?
OK – so here are my questions to you:
Q1: What is the chances that Bruce has an occult malignancy?
Q2: what screening tests, inquiries, imaging etc would you recommend / order for Bruce?
Specifically will you get a CT of the torso?
Q3: Does it really matter if he has an asymptomatic cancer? Will it reveal itself in time anyway?
Let me know your thoughts…
But in case you were wondering. Here is the link to the recently published SOME trial out of Canadia in the NEJM in June 2015
They looked at a limited vs. “limited + CT ado-pelvis” strategy and found not much difference. Both groups had about a 1% cancer rate at work up and had a similar “diagnosis rate” of cancer in the following year. So the CT didn’t help reduce the time lag to diagnosis much.
However, there is of course a risk of finding incidentalomas and the harms associated with those and their further IX or Rx…
So for me it si back to simple thorough Hx, Exam, do the things you would normally do for a 50 yo bloke and watch him. Really a great case for Shared decision-making here now that we have some rough numbers that we can present to the patient as risk ?