Cancer diagnosis

GPs view of diagnosis and treatment

Bruce ArrollDept of General Practice and Primary

Health care School of Population Health

Disclaimer• Asked to talk about experience• Some in audience may have had worse health

experiences• AML is rare and there may be some interest in

the treatment aspects

Diagnosis• Pharyngeal pain 1 month• Difficulty in swallowing• Practice meeting in public holidays• Partners think they can see something and so

can I • Email ENT classmate offers to check • Referred to public system –CT scan normal

apart from lump on tongue

Two biopsies• GA for biopsy• Preop/post op very friendly to everyone

– no special doctor treatment • ENT surgeon going overseas so phone call to

say possible lymphoma• 10 minutes later at Uni farewell and colleague

asks how biopsy went : decide on everyone knowing or no-one knowing

• Tell people –the word is out so pass it on

Diagnosis• Needed bone marrow biopsy – painful • Needed lumbar puncture not painful

– Colleague advised me to enjoy the pain and not resist

• Registrar says I have acute myeloid leukemia on my tongue but not in the bone marrow- no other cases in the literature

• Gap to getting treatment knowledge – hematologists have a conference

Toxic uncertainty• Will I be dead in a week or live to 90• Appreciation of what patients go thru• Relief to know that will only get chemotherapy

and not radiotherapy (teeth issues)• Although bone marrow clear will get ¾ rounds

of chemotherapy• Inspired by a patient who wanted

chemotherapy for her bowel cancer• Adopted a “bring on the chemotherapy”

Getting the hardware• Insertion of a Groshong line in to chest. Goes

in to the superior vena cava • Done by radiology in small operating room• Some fentanyl and meditation and enjoy the

pain • Sits in chest indefinitely

– Two ports– Can infuse chemotherapy – Can take blood– Can give blood

Removing the hardware• Klebsiella infection on Groshong• Removal like pulling a weed from the garden

– Not painful just alarming

Single room or 4 patient room• Given choice most would take single room • For cyclical treatment advantage of 4 patient

room – Education – company

• For cyclical treatment advantage of 4 patient room

• First impression– We are all up the same creek –instant camaraderie

Starting chemotherapy • Daunorubicin (red) and cytarabine• Nurses (? Informal meeting) decide to treat me

a normal patient rather than a doctor• Suited me as I was pretty clueless about what

was happening• Except when inserting IV lines later saying

doing this to a doctor made them nervous• Told I would need blood and platelet

tranfusions and get infections• Wont happen to me!!!!!- 10 of both

Chemotherapy • Red chemo causes red urine• Blue chemo causes blue urine• No vomiting –most amazing

– Ondansetron • Historically patients would vomit the whole

time• Took anti-nauseants happily as too afraid of

nausea

Aim of chemotherapy • “Wipe out” the bone marrow• Kept alive with transfusions and antibiotics• When bone marrow restarts they “wipe it out”

again

First infection • A few days after completing first treatment

admitted with ‘infection” and neutropenia

Infection versus septicemia• Admitted for infection

– Main risk is own flora not that of others• Colleagues “ingrown toenail versus

septicaemia” • Neutropenia and fever• Don’t usually grow bacteria• Klebsiella called bacteremia• Mortality for treatment 5%

– For BA 1%

Platelets• What level safe to go to gym• 50 ???!!!• BA would consider rapid referral of someone

with platelets of 50. Can do eye surgery at about 80

• 4th standard deviation world

Allergic reaction• 4th cephalosporin and gentamicin• Maculo papular rash on trunk –non itchy• Decided later to try gentamicin • I was amazed that they still use it

Other effects

• Hair loss • Most people bald on ward

Cancer out patients • Got to like going there –contrast to ward I was

not sick • “major stress” – 3hrly temperatures• “Forced retirement” – social contact

– More understanding of patients

Sign that is was over • Next slide

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