Lessons From Pulmonary Nodules

Today, I was working in a Thoracic Surgery clinic.  The most common thing seen in thoracic surgery clinic – pulmonary nodules.  A pulmonary nodule is a lesion in the lung less than 3cm in size.  They are sometimes called coin lesions.  Second most common thing seen in the thoracic surgery clinic – lung cancer.  The thing is, pulmonary nodules could be early lung cancer… and when people get “spots” on their CT scan and get sent to see the thoracic team, they are “dying”.  Well, we are all dying, but more on that some other time…

The trend I noticed in the clinic today, like many others is that those with the nodules are more distressed than those with the cancer.  The people with the cancer diagnosis or strong suspicion, well, they have heard the “news” already.  Processing has occurred.  Questions have been answered to the extent they can be answered and the visit is to answer more questions, such as further management and such.  Pulmonary nodules… not so simple.  In my head, knowing what I know, I would much rather hear I have a 6mm pulmonary nodule than a lung cancer… or even a 2cm nodule.  The thing is any “shadow on the lung” is scary.  The scarier part for most people is that there is no answer for the pulmonary nodule on first visit.  They are generally too small to hit directly with a needle on one or two shots.  Thus, tissue diagnosis without being invasive is out of the question.  They are so small that even going in and doing an open procedure may result in difficulties finding the lesion and having it actually seen in pathology.   Plus, the uncertainty of the diagnosis combined with the risks of a surgical procedure… Eep.  The guidelines suggest following these nodules along for a while at intervals of 3-6 months to see if they grow.  Often, the people coming have had this done… Often the nodule is unchanged or has grown a millimeter or two… that doesn’t really help; CT image slices can cause that sort of discrepancy.  Sometimes the nodule does change greatly, but mysteriously shrinks.  Other times, it grows, consistently.  Those are likely cancer.  They grow to a size where they can be biopsied and removed, still in an early and potentially curative stage… usually.  The odd thing can go wrong.  Some cancers are strangely aggressive.  But, most of the time, the nodules are nothing, just scars from an old infection or irritation, or become nothing with intervention.  The scariest part of the nodule is the waiting, the uncertainty, the fear of the unknown and the thoughts of the worst-case scenario.  We provide reassurance and information and send them for repeat scans and visits.  Until the result comes back as officially  “not cancer,” which is something that is virtually impossible to confirm beyond a doubt, some people will not rest.  Now, I am not belittling the experience of a true cancer diagnosis and the process that goes into it.  Both of these are emotional and trying.  It is just interesting how our minds work.  How we can deal with so much, but the more we know or the more we think we know can prove to be a tool for us to cope.

A few things came of my thoracic surgery experience:

1.  The management of pulmonary nodules.  For more info see: http://radiology.rsna.org/content/237/2/395.long or http://emedicine.medscape.com/article/304534-overview

2.  We often let fear and uncertainty drive.  Whether or not we want to, a glimmer of something bad or unknown can often lead us into panic mode.  A fear of the unknown is probably a universal issue.  I think that it is probably a survival instinct programmed into us, so God wouldn’t have to stop us from walking off cliffs and poking bears and such.  If it exists in reasonable amounts, that is.  In our society, we have so many pressures to achieve, so much information thrown at us, so much available to us, that when a little uncertainty strikes, fear sets in.  A pulmonary nodule is something to have a healthy worry about.  But, what about my psychotic panic about residency applications, is that healthy?  What about our distrust of others?  When we let fear and uncertainty take the wheel, we lose a bit of ourselves, a bit of joy, a bit of freedom.  For instance, I could have hours of time back by not worrying so much about my residency applications.   Information can be the solution even if answers are lacking… reassurance from someone who knows more about the subject, it can tide you over until more is known or confirmed, like those getting follow-up for the nodules being told that the chances of cancer are there, but it will be early and caught if there is change.   God can do the same for us.  God promises to give us peace – “I have said these things to you, that in me you may have peace. In the world you will have tribulation. But take heart; I have overcome the world.” (John 16:33) – and to help us persevere – “May you be strengthened with all power, according to his glorious might, for all endurance and patience with joy” (Colossians 1:11).  I truly believe God can provide comfort in those times of uncertainty even when worldly answers are lacking.

3.  Not all surgery is terrible.  I do like thoracics clinics.  There were no procedures.  Always good.  There was a lot of oncology… Awesome.

4.  When things start to look bad, take action if you know what you can do to help improve things… If things are out of your hands, try watchful waiting.  I am all about getting involved.  Trying to work things out.  I am a people fixer.  Probably why I went into medicine.  I believe that as a Christian, I should step in and help those who need help practically or otherwise.  There are times, where it seems diving in is not advisable because it is too dangerous or there is uncertainty about a circumstance.  Perhaps then, watchful waiting is best.  I am not saying do nothing.  Like the nodules, it is important to keep watch, follow-up… don’t ignore the problem.  Watchful waiting in life can look like staying informed, praying for wisdom and direction, looking for ways to help more indirectly that can have an impact.  Perhaps, we sometimes need to watchfully wait to prepare for taking an appropriate course of action in a situation.

5.  Technology has some negative aspects.  Yes, it is awesome that these CT scans – often done because someone has had a cough or a couple pneumonias or whatever – can detect lesions as small as a couple millimeters.  We are detecting some cancers earlier.  Potentially saving lives.  The thing is, we are also causing some people to lose lives.  They are losing their life to worry and anxiety, to waiting at appointment after appointment to sort out that tiny spot only to learn it was nothing.  These scans, and repeated scans and the travel and physician/technologist time cost money.  There are debates about how sustainable the Canadian healthcare system truly is.  This is one of the reasons.  The cost of these scans.  It doesn’t always counteract the costs saved on the other end of earlier diagnosis.  Then, there are the long-term side effects.  CT scans are radiation.  I think radiation is fabulous… but, it comes with risks.  The exposure people are getting these days, especially those with serial exams can be significant.  When necessary it is a cost that can be outweighed, but what about the people who end up being well, just having an incidental nodule confirmed 6 scans later?  What if they end up with a chest cancer later in life?   The CTs may not have caused it, but perhaps they contributed?  Something to ponder.

6.  We are very afraid of cancer as a society.  Cancer is not the only thing out there that kills.  I am passionate about oncology and am aware it is a significant killer, but other things, some just as common and others rare are also big and bad.  We shouldn’t live in fear, but be aware that there are things worse than or equal to cancer.  I heard someone diagnosed with a fatal lung disease exclaim to us today “well, at least its not cancer.”  She likely would have lived longer if it were.  Cancer is more treatable than it once was, still deadly, but people live longer and better than before.  Some other diseases have not made that much progress.

I hope you have learned something from the pulmonary nodules.  I took away much more than I bargained for (and didn’t have to do procedures).  Here is a fantastic song by the Casting Crowns about fear.

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