Sally’s Dilemma

Sally is about sixty. She was widowed a couple of years ago. I usually only see her once a year for her routine physical. She and her spry eighty-four year old mother always go together for their annual mammogram.

When Sally came in for her physical a while ago, her blood pressure was up. I didn’t act on it then, but did some blood work and brought her back a few weeks later for a recheck. Her pressure was still up. I made the judgment call to pursue this further instead of just treating her pressure, and ordered an ultrasound of her kidneys with an office follow-up. A blood pressure that suddenly goes up can be a sign of an underlying problem such as poor circulation to the kidneys. We often look for “secondary hypertension” when the clinical picture isn’t typical for “essential hypertension”.

Sally’s renal ultrasound showed normal size of both kidneys, but one kidney had two suspicious areas in it, which could be either benign or malignant. The radiologist recommended a CAT scan. Sally wasn’t thrilled when I called her to let her know the results; she generally doesn’t like to have a lot of tests done, but now we had the possibility of kidney cancer versus something harmless. She agreed to the CAT scan, which required intravenous contrast.

A few days later the report came in. My heart sank. The larger of the two kidney lesions was benign looking, but the smaller one looked suspicious and was too small to completely characterize on the scan – follow-up was suggested (how soon, I wondered…). But there was more: The head of the pancreas looked a little enlarged, and the bile ducts were a hair wider than usual. A dedicated pancreas CAT scan was suggested in order to rule out pancreatic cancer.

The follow-up appointment we had scheduled at the beginning of this process was three days after the CAT scan. I looked her straight in her eyes and told her about the small suspicious area in her kidney and the suspicious looking area in her pancreas. She moved her head back in slow motion and moved her hands up toward the ceiling and said:

“You know my husband died from pancreas cancer? I watched him go from a big, strong man to nothing in five months, and his sister died from the same thing! If this could be pancreatic cancer, I don’t think I want to know!”

“And if it isn’t, wouldn’t you want to know if you have a small, curable kidney cancer?” I asked.

“I don’t know,” she said, “what would I tell my mother? I don’t know if she can handle this.”

“Would you be OK with getting an opinion from an oncology surgeon before you say no to the pancreas scan?” I asked. She agreed, reluctantly. I have a call in to Dr. G.

Sally needs more answers than I can give her right now.