Absolute Risk

Gladys Peppercorn was in to see me the other day, very concerned about a letter she had received from one of the Cityside gastroenterologists.

In very formal words, the letter said the GI office had tried several times to reach her in order to schedule her next upper endoscopy to monitor her Barrett’s esophagus and would she please call them back to schedule the procedure so they could monitor her for her increased cancer risk.

“You know me, I don’t want any unnecessary procedures”, Gladys said as I read the letter she handed me. She had only gone for the test two years ago because she had experienced heartburn for years, and at that time certain foods had been a little difficult to swallow. Her test really came out okay except for the Barrett’s esophagus. Her biggest problem with swallowing was some age-related stiffness of her esophagus.

Gladys’ age was not apparent when I looked up from reading the letter. Ninety years old in just a couple of weeks, she looked radiant, healthy and on top of the world in her purple silk blouse and khaki slacks.

“I do hear you, and I’m going to do some math with you”, I said as I pulled my chair over next to hers and minimized the EMR on my tablet computer and opened UpToDate, the medical database from Boston many doctors use as a reference.

“Okay, here are the numbers”, I began as we both peered at the small screen.

“Having Barrett’s increases your risk of esophageal cancer 30-fold”, I said, pointing at the website. Her eyebrows rose slightly. I continued:

“That would be like me saying that wearing purple increases your risk of getting hit by lightning 30-fold. Would that stop you from wearing this blouse?”

“No, it’s my favorite color”, she smiled.

“And thirty times nothing is nothing!” I concluded. She agreed.

“Look here”, I pointed. “Studies have shown between 1.2 and 4.3 cancer cases per 1000 person years in people with your condition. Let’s exaggerate and call it 5 cases per 1000 patient years. That means that out of a hundred people like you, in the next ten years only five would get cancer and 95 would not.”

She nodded slowly.

“So you have at least a 95% chance that you will not get esophageal cancer in the next ten years, probably more in the order of 96-98%.” I continued: “And then you have to weigh that risk against the risk of anesthesia or the procedure itself causing you harm in some way.”

“I know I don’t want the procedure!” Gladys smiled and rose from her chair. I quickly got up, too. She stretched her hand out toward me and thanked me.

“I always feel better after talking to you”, she said.

I shook her hand and thought that she probably used to wear white lace gloves on warm days like this when she was young.

2 Responses to “Absolute Risk”

  1. 1 Jen May 28, 2013 at 11:45 pm

    I happened upon your blog when searching for warfarin dosing adjustments. It seems to be a very interesting blog and very well written. My reason for replying to this post was to inquire about your acknowledgement of the HIPAA policy and whether you are changing the names of your patients you discuss on your blog.

    Just wanted to bring this to your attention.

    More information can be found here: http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

    • 2 acountrydoctorwrites May 29, 2013 at 2:01 am

      Of course.
      I spend a fair amount of effort re-weaving the material to a cloth of different appearance but similar texture.

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