Competing mortality in cancer screening: a teachable moment.

Story From the Front Lines A70-year-oldmansawhisprimary care clinicianandexpressed concern about his lung cancer risk after learning a friend had recently died of it. The patient had had an 80-pack-year history, and had quit 7 years previously. His physician ordered a screening chest computed tomographic (CT) scan, which demonstrated a spiculated 12-mm lungnodule thatwasnewwhencomparedwithscansdonepreviously forother reasons.This promptedapositronemission tomographic scan,which showedmetabolic activity, raising the suspicion for lung cancer. He was referred to a pulmonary-nodule clinic. The man presented to the pulmonary clinic in a wheelchairwhile receivingcontinuousoxygen.Hismedicalhistory revealedseverediastolicheart failure; chronic obstructive pulmonary disease; obesity (his bodymass index,calculatedasweight inkilogramsdividedbyheight in meters squared, was 54); diabetes mellitus with microvascularcomplications, includingstage III chronickidneydisease;andperipheralneuropathy.Additionalmedical history included several recent falls attributed to progressiveneuropathyanddeconditioning.Theseconsiderations were discussed with the patient and ultimately, invasive diagnostic testing was discouraged. A conservative plan that included a repeatedCT scan in 4 monthswasmutually agreed on. Twomonths after this visit, thepatientwasadmittedand treated forpneumonia. While recovering in the hospital, his primary team noted that this nodule had not undergoneworkup and he had another CT scan, which demonstrated interval growth. Hewas scheduled for an outpatient CT-guided biopsy. Prior tothebiopsy, thepatientwasrehospitalizedfor pneumonia, this timerequiring intensivecareunitadmission. His medical history was addressed at a multidisciplinary thoracic tumor conference.Hewasnot a surgical candidate, and attempts to biopsy the nodulewere also considered tobehigh risk. Therefore, hewas referred to radiationoncologytodiscusstherisksandbenefitsofempirical radiation therapywithout a tissue diagnosis. Prior tomeetingwithradiationoncology, in follow-upatanoutpatient clinic 2 weeks after discharge, he had increasing dyspnea,wasdelirious,andwasthoughttoyetagainhave pneumonia.Hewas ultimately referred topalliative care for consideration of hospice.