Uncertainty, Acceptance and Trans-Atlantic COPD

I taught some 4th year medical students last week, in my bronchiectasis. We saw a variety of patients, mostly chronic infection, but some IPF, some difficult asthma, and some lung cancer, such is the way in a small department, such as ours. The students were most interested in the lung cancer patients. We, like many centres, run an accelerated investigation process for our patients, whipping them through the CT scanner, and up to clinic very quickly. One of the students asked if the patients get scared, getting tests before they see us. The other asked what happens to the patients who go through the scanner, and don’t have a tumour: “Do they get a non-urgent appointment instead”?

Everyone gets an urgent appointment if they’re in the ‘urgent, suspected cancer’ stream. The student looked puzzled – but if the scan is normal, why would you see them urgently, she asked, increasingly puzzled.

It led to a discussion about what leads patients, people, all of us to stress and anxiety. I think the worst thing for anyone is uncertainty. You see your GP, they say that you might have cancer, and you spend every waking hour from that point worrying, stressing, panicking, even, about the possibility you might have cancer. The uncertainty is the stressor. The patients come in wanting an answer, a release from the uncertainty – being told there’s nothing wrong is the best release, but being told that the do, indeed, have cancer, leads to a release also. Once you know, you can start to cope. It’s very hard to cope with uncertainty.

Later in the clinic the students asked me about eCigarettes; are they safe? I’m not certain. And that’s the problem – uncertainty again. We simply just don’t know enough about the effects of eCigarettes on the lung, and their standing as a medical instrument, rather than a medicine, means we’re not likely to see any evidence for a while. This case discussion in this Month’s Thoraxreports on a patient with marked deterioration in pulmonary function, cough, sputum production and breathlessness, which abated once the patient stopped vaping. The first of many? Or an idiosyncratic reaction that’s unlikely to be repeated? Certainly I see more and more people vaping around Dundee. It seems to be slowly gaining acceptance.

We’d like everyone to stop smoking, holistically speaking – everyone can exert their free will to smoke or not, of course. How can we stop people smoking? A manager in the department asked me for advice a couple of years ago, as her 14 year old daughter had started smoking. I shared the link to a Flickr photostream of post mortem lung cancer specimens – she showed them to her daughter, who immediately quit, or so she said. So the spectre of lung cancer was sufficient to induce smoking cessation on this occasion, but this study in Thorax shows that, in Denmark at least, being screened for lung cancer doesn’t increase smoking cessation.

Last week COPD made the news in the US, and the UK. The news in the US was the FDA’s decision to approve umeclidinium/vilaterol, and the publication of more safety data for the same combination. Over on this side of ‘the pond’, COPD made the news when Phil Everly succumbed to COPD, but the reporting didn’t focus much on the disease, rather focussing on the music. When Kylie Minogue had breast cancer, the profile of breast cancer increased significantly. Perhaps Phil Everly wasn’t big enough news.

Remember to check out the Thorax Weekly Scoop.it to see the snippets I find through the week, the Thorax Facebook page, and the Thorax Twitter feed.

And next week, more musings.

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