Watching the Cancer Grow

Here's a little game some radiologists like to play (surely no one you know). It's called "watching the cancer grow." Here's how it's played: Take a patient with lung nodules that are being followed. Each time you read out their chest CT exam, you compare it only to the most immediate prior study, not the oldest exam.

You report, accurately enough, that the nodules are stable from the prior study and you recommend continued surveillance. At no point do you bother going back to the original study and observing that, when compared back to the original exam, one or more of the nodules are slowly growing over time and therefore extremely suspicious for malignancy (ie, cancer until proven otherwise).[[{"type":"media","view_mode":"media_crop","fid":"44375","attributes":{"alt":"Francis Flaherty, MD","class":"media-image media-image-right","id":"media_crop_1286219409600","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4953","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 237px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Francis Flaherty, MD","typeof":"foaf:Image"}}]]

Here are some variations to the game: Maybe you note that a lesion may have "slightly enlarged" but that this may be due to technical factors such as "slice selection." You recommend continued surveillance. Maybe you actually acknowledge that the lesion is enlarging, but you don't dare use the C word or the M word (cancer and malignancy, in case you were wondering).

Maybe you recommend PET scan for further assessment of your enlarging nodule (logically inconsistent, as an enlarging nodule would remain highly suspicious for malignancy even if it is PET negative).

Why do you do these things? Maybe you are too busy to compare the study with all the old priors. It is tedious. As long as you keep recommending follow-up, you're covered, right? Eventually some other radiologist will actually compare to all the old exams and find the cancer.

Well, what happens if you are forced to acknowledge that a nodule has enlarged? Why don’t or can't you call your enlarging nodule cancer until proven otherwise? What’s with the obfuscation and hemming and hawing? Perhaps you don't even know. Perhaps you don't like making the call, preferring instead to kick the can down the road to the next rad.

Perhaps you've internalized the caricature of the radiologist sitting on a fence eating a waffle. Whatever the case, you’re not doing anyone any good, not the patient, not yourself. Get down off the fence. Step away from the waffle. Make the call.