Four years ago, Brian stepped into my office to discuss his elevated prostate-specific antigen. I recommended that he complete a prostate biopsy and explained that I was concerned about his increased risk of prostate cancer. Brian, who upon arrival appeared ready to have the discussion, chided me in sharp clipped sentences that somehow I was wasting his time and his money by wanting to complete an additional procedure.
“Don't you have enough information to treat me? To tell me what’s going on?” he asked. His wife sat across from me, silent and almost fearful of what he was going to say next. As I surveyed Brian, trying to figure out why a conversation I had had so many times before had gone wrong, he got up and walked toward the door. Before he could open it, I said, “It looks like you have some thinking to do. We will schedule a follow-up appointment for you. Please reach out to me with questions."
A few weeks later, he returned and I reviewed his clinical findings: an abnormal exam and PSA blood test above 10 nanograms per mililiter. After I stressed the need for further evaluation and explained that a biopsy was quick and he would not need to take time off, he consented to move forward with the biopsy. A few weeks later, he returned, and once again I sat across from him with more news I knew would be difficult to deliver.
I explained that his biopsy results confirmed the diagnosis of prostate cancer. His pathology returned as adenocarcinoma with a Gleason score of eight, which was low volume but aggressive.
Treating prostate cancer with surgery in our community has become a common occurrence. Most patients initially are surprised by the confirmation of disease, and when the biopsy results are low-grade non-aggressive prostate cancer, I spend most of the consultation explaining that prostate cancer is extremely common and when treated properly and quickly will not limit the patient’s life expectancy. I couldn’t recommend surveillance in Brian's case and explained that he would need additional testing. I could see another flash of anger and once again he asked why he needed additional tests and why he needed to see another specialist.
After Brian visited the radiation oncologist, he returned to my office. We reviewed the risks of surgery, his option for radiation as a primary treatment, what he should expect, and the need to convalesce postoperatively.
He laughed and said, “I’m sure I’ll be up and back to work way before that.” To which I replied sternly, “No, you will need time to heal. There are no exceptions.”
I smiled and said I was counting on him to make sure he adhered to the postoperative care plan. He glanced at his wife, who was dabbing a slow stream of tears from her cheeks, and smiled at her. I took her hand and he consented to robotic prostatectomy. Finally, I thought, I can get this man the treatment he needs.
Over the next few weeks, Brian then proceeded to cancel and reschedule the operation four times. When I received the notification that his surgery had been rescheduled for the fourth time, I requested that he return for another visit. When he returned to my office, I was professional but swift, starting with a brief synopsis of his medical history and ending with an emphasis on the word aggressive.
“I just couldn’t do it this month,” he spat back at me. His wife glanced down at the floor. Clearly, the rapport we had established, the bridge that had allowed me to take his wife’s hand, had eroded during the stint between visits. Nonplussed and bothered by his lack of concern, I explained that I was worried but that he did have options. If he no longer wished to proceed with surgery, the option for radiation was still available. When he still had no response, I asked him if he wanted to go for a second opinion. I used words like “urgent” and phrases like “window of opportunity” in an effort to reconnect with him. After some time, Brian broke.
“Listen, Doc, I don’t care about my life. Just give me a few more months, and I will let you remove anything that you want.” He leaned toward his wife for support, and she reciprocated by pressing her palm onto his arm. I took a moment to adjust to his new tone. “What do you mean?” I asked him. He did not wish to harm his family by creating a financial burden. He was not afraid of the operation and understood the risks. But he needed to work, and he did not want to tell me or anyone that he was in danger of losing his home.
How had I missed this? This family did not appear to be in need. His children were in college, and he was employed. I had no reason to inquire about his financial health, and I was unsure if he would qualify for assistance. What I did know was if he didn’t act, his treatment options would change.
I went to our cancer liaison and was relieved to find out that he did meet the requirement for financial assistance.
The assistance was what Brian needed to feel comfortable moving forward with treatment that would prevent him from working for the next few weeks. While he appeared comfortable, the truth was that even with the assistance, his decision to move forward with treatment would threaten his income. Ultimately, he would default on his mortgage during his convalescence period. There are so many people making these decisions when it comes to health care. In the U.S., nearly 1 in 10 adults owe significant medical debt, yet screening for financial health is not a part of our evaluation. While there is no simple solution to mending the health care crisis in America, one thing that we can start doing is screening for the patients that are likely to forgo services without financial support. In this way, we can advocate for comprehensive care and financial assistance while treating disease.
What else do you think we should screen patients for? Share your thoughts in the comments.
All names and identifying information have been modified to protect patient privacy.
Alexandria Lynch is a general urologist with a focus on robotic surgery practicing in New York. She believes that practicing medicine is a privilege that can build a well-educated, healthier society, and encourage a just culture. As a native New Yorker, she enjoys long walks along the Westside highway admiring the Manhattan waterfront, thin-crust pizza, writing, flying, and endless afternoons at the Strand. Dr. Lynch is a 2021–2022 Doximity Op-Med Fellow.
Image by Fanatic Studio / GettyImages
