Diagnostic Technology Is Great...Until It Isn't

Kate Hitchcock, MD, PhD

Disclosures

July 20, 2021

"Your exertions below decks were no doubt exhausting."

–Caledon Hockley, Titanic, 1997

I once heard of a patient who developed edematous red patches in the skin of her face that looked a lot like the lesion in this photo. This was initially treated as shingles and got worse. It was eventually biopsied and called a cutaneous lymphoid hyperplasia. A number of different treatments were tried with no improvement. It was biopsied again, same result. This time they did molecular genetic analysis by PCR for an immunoglobulin heavy chain gene rearrangement. The result, which took more than a month to get back: polyclonal, cutaneous lymphoid hyperplasia. Eventually when nothing else worked, this was treated with radiotherapy, responded beautifully like lymphomas do, and never came back.

In an earlier time, her doctors would have looked at the clinical presentation, seen the B-cell infiltration on pathology, called this a cutaneous lymphoma, and treated accordingly, skipping almost 2 years of other management which did not result in any improvement in this patient's condition.

I don't know what I'm trying to say about this, except that sometimes our fancy new tools fail us. Testing with immunohistochemistry and genetic analysis can be incredibly powerful tools in the fight against cancer. They can also result in weeks of dithering while the patient's face falls off. They undoubtedly prevent many situations in which the patient would get the wrong treatment for what they actually have, but used injudiciously they can also really delay the right treatment. Time is cure.

This reminds me of a funny story from my Navy days. Back when Admiral (then Captain) Hyman G. Rickover managed to convince Congress to put mind-numbingly expensive nuclear reactors in Navy ships, he was faced with a difficult dilemma: Should he take Navy ship drivers and try to teach them nuclear physics, or take nuclear physicists and try to make them into naval officers? He chose the latter, and to maintain quality control personally interviewed each and every one of them before hiring, to the tune of tens of thousands of job interviews over the next 24 years.

The decision caused another dilemma, though. Nuclear physicists tend to get deeply involved in solving the puzzles inherent to their work. Everyone worried that those eggheads down in the "hole" (engine room) at the bottom of the ship would lose focus on minor details of their environment, such as incoming enemy missiles, in their zeal to solve one engineering mystery or another. The result of this concern was that every Nuke was required to learn how to drive the ship, so that he could picture exactly how tense the situation on the bridge must be while he worked on getting the engines/electrical system/aircraft-launching catapults back online again. And that, comrades, is how yours truly learned to drive a ship the size of the Empire State Building and packed to the brim with 5000-plus of her closest friends. Turns out I'm pretty good at it and so kept at it for 2 years afterward, in addition to my main gig running the reactors.

The parallel that I'm attempting to draw here is that I occasionally have a twinge of desire to grab my diagnostic-specialty friends *cough rads path cough cough* into the room with my wailing, bleeding patient whose spouse is screaming at me about how long I'm taking to get treatment started, just to refresh their memories a bit as to the status of affairs above decks. But then the cooler, more rational part of my brain takes back over. I'd rather they do their work free of such distractions. They really are a great crew and work very hard.

Please join the discussion below, but if you need to communicate with me offline you can reach me at OncBlogMedscape@gmail.com.

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About Dr Kate Hitchcock
Kate Hitchcock, MD, PhD, is a radiation oncologist, biomedical engineer, and retired aircraft carrier driver who grew up as a Wyoming cowgirl. When she is not at the hospital, you can find her with Carolyn, Mary, Tyler, Nick, Marlee, and Colby the barking dog, enjoying the natural splendor of the great state of Florida. She thinks you should visit sometime and try to solve the puzzle of why the natives have so carefully shunted all of the tourists toward the House of Mouse. Connect with her on Twitter: @hitchcock_kate

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