Questions difficult to answer

Tagged questions; Posted 11 years ago

In my gynaecological surgical practice, patients are encouraged to ask questions. I really enjoy working with well-informed patients. From our patient satisfaction surveys it appears that well-informed patients are happier and give us better marks.

Some questions patients tend to ask me are easy to answer: What exactly is it that you will remove? What are the risks of a surgical procedure? How many of these operations have you done in the last 12 months?

Some other questions are also commonly asked but are more difficult to answer. I hear from my colleagues that they seem to struggle most with exactly these same questions in their practice.

The most likely reason I struggle with some answers is because as a doctor and researcher I try to answer them scientifically correct. Unfortunately, sometimes there is no “correct” or exact answer.

I see patients with gynaecological malignancies but also with benign tumours, such as fibroids, ovarian cysts or endometriomas. The most common question I receive from affected patients is:

How did this growth develop and how long has it been there?

The truth is that no one knows: Take for example the Human Papilloma Virus (HPV), widely accepted to be a necessary but not sufficient cause of cervical cancer. While HPV is extremely common in sexually active women and men, most people who are infected by HPV can easily deal with the virus and clear it, but others cannot.  True, there are co-factors that increase the risk of developing a HPV-associated  tumour, such as smoking. However, a large number of women who I see and treat for abnormal PAP smears, cervical or vulval cancers do not smoke and also do not have any other obvious immunosuppressive risk factor, and we do not as yet know exactly why their body could not clear the virus.  

Obesity is another complex example. With rising obesity rates, the incidence of endometrial cancer increases. In Australia, we have one of the highest rates of endometrial cancer worldwide. I attended a conference in the US last week that suggested bariatric surgery (surgery to decrease the size of the stomach) reduces the risk of endometrial cancer. It sounds logical, given that obesity is a risk factor for tumour development and bariatric surgery reverses reduces obesity. However, it is still unclear how exactly obesity of linked to endometrial cancer. Is it the hormones or is it inflammation? Once we know we will be able to better advise women on how to prevent getting endometrial cancer. Already now, many  obese women never develop endometrial cancer, and we need to learn from these women the secrets of staying healthy.

Sometimes patients endeavour to track the onset of a cancer back to a significant circumstance in life. The death of a loved one, personal stress, or grief. Good research suggests that life events are unlikely to bring on cancer. Lifestyle factors (what we eat and drinking, whether we smoke or not, and whether we take enough time to exercise and move our body) or genetic factors (BRCA, Lynch) are far more likely to cause cancer.

How long has the tumour been there and how fast does it grow?

This question is impossible to answer exactly, because as each tumour is unique in the exact cellular changes it has experienced. We can watch tumours grow in mice but those data are not applicable to humans. All we can say is that it is likely that it takes many years for a tumour to grow into a tiny detectable mass of a couple of millimetre cubic. Then, it may take another number of years for the tumour to grow to a size where we can actually diagnose it. Most tumours less than a centimetre in diameter escape any investigations. Until a malignant tumour is 5 or 10 centimetres in diameter, it probably has been developing for many years, which make it difficult and impossible to track it back to an isolated life event that could have brought it on.

Cancers develop as a result of a step-by-step, over considerable time, with many changes in the cells on a molecular level contributing. As for the exact time, this would differ depending on exactly what molecular changes the particular cells acquire, but usually cancers only become diagnosed when they have 10 billion to 100 billion cells, which would take years in time.

How long will my recovery from surgery take?

I find that the majority of patients who have laparoscopic surgery recover faster than patients who require a laparotomy. While the vast majority of patients bounce back very quickly, sometimes and for reasons that I am unable to explain, some patients recover very slowly. However, again it’s hard to predict recovery exactly. I also know patients who have a laparotomy for rather advanced surgery and are well enough to go home after only three days. Recovery is a steady process that goes fast for many women and slower for others. I find that women, who had surgery previously and recovered quickly, will again have a quick recovery. Women, who had made the experience that it takes them a while to  recover, will likely also need more time for full recovery at the next surgery and should give themselves that time.

Some patients have physically demanding work and for those patients I usually recommend a longer time off work. Generally, my impression is if women are under pressure either by themselves or work or family commitments to recover quickly, that can be a good thing if it causes positive stimulus. Sometimes however, too much pressure distresses patients and hinders them to get well. One of the presentations at last week’s international conference suggested that women who already have with low quality of life prior to surgery may have a longer recovery, indicating that these women may have exhausted their inner resources and need to recharge.

I find it impossible to predict a patient’s recovery. The old story of a 6-weeks recovery after hysterectomy is definitely out-dated and applies to hysterectomy trough an abdominal incision. Good evidence suggests that recovery from laparoscopic hysterectomy is much faster with a lower risk of complications. Laparotomy for hysterectomy should not be practiced any longer except in a few cases where there are contraindications. It exposes patients to unnecessary complications, pain and prolonged recovery.