Thursday, June 6, 2013

Second Opinion

Everybody says you should always get a second opinion on important medical decisions. But the conventional wisdom peters out before it says anything about what to do when the opinions disagree.

A third opinion? A coin toss? A debate moderated by Jim Lehrer?

That's what we'd be wondering after our visit today with Dr. Samuel Singer at Sloan Kettering if we hadn't been convinced going in that Singer looks on paper like the rock star of soft tissue sarcomas and that Sloan Kettering is an unparalleled killing field for cancers of all kinds.

The two opinions we've now heard differ on every key point, right down to the identity of the invader.

Dr. Martin Karpeh, the surgeon we saw Monday, says all but categorically that it's a sarcoma, probably late stage and high grade, a tyrannosaurus rex of tumors.

Dr. Singer says it may well be, but there's no way to know for sure without a biopsy, and no way to determine treatment until we know. It could still be a lymphoma or some other tumor type. Even if it is a sarcoma, there are 50 varieties, each responsive to therapies that can differ widely.

Dr, Karpeh says the tumor must come out as soon as possible and can still be extracted in one piece without doing lasting harm.

Dr, Singer says that because part of the tumor is embedded in my backbone, it would be impossible to do that without unacceptable risk of breaking it open and spreading malignant fragments far and wide.

Dr. Karpeh says attempting to shrink the tumor before surgery would take time I don't have because the spinal invasion will soon be too close to the spinal cord and other major nerves and vessels to be safely removed. Furthermore, radiation or chemotherapy prior to surgery would probably be ineffective at the dosage levels the surrounding healthy organs could tolerate. Better to remove the tumor and irradiate whatever is left of it directly while I'm open.

Dr. Singer says the tumor is already beyond safe removal, there are ways to administer safe doses of chemo or radiation that can shrink it at least at the margins, and there are severe limits to intra-surgical radiation too.

Dr. Karpeh says the chunks of vertebrae that need to be surgically removed will still leave me a viable spine, supported by surrounding muscle and fat that will move into the gap.

Dr. Singer says that in the event the tumor can't be forced to retreat from the bone it has occupied, the damaged vertebrae will have to come out entirely and be replaced with man-made material.

Dr. Karpeh wants to operate within three weeks.

Dr. Singer told us the specifics of his approach will be determined by the biopsy I will have Monday. But he outlined a likely course of treatment involving chemo and/or radiation that will span many weeks before any surgery is attempted. In fact, under some circumstances he said it's even conceivable there might be no surgery at all.

Both these highly qualified doctors made their assessments with a lot less diagnostic information than they would have by the time of an actual operation. Each would also consult with other members of their surgical teams. It seems likely to me that their opinions would ultimately converge on at least some of these points.

But we need to commit to one or the other now. I plan to call Dr, Karpeh's office tomorrow and tell him I will be treated at Sloan Kettering.


  1. Difficult to read between your well-written lines, but Dr. Singer sounds like the more nuanced of the two you consulted. That Dr. Karpeh apparently did not think a biopsy would provide information critical to the decision whether to operate is more than a tad revealing (as is your description of him in the previous post). Having taken a look at their bios online, I think your choice of the more specialized doctor (Singer) is the right one.

  2. Dave,
    I think your decision makes all the sense in the world, and I'm relieved to read that that's what you're doing. Thanks for writing this blog. I'm sure I am one of many who are thinking of you and trying to figure out how best to help and support you.

  3. Good choice I agree..a chance of no surgery at all! Thanks for keeping us posted Dave. Sending very positive thoughts and lots of love