Tuesday, 24 November 2009

Overhaul Day

It is now just over 1 year since the last of the 4 hip operations last year and by chance I have had a mini overhaul today. In the morning I went to the Chiropodist that has tended to me for the last 4 years or so - about 5 times a year - for nail clipping and scraping away of various bits of hard skin.

About 90 minutes of useful time at home after this appointment and I was driving back across town for an annual appointment at the metabolic unit. I had about 6 weeks before attended for a scan and blood tests. After 3 good years leading up to the hip ops last year I had managed to add approx 3% bone density per annum. The inactivity for most of 2007/8 not surprisingly meant that the trend was reversed. A sensible discussion then resulted in a decision to defer any further intervention pending increased weight bearing and mobility and Vitamin D augmentation ( through sunshine rather than activated Vitamin D capsules). I was therefore pleased that bone markers in the blood were showing less activity ( in other words I was not needing to replace bone lost through inactivity) I have stabilised at the extreme of the normal range for a man of my age, which is not bad given all the other problems and long term steroid use.

We have again agreed on a conservative approach with no addition of biphosphonates ( which will be complicated by the renal impairment and might require discussion at a quarterly joint clinic in my absence).

I have been reading Gerd Gigeenzer's excellent book "Reckoning With Risk" - learning to live with uncertainty and have realised with my multiple long term conditions and complicated polypharmacy I am much more likely to die WITH any number of of conditions rather than FROM most (if any) of them.

So against that background I attended the 3rd of my clinical appointments today. This was a 30 minute visit to the dentist to have a bridged crown cut into 2 in preparation for a follow up appointment at the dental hospital on Friday afternoon to have debris cleared out, at which time the surgeon will take a biopsy to "rule out" oral cancer.

Now here is the background to this last "interesting" episode of my medical history.

About 1 year ago - after the 4 hip operations - I became aware of a soft tissue bulge at the back of my upper right 4 tooth. As it happened I saw a public health leaflet at the pharmacy which was drawing attention to Oral Cancer. It advised that if such changes had not resolved within 3 weeks it was important to let a dentist have a look. Feeling a little like one of the "worried well" I made an appointment and was reassured when after X-Ray a lot of broken tooth, root etc was revealed. It was unlikely to be cancer and it was agreed to watch and treat in a conservative manner. A scheduled 6 month follow up early this year resulted in no action other than a number of photographs - it is something that is uncommon enough to be worthy of sticking in an album / lecture notes. However the latest 6 monthly check led to a different dentist (tutor - as this is a teaching practice linked to the dental school) deciding that a referral to the dental hospital was required.

So I was referred to Mr Payne! the dentist ( I kid you not!) who decided he would prefer the dental practice to cut the tooth shortly before he would clean out the debris ( which might require some cutting and stitching). We agreed a date when he could do stage 2 and I was left to arrange for the local practice to carry out the first stage.

Now I know I am not in any of the high risk groups for oral cancer ( I do not smoke or chew tobacco nor do I drink above advised levels of alcohol). So even if the biopsy is "positive" I will not proceed with any heroic intervention. Any assessment of risk based on testing is often expressed in percentage terms ( you know 80 % - or whatever - of positive tests are associated with Cancer). In reality this confuses people tested who are in high risk groups and those like me who are not. I suspect that the probability of a positive result being wrong for people in low risk groups is not known - so my chances will be distorted by including me in a reference group of people with high risk.

So imprecise is the understanding of relative risk and what represents the correct reference set that it does make me wonder how likely it is that we can ever achieve "informed consent".

Given that I have already survived longer than we thought likely in the 80's - and that I have lived the last 4 or 5 years as if I was on borrowed time(wanting to make the most of the rest of my life) I will neither be relieved if the biopsy proves "negative" nor anxious if it turns out "positive".

Oral cancer is of course more destructive than say prostrate cancer for example and the prognosis is certainly less promising but given the chances of a really accurate diagnosis and assessment of risk I do not think ( at this stage at least) that it will make any difference to how I will react. Time of course will tell and I aim to make the most of that limited commodity - for as long as I can :-)

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