A 59-year-old man comes to the office for a preventive visit. He feels well but has experienced an unexpected 2.3 kg (5 lb) weight loss in the last 2 months. The patient has a 40-pack-year smoking history, and medical history is otherwise unremarkable. Physical examination is normal. Fecal occult blood testing is positive and colonoscopy is advised. The patient asks, "A colonoscopy, that sounds serious! Do you think I have cancer?" Which of the following is the most appropriate response to this patient's question?

Question

A 59-year-old man comes to the office for a preventive visit.  He feels well but has experienced an unexpected 2.3 kg (5 lb) weight loss in the last 2 months.  The patient has a 40-pack-year smoking history, and medical history is otherwise unremarkable.  Physical examination is normal.  Fecal occult blood testing is positive and colonoscopy is advised.  The patient asks, "A colonoscopy, that sounds serious!  Do you think I have cancer?"  Which of the following is the most appropriate response to this patient's question?

Quizplus · Accepted Answer

11ec25c8_d533_5253_bc81_a718c6bc0222_MD0003_00 This patient with a significant smoking history has unexplained weight loss and a positive fecal occult blood test, which together suggest a possible malignancy in the colon. This presentation warrants further evaluation with colonoscopy, which should be completed in a timely manner. However, the patient's clinical features are not specific for malignancy, and there is significant uncertainty as to the cause of his symptoms. Counseling this patient should include a clear statement that his symptoms could represent a serious condition; the conversation need not detail every possibility in the differential diagnosis, but the clinician's suspicion should be explained in a way that the individual patient can understand. The clinician should also convey an appropriate sense of clinical uncertainty. In this particular case, the level of uncertainty is high, which should be expressed to the patient. The plan for diagnostic tests and subsequent follow-up should be as clear and specific as possible (eg, "I will call you with test results on Monday"). Finally, the patient should have adequate opportunity to ask questions and obtain clarification. (Choice A) Colonoscopy is routine for patients with a positive fecal occult blood test. However, this statement does not explain why it is necessary or encourage shared decision-making. (Choice B) Expressing uncertainty is appropriate. However, this statement is unnecessarily vague, and uncertainty alone does not justify invasive testing. (Choice C) Discussing life-changing conditions (eg, cancer, dementia) requires tact. Although the possibility of serious disease should not be hidden from a patient, blunt and direct statements such as this can be alarming and are more appropriate when specific features (eg, lytic bone lesions, visible mass on CT) make a benign diagnosis unlikely. This patient's symptoms are suspicious but highly nonspecific. (Choice E) Although this statement includes an appropriate expression of concern and support, it is unnecessarily alarming and does not lead to discussion of the necessary plan of care with the patient. Educational objective: Counseling a patient in the setting of clinical uncertainty should convey the potential seriousness of the situation and include an individualized discussion of differential diagnosis based on known facts of the case. The degree of uncertainty should be acknowledged. The discussion should also explain the need for further evaluation, include a clear plan for follow-up, and allow the patient an opportunity to ask questions.

A 59-Year-Old Man Comes to the Office for a Preventive