Lessons from a paracentesis

February 17, 2021


Clinical Correlations is proud to present our section for humanism in medicine, Tales From The Bedside, where we showcase our community’s unique and diverse experiences as physicians and trainees in internal medicine.

By Simone Blaser, MD

My second palliative paracentesis did not go as smoothly as my first. At my first, I inserted the catheter into the patient’s taut belly, and when the catheter suddenly gave way and I felt the pop of the punctured peritoneum, I almost gasped. The straw-colored fluid began to drain out, from one suction container to the next to the next. We drained five containers in all. The patient was an elderly hospice patient with end-stage hepatocellular cancer.

The second was also for end-stage cancer. This patient yelled at the moment I felt the pop, and the yell rattled me. I had not seen him lose composure during the three days I had been taking care of him – no time at all, but in hospitals, intimacy is rapid.

The straw fluid again appeared, but this time, as I pushed the catheter deeper into the abdominal cavity, the needle moved in the opposite direction out of the hole, taking with it the backbone that kept the flimsy catheter rigid. The catheter kinked. We retracted it and reinserted at a different angle, but the syringe pulled back air. We’ll have to try again with a new catheter, I told the patient. Tears welled in his eyes. He had been waiting days for the relief the fluid drainage promised. He had stage IV gastric adenocarcinoma, peritoneal carcinomatosis, and malignant ascites – and he was thirty-seven years old.

***

Cancer strikes too soon, no matter when it strikes. In thirty-seven-year-olds, or any younger adults for that matter, the striking has an additional sense of urgency and injustice: not for unfinished business but for life interrupted. These are men and women rooted in adulthood, perhaps with the angst and invincibility of youth in rearview mirrors; perhaps now with responsibilities, families. When illness – especially this empress of all maladies – strikes those in media res, we hope it is a fluke, for it seems to violate the very fundamental natural history of human life cycles.

We then look for answers. We ask: Why? Why did he develop advanced-stage gastric cancer? Why at such a young age?

Born in Mexico to a father who died of gastric cancer in his 60s, the patient fits nicely into the population of a 2007 study whose authors found rates of gastric non-cardia adenocarcinoma in Hispanics almost three-times-higher than other ethnic groups [1]. The difference is accounted for by H.pylori infection (NHANES III estimates 63% seroprevalence in Mexican-American men), intake of nitrates from high-salt diets, and tobacco use [2,3]. However, while the researchers adjusted for age in their analysis, in my own, I could not chalk up my patient’s youth to outlier.

In fact, during a recent month of Bellevue wards, my team had a second young patient in her mid-twenties with stage IV cholangiocarcinoma. In medical school, I learned that these cancers occur in older adults with a lifetime of risk factor exposures. My guy had no prior medical problems, no toxic habits, a reasonable diet. Was 37 years of presumed H.pylori enough to grow a raging cancer? Or rather: how many years comprise a lifetime?

My patient’s case, it turns out, is no outlier. A 2019 article published in the Journal of the National Cancer Institute (JNCI) Cancer Spectrum found a surprising trend in cancer incidence over the last 40 years that upends our traditional ideas about cancer and age. Incidence appears to be increasing in younger adults and dwindling in older adults. Most strikingly, in women aged 25-39 years old, rates increased by almost two times faster than in any other group. In men of the same age group, cancer rates also continue to increase, although the slope is not as steep.

What is alarming here is not only the inversion of what we expect, but also our inability to explain the phenomenon. We can attempt to address bits and pieces: better screening may explain decreasing cancer rates in older populations, but this doesn’t explain the upsurge in younger populations who are not routinely screened.

Have the risk factors changed in one generation? Or to consider ecology: have our internal landscapes become more conducive to certain cancers? The authors of the JNCI article posit that obesity and increased exposure to carcinogens are two of many multifactorial etiologies for this rapid rise [4]. But the data from the article lacks information on exposures, family history, geography, race, socioeconomic status, and ethnicity – all factors that may contribute to an environmental shift or a change in early-life exposures to account for advanced disease at earlier ages.

A literature search does not reveal much else in the way of evidence-based explanations for the rapid rise. Many believe the changing gut microbiome plays a role in carcinogenesis of gastrointestinal malignancies. A recent consensus statement by the International Cancer Microbiome Consortium concludes that despite mechanistic evidence in human and animal studies, direct evidence linking dysbiosis to cancer remains lacking [7]. More recently, a retrospective study links Epstein-Barr virus (EBV) to early-onset gastric cancer, though the sample size was small [8].

It is evident that more longitudinal studies are needed. So, too, do we need a revaluation of our screening guidelines for young adults. Cervical cancer was the sole cancer rate to decrease in the JNCI article, a decrease that causes us to wonder whether earlier screening in other cancers could help [3]. While the link between human papillomavirus and cervical cancer is well-known, for most other cancers, how to screen and what to look for remains unclear without a specific culprit. Although EBV has been identified in relation to gastric cancer, screening for this virus would be ineffective given its ubiquity. For a screening test to be useful, it must be easy and relatively cheap; and of course, it must save lives.

This trend’s relentless march forward will not wait for new guidelines to be developed or for clarifying research to be executed. For clinicians on the wards, this interim will be marked by a special sense of powerlessness that stems from both the injustice of the phenomenon of young adults with cancer – and in this injustice, we see our own mortality – and our inability to explain why.

***

To return to the paracentesis: the catheter has just kinked. My patient is holding back tears. The fluid stretching his peritoneal cavity and pressing on his organs is the only thing standing between him and his family. The medical student leaves to secure a new kit, and I stand sentry at bedside in surgical cap, gown, gloves, and mask. We wait in silence.

“How old are you?” he asks me suddenly.

“I’m 33.”

He peers up at me.

“We’re almost the same age.”

“Yes.”

“Do you have kids?”

I shake my head.

“My family sustains me. I need to get home to them.”

The air is thick. I am holding gauze over a hole I have carved in the abdomen of my peer. I want to reassure him, to apologize; for the kinked catheter, for his four daughters who will be fatherless, for being spared. The medical student returns with the new kit, and we begin again. This time, the patient does not yell. The straw fluid flows. His brow relaxes. You did it, he says, and he smiles at me.

The fluid will almost certainly reaccumulate, and he will need another procedure, and then another, likely with increasing frequency as the cancer progresses. He will likely die before any light is shed on his own “why.” But he understood that brutal calculus. He had made his peace with powerlessness. What was important to this young patient with end-stage gastric adenocarcinoma was simply the ability to return home to his family pain-free – not the chasms of all we do not know about his disease, not the risk factors, not our inability to reassure. Instead, it was he who offered reassurance to me.

The story of young people and cancer remains nebulous. Answers are being sought in laboratories and in hospitals. The research will further shed light on the epidemiology and pathophysiology – and, ideally, one day, offer substrate for prevention.  And for the young patients we meet on the wards, whose cancers have already advanced, we must transform our feelings of futility into action, using whatever temporary palliation we have at our disposal. Although we may not have answers, we do have the ability to discover what is important to our patients, to discern how each wants to live his remaining days and months, and to do what we can to honor our patient’s own conception of a dignified death.

Dr. Simone Blaser is a second-year resident at NYU Langone Health

Note: While this is a piece of nonfiction, certain details have been changed to protect patient confidentiality.

References

  1. Wu X, Chen VW, Andrews PA, Ruiz B, Correa P. Incidence of esophageal and gastric cancers among Hispanics, non-Hispanic whites and non-Hispanic blacks in the United States: subsite and histology differences. Cancer Causes Control. 2007;18(6):585-593.
  2. McQuillan GM, Kruszon-Moran D, Kottiri BJ, Curtin LR, Lucas JW, Kington RS. Racial and ethnic differences in the seroprevalence of 6 infectious diseases in the united states: data from nhanes iii, 1988–1994. Am J Public Health. 2004;94(11):1952-1958.
  3. Anderson WF. Age-specific trends in incidence of noncardia gastric cancer in us adults. JAMA. 2010;303(17):1723.
  4. Kehm RD, Yang W, Tehranifar P, Terry MB. 40 years of change in age- and stage-specific cancer incidence rates in us women and men. JNCI Cancer Spectrum. 2019;3(pkz038).
  5. Plell, A. There Are Hidden Chemicals In Our Clothing. Remake.com. January 5, 2018. https://remake.world/stories/news/there-are-hidden-chemicals-in-our-clothing/ Accessed 8/31/2019.
  6. Rabin RC. Can eating organic food lower your cancer risk? The New York Times. https://www.nytimes.com/2018/10/23/well/eat/can-eating-organic-food-lower-your-cancer-risk.html. Published October 23, 2018. Accessed February 16, 2021.
  7. Scott AJ, Alexander JL, Merrifield CA, et al. International Cancer Microbiome Consortium consensus statement on the role of the human microbiome in carcinogenesis. Gut. 2019;68(9):1624-1632.
  8. Moore A, Hikri E, Goshen-Lago T, et al. Young-onset gastric cancer and Epstein–Barr Virus (Ebv) – a major player in the pathogenesis? BMC Cancer. 2020;20(1):34.

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