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Deep Dive into Tough Medical Choices for an Older Adult with Slow Growing Cancer
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Jun 13, 2025
The Deep Dive Podcast offers valuable insights into making complex medical decisions, particularly when it comes to surgery for older adults. It aims to distill the key points from various sources, enabling viewers to feel more informed and confident about these choices.
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0:05
okay let's dive in You've handed us some
0:08
really um thoughtprovoking material
0:11
today all centered around making these
0:13
tough medical decisions especially Yeah
0:15
when surgery's on the table for older
0:17
adults right So our mission here for
0:19
this deep dive is to really unpack these
0:22
sources you shared pull out the
0:24
essential knowledge so you listening can
0:27
feel you know properly informed about
0:29
what is a complex topic It really is
0:31
it's a fascinating intersection we're
0:33
looking at You've got surgery these slow
0:35
growing tumors and then layered on top
0:37
all the unique things you have to
0:38
consider when the patient is older And
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the material gives us this great
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specific case study that brings it all
0:44
to life We're talking about a
0:45
78-year-old gentleman uh called Mr are
0:48
in the sources That's right And his
0:50
diagnosis of a pancreatic neuroendocrine
0:53
tumor a peanut And what makes his
0:55
situation so well compelling is that
0:59
surgery might seem kind of standard for
1:01
his tumor type and size but his age his
1:04
medical history they add so many layers
1:06
of complexity It really shines a
1:08
spotlight on why this geriatric risk
1:11
assessment it isn't just you know nice
1:13
to have It's absolutely critical Got it
1:15
So let's start with the basics from the
1:18
material the diagnosis itself What do we
1:20
know about this particular tumor Okay so
1:24
Mr R was diagnosed with a peanut It's in
1:26
the tail of his pancreas right It
1:27
actually first popped up on scans back
1:29
in 2023 Okay And then the diagnosis was
1:32
formally confirmed with a biopsy uh more
1:35
recently early 2025 And the good news
1:37
reading through this is that it doesn't
1:39
seem like an aggressive fastmoving
1:40
cancer Correct And that's that's really
1:43
a key piece of the puzzle here The tumor
1:45
is classified as well differentiated WH
1:48
grade 1 Okay And crucially it's KI67
1:52
rate That's a marker for how fast cells
1:55
are dividing gray It's very low less
1:57
than 1% Wow So that low Kai 67 tells us
2:01
this thing is growing very slowly Right
2:03
And the imaging over time backs this up
2:05
It's been stable in size Right now it's
2:06
about 3.2 cm So from the tumor's point
2:09
of view no five alarm fire How did Mr R
2:13
actually report feeling when this is all
2:15
coming out Well he reported feeling and
2:17
this is a quote generally well Okay He
2:20
wasn't having those typical peanut
2:22
symptoms you sometimes hear about like
2:24
palpitations flushing bad pain nausea
2:27
losing weight unexpectedly None of that
2:30
But the sources seem to paint a slightly
2:32
different picture between how he felt
2:34
generally and his sort of physical
2:37
reality That's the disconnect Yeah
2:39
Despite feeling okay dayto-day he has
2:41
these significant physical limitations
2:43
Uhhuh He specifically said he's unable
2:46
to walk two blocks without experiencing
2:48
shortness of breath Okay It's quite
2:50
limiting It is He thinks some of it is
2:52
down to chronic back pain he has from
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herniated discs Right And he describes
2:56
his lifestyle as uh largely sedentary
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Okay So chronic pain being active
3:02
definitely factors Yet the material also
3:04
mentions he finds much enjoyment in life
3:06
even with these limits which is really
3:08
important right It tells you something
3:09
about his priorities his quality of life
3:11
as he sees it Sure Now when the clinical
3:13
team did their objective geriatric
3:15
assessment that limited mobility the low
3:17
activity tolerance
3:19
those were major red flags What that
3:22
immediately signals and this is key in
3:24
geriatric care is it suggests
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significant
3:27
deconditioning and potentially um very
3:31
poor physiological reserve Physiological
3:33
reserve Remind us again that's like the
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body's backup capacity for handling
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stress like surgery Exactly Think of it
3:41
like the spare tank in your car but for
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your body's systems Heart lungs kidneys
3:47
muscles Got it A healthy younger person
3:49
usually has lots of reserve They bounce
3:51
back fast right But as we age and
3:53
especially if we're inactive or have
3:55
other health issues that reserve shrinks
3:58
Deconditioning means his body just isn't
4:00
used to working hard so it's going to
4:01
struggle when pushed And his other
4:03
health conditions kind of added to this
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picture didn't they They did His medical
4:06
history includes hypertension hyper
4:09
lipidmia that chronic back pain and also
4:12
obesity based on his BMI These are what
4:14
we call coorbidities other existing
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health problems And having multiple
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coorbidities it really ramps up the
4:20
complexity and the risk for any big
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medical intervention especially surgery
4:25
because each one can potentially
4:26
complicate things Recovery how the body
4:29
handles the stress But here's the thing
4:31
that really jumped out from the sources
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you gave us The sort of crucial piece
4:35
his past surgical experience This is
4:38
where it really hits home Yeah Mr R had
4:40
a very difficult recovery after a much
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less invasive procedure before a TURP
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procedure Okay He had significant
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bleeding needed intervention ended up in
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the ICU Wow And most concerningly
4:54
experienced a cardiac arrest Oh my
4:56
goodness Now the exact trigger might be
4:59
complex Maybe blood loss needing
5:01
transfusions something like that Yeah
5:03
But the key takeaway the source's stress
5:05
is that past event is a powerful
5:07
predictor I see It showed his body had
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severely diminished resilience very
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limited reserve even for a relatively
5:13
minor stressor Right Pancreatic surgery
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That's a whole different ballgame in
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terms of stress Much much higher So
5:19
connecting those dots from the
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assessment what were the main things
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flagging him as frail Well his age 78
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that's a factor his limited functional
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status Those multiple coorbidities we
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mentioned the hypertension high
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cholesterol obesity back pain they all
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contribute But the most significant
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marker highlighted in the material is
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that history that catastrophic outcome
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after a less demanding surgery okay that
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kind of past event is just a very strong
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signal for how someone might handle
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future surgical stress We also learn Mr
5:53
R isn't going through this alone His
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daughter's involved shared decision-m
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which is so crucial in these complex
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cases Yeah And they both understood the
6:01
key facts about the tumor right It's
6:02
slow growing Yes And normally for this
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size surgery would be you know the
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standard recommendation right But they
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also clearly saw Mr R's age that prior
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bad experience his current physical
6:14
state Mhm And the sources say they
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specifically asked for this formal
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geriatric assessment precisely to help
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them weigh the options keep monitoring
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or go for surgery despite the obvious
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challenges And what was the sort of
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blunt conclusion from that assessment
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The assessment concluded that Mr R
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presents as a frail individual So while
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surgical
6:33
resection probably a distal pancreattomy
6:36
for where the tumors was talked about
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right It was considered very high risk
6:41
high risk for major complications and
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even mortality around the time of the
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surgery And the sources give us some
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numbers to kind of put that risk level
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in context They do It helps to think
6:52
about surgical risk in categories You
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know low-risisk procedures might have
6:55
around a 1% chance of death within 30
6:57
days Okay Intermediate risk maybe about
7:00
5% Right High- risk procedures you're
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looking at closer to 10% And Mr Based on
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his assessment he fell squarely into
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that high-risisk category Estimated
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about 10% mortality risk And the
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material made a point about how you
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communicate that number right Framing
7:15
Absolutely How you frame it for the
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patient and family really matters in
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that shared decision-m Mhm You could say
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he's 10 times more likely to die than a
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low-risk patient which sounds terrifying
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Yeah Or you could say there's still a
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90% chance of survival Right Different
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perspective Exactly Both are
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statistically true But one emphasizes
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the danger the other the likelihood of
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getting through The critical thing is
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making sure they grasp the magnitude of
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the increased risk compared to average
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Let's dig a bit deeper into why the
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assessment landed him in that high-risk
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zone What was the full rationale It's
7:53
multifaceted First that history of
7:56
cardiac arrest after the TUR that's
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probably the biggest single factor Okay
8:00
it just showed his systems low tolerance
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for stress Second his poor functional
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status the deconditioning low exercise
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tolerance we talked about right Those
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are strong predictors of poor surgical
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outcomes Things like heart and lung
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complications much longer hospital stays
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often ICU time and a real risk of
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decline in his independence afterwards
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Even if the back pain contributes to his
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walking limits right Even accounting for
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the back pain the underlying
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deconditioning from being sedentary is a
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huge driver of his surgical risk And his
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other health issues played a part too
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Yes His age hypertension hyper lipidmia
8:34
obesity they all add layers to that risk
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profile And a really key point here
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because the tumor is indolent stable
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slow growing for what over 18 months
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Yeah There wasn't this immediate
8:47
oncologic pressure to operate now Ah
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okay That gave them space Exactly It
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allowed the team to really prioritize
8:55
evaluating and focusing on the
8:56
significant surgical risks to Mr R's
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overall health and life and weigh that
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against the potential benefits of just
9:03
removing the tumor So specifically what
9:05
were the major risks they foresaw if he
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did have the surgery They were
9:09
considered very high The sources list
9:11
major adverse cardiac events including
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you know possibility of another cardiac
9:15
arrest worrying very significant
9:17
pulmonary complications too like
9:19
pneumonia or respiratory failure real
9:21
concerns there They expected a high
9:23
likelihood of a long hospital stay
9:25
probably starting in the ICU Okay And
9:27
critically a significant maybe
9:29
irreversible decline in his ability to
9:31
function independently afterwards That's
9:33
huge Yes Plus the other common risks for
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older adults delirium confusion blood
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clots those were noted too Wow That's a
9:41
heavy list of potential downsides What
9:43
about the potential upsides What were
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the benefits The main potential benefits
9:48
were one the possibility of curing the
9:51
localized tumor by removing it
9:53
completely right And two potentially
9:56
preventing it from slowly progressing or
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spreading later on down the road So
9:59
boiling it all down what were the key
10:02
vulnerabilities the assessment really
10:04
zeroed in on for Mr R The sources
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highlighted his extreme physiological
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frailty his poor cardopulmonary reserve
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that limited heart and lung capacity his
10:15
deconditioning from inactivity and his
10:18
chronic pain Okay these are the core
10:20
things that would make undergoing major
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abdominal surgery and that whole
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demanding recovery profoundly difficult
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for him And so the ultimate
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recommendation from this comprehensive
10:30
assessment was the bottom line was that
10:32
Mr R is currently considered a poor
10:34
candidate for surgical resection Right
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The assessment basically determined that
10:37
the exceptionally high risks for him
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likely outweigh the potential benefits
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especially given how slow growing that
10:43
tumor is and how it's behaved so far How
10:45
did Mr R himself feel about all this
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about the recommendation and his
10:49
situation The material is very clear
10:52
here Mr R is currently very firm
10:55
He is not interested in surgery Okay He
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said he enjoys his life as it is and
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he's content happy even that the tumor
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has been stable while they've been
11:04
watching it But his daughter
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understandably perhaps brought up a
11:08
point about the future She did She
11:10
voiced a really valid concern What if
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the tumor does start growing later Could
11:15
that make surgery even harder or maybe
11:18
impossible down the line She framed it
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as a potential window of opportunity for
11:23
surgery that might eventually close Yeah
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I can see that It really highlights
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those difficult long-term timing
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decisions you get with slow growing
11:30
problems in older patients It's tricky
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How did the clinician respond to that
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specific concern from the daughter Well
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the clinician acknowledged her point
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about possible future scenarios Made
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sense sure But they gently steered the
11:43
focus back to the present reality Mr R's
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current status They emphasized look the
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tumor hasn't shown recent growth Mr R is
11:52
currently very clear he does not want
11:54
surgery right And that actually from the
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clinician's viewpoint they were more
11:59
worried about the potential impact of Mr
12:02
R's other health conditions on his
12:04
well-being than they were about the
12:06
immediate threat from this very slow
12:09
growing tumor Were any future
12:11
possibilities discussed like what if
12:13
things change Yes they did outline what
12:16
might happen if Mr R's view changed
12:18
later or if the tumor started acting
12:20
differently Okay that would mean another
12:22
in-person visit Mhm They acknowledge the
12:25
limits of maybe doing this remotely
12:27
right They try to optimize his other
12:29
medical conditions as much as possible
12:30
first Makes sense Then there need to be
12:33
a re-evaluation if future scans showed
12:36
significant growth They mentioned maybe
12:38
a 10 20% increase as a trigger for
12:40
discussion Got it And then they'd have
12:42
more talks with the surgical team to
12:44
rebalance those risks and benefits at
12:45
that new point in time And how did Mr R
12:48
and his daughter seem to take all this
12:50
the assessment the conclusion The
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sources say they appeared happy with the
12:54
consultation with the clarity of the
12:56
assessment They seemed reassured that
12:59
these decisions aren't set in stone They
13:01
could be dynamic Mhm And they were told
13:03
the geriatric oncology team would still
13:05
be available if down the line Mr R
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decided he did want to explore what they
13:11
called potentially safe surgery which of
13:13
course really depends on his health at
13:15
that future time Okay Stepping back from
13:18
Mr R's specific case then Yeah What are
13:21
the broader takeaways here What's most
13:23
valuable for you listening trying to
13:26
understand these complex decisions Well
13:28
I think this case just powerfully
13:30
demonstrates why a really thorough
13:32
geriatric risk assessment is absolutely
13:35
fundamental when you're considering a
13:36
surgery for an older adult Yeah It
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hammers home that the decision is never
13:40
just about the disease the tumor here
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right It's fundamentally about looking
13:44
at the whole patient you know their
13:46
functional status day-to-day abilities
13:48
their complete list of other medical
13:50
conditions their history how their
13:52
bodies handled stress before like Mr R's
13:54
previous surgery their underlying
13:56
physical resilience their current
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quality of life as they define it and
14:01
crucially their own goals and priorities
14:03
for their remaining time And how does
14:05
that whole picture then feed into the
14:08
actual decision That's where shared
14:11
decision-m is paramount Yeah You have to
14:13
bring the patient their family fully
14:15
into the conversation Lay out the
14:17
nuanced risks the potential benefits
14:20
clearly Yeah Honestly it's really the
14:23
only ethical and frankly practical way
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to reach a decision that truly aligns
14:28
with what matters most to that
14:29
individual at that stage of their life
14:31
Yeah Balancing the medical options
14:33
against their overall health their life
14:34
priorities This deep dive into Mr ours
14:37
case it really shows how these medical
14:39
decision even something seemingly
14:41
straightforward like removing a tumor
14:43
just become incredibly complex once you
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factor in the full reality of a
14:47
patient's life right their history state
14:50
what they value it's not just the
14:52
disease in a vacuum you shared these
14:54
sources because you wanted to understand
14:56
these nuanced situations and hopefully
14:58
by walking through Mr ours journey with
15:00
us You can see how all these different
15:03
pieces a past medical event a physical
15:07
limitation even a personal view on
15:10
quality of life they all fit together
15:12
They guide a decision that aims to be
15:14
the best fit for that specific person
15:16
Exactly It's personalized medicine in a
15:19
very real sense And it leaves us with a
15:21
really challenging thought doesn't it
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You know Mr R isn't interested in
15:24
surgery now The risks are clear high and
15:27
he values his current life right But his
15:29
daughter raises that powerful idea that
15:32
the window of opportunity potentially
15:34
closing later Yeah How do we ethically
15:37
practically navigate that tension
15:39
balancing that urge to act now against a
15:42
potential future problem with respecting
15:44
a patient's current wishes and avoiding
15:46
really significant immediate harm
15:48
especially when the disease itself like
15:50
Mr R's tumor is moving so slowly It's a
15:53
tough balance It really makes you think
15:54
deeply about time about risk and about
15:57
what well-being truly means Not just
15:59
medically but you know in the context of
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a whole life being lived
#Aging & Geriatrics
#Cancer
#Surgery