you are a junior doctor working on a general medical ward.

You have admitted a 58-year-old woman for urgent investigation.

She has a 2-week history of low back pain which is now keeping her awake at night.
Over the past 2 days she has noticed progressive numbness and weakness of both legs, and also sphincteric
weakness.
She had breast cancer with axillary node involvement 4 years ago, but was told at her last outpatient
appointment in the oncology clinic 6 months ago that she was‘fine’.
On examination she has bilateral lower limb sensory impairment and lower motor neuron weakness.
A plain radiograph of the spine shows at least one suspicious lesion.

to explain to her that she has cord compression of uncertain cause but with a strong suspicion of malignancy.
The plan will be for her to have MRI of the spine and that surgery will probably be recommended, but that this
will not be curative.

Your discussion with the patient should cover the following areas:
• her understanding of the problem;
• your explanation of her symptoms;
• the probable underlying cause;
• the treatments available;
• the likely prognosis.

• That there is a problem with the patient’s spine: it is pressing on her spinal cord and causing a blockage of the
nerve signals to the lower half of her body.
• That this is a serious problem, probably related to her breast cancer, which needs urgent investigation and may
require surgical intervention.
• That, even in the worst case, there will always be support and a plan of management.
In routine clinical practice (and in PACES, although the offer will inevitably be declined) encourage the
presence of a close friend or relative if the patient wishes it.
As well as providing support, this will spare the patient the necessity of repeating the explanation and may
improve her overall understanding of the problem.

 I don’t know, but I’m afraid that there is a good chance that it could be the cancer.
 We won’t know for certain until we have done some tests.
 We’ll start off with a scan, an MRI scan, of the spine and then probably perform an
operation to relieve any pressure on the spine and take samples for analysis.
 If it is the cancer, we will arrange for you to see the cancer specialist to talk about
further treatment.
  I know, because at that time you hadn’t got any back pain or any problems with your
legs.
 If this is the cancer coming back, then it seems as though that’s happened just in the
last few months.

 that’s a good question, but I’m afraid that I don’t know the answer.
 Scans of the spine aren’t organised as a routine, only if there seems to be a problem.
 However, this is something that you could discuss with the oncologists if and when
you see them.

 you’re right in saying that all surgery has risks, but this is not something we’re going
to race into.
 The surgeons will look at your scans very carefully and will discuss things with you
before you make the final decision.
 They will only recommend going ahead if they agree that there is a good chance of
success.
 If you didn’t have surgery, your legs might get worse and it would be difficult to
know what was causing the problem or how to treat it.
 Is there anything in particular about the surgery that is worrying you?

 if it is possible to remove it, then the surgeons would do so.

 However, trying to remove the whole tumour may well damage your spinal cord so
it’s likely that the surgeons will just take enough to relieve any pressure.
 If further treatment is necessary, then radiotherapy treatment or medication will
probably be recommended, but this is something on which the oncologists would
advise.

 if it is cancer, then you are right in thinking that we probably won’t be able to get rid
of it completely.
 But having said that, there are treatments that can work pretty well and it is possible
for some people to live a relatively healthy and normal life for some time, even
though the cancer is not completely removed.

 It is important that you are realistic in your explanations.

 This patient will undoubtedly need to have trust and confidence in her medical team in the future.
 Although it is important to be as positive as you reasonably can be in your attitude, a falsely over-
optimistic assessment at this stage is likely to result in increased distress and loss of trust in the medical
team in the future.