Diagnosis – pro

Diagnosis is when things get serious.

One can avoid engaging with the illness only up until the point of diagnosis. Few people forget the moment in which they learn of having a cancer diagnosis. No matter how serious and disabling the symptoms, they can be denied or rationalized away – not so the diagnosis of cancer. Denial after this point is not uncommon but it is clearly recognized for what it is – a maladoptive response to intolerable stress.

These three words overturned my life – Soraya.

However, diagnosis is a beginning. It can be a beginning of a struggle for life, of meeting challenges with courage and determination, or it can begin a process of retreat before the harsh reality of a serious illness.

Diagnosis is inextricably related to prognosis and the prognosis is what will determine the plan of treatment.  For your doctor a diagnosis of cancer launches a process of staging, and treatment planning. For the patient, it begins the process of  taking  responsibility of working with or along your health care provider.

The first question that the diagnosis often provokes is, “Doctor, are you sure?”. A better question to ask is: “How certain is the diagnosis”. As we will soon see, only a pathologic diagnosis deserves respect.

How is the pathologic diagnosis made?

One of the first things that I learned in my medical training was that there is no diagnosis of cancer without pathology. In fact, when a physician wish to ascertain that a final (rather then a clinical or preliminary) diagnosis has been obtained, he or she would ask: “Is there a pathologic diagnosis?” Without a pathologic diagnosis, not only is there no seciue diagnosis, there also cannot be treatment plan (we will discuss the rare exceptions to this principle later). Let us explain what is a pathologic diagnosis.

No meat, no treat – Medical “pearl”.

First, understand the concept of “differential diagnosis”. The term “differential diagnosis” refers to the many possible diagnoses that can cause a specific symptom (what the patient feels) or sign (what the doctor finds on a physical exam). Thus, for example, a headache can be caused  by literally dozens of potential diagnosis (see Table 14). Medical students are taught to construct lists of “differentials” for every symptom and sign and that compare these lists to one another (experienced physicians, like all experts often skip these steps and directly zero on the most likely diagnoses)`. Thus, for example, a patient who has a headache, stiff neck, nausea and vomiting will have lists of possible diagnoses for each of these symptoms; however, meningitis will be present on all of these lists. It will, therefore, become the leading potential diagnosis. However, until, a lumbar puncture provides patologic ( or microbiologic) evidence of meningitis, it will remain a potential but unproven diagnosis. It might be, that the spinal tap will surprise the physician with a heretofore not considered diagnosis.

The same is true of cancer diagnosis. Until a breast mass is biopsied it is only potentially a breast cancer. It may turn out to be an abcess, a lymphoma or a benign tumor located in the breast. Only after the pathology had been obtained, would the differential list translate into the final diagnosis.

If you hear hoofs behind you assume it is a horse; don’t assume it’s a zebra – Osler, explaining why the more common conditions would top the lists of differentials)

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