Update: A 68-Year-Old Man With COPD Contemplating Colon Cancer Surgery

In a Clinical Crossroads article published in May 2007,¹ Gerald Smetana, MD, weighed the pulmonary risks of colon cancer surgery for Mr A, a 68-year-old man with severe chronic obstructive pulmonary disease, peripheral vascular disease, high cholesterol, high blood pressure, and extensive tobacco use. In December 2005, Mr A had a colonoscopy revealing a malignant-appearing, friable infiltrative sigmoid mass. Mr A subsequently consulted 2 general surgeons; both recommended that the tumor be resected.

Mr A had a 75-pack-year history of smoking. He had tried to quit smoking several times with a nicotine patch but never had any long-term success. The discovery of the mass in his colon increased his dependence on cigarettes for stress management and impeded any further efforts to quit. He regularly coughed up sputum in the morning, experienced a chronic cough, and had several episodes of “bronchitis” and upper respiratory tract infections. He also had intermittent episodes of angina. His peripheral vascular disease limited his ability to exercise.

Mr A was extremely anxious about undergoing surgery, worrying especially about the risk of never coming off a ventilator. Consequently, he was forced to weigh the risks of abdominal surgery against the risks of leaving the tumor untreated. Although the nature and severity of the tumor could not be assessed before surgery, Dr Smetana believed that Mr A faced a greater mortality from untreated colon cancer than from surgery. He recommended that Mr A and his physician discuss the risks of postoperative pulmonary complications and weigh the benefit of smoking cessation at least 2 months before surgery against the risk of cancer progression over that time. Furthermore, Dr Smetana encouraged Mr A to explore whether laparoscopic surgery or a lower abdominal incision would be possible to reduce the risk of postoperative pulmonary complications. Finally, given Mr A's significant cardiac history, Dr Smetana suggested Mr A might benefit from the administration of perioperative statins and clonidine.

Mr A preferred that we speak with his primary care physician, Dr N, about his current health condition.

Mr A decided to have the tumor in his colon resected. Because there were no nonoperative approaches to treating his cancer, the tumor was expected to spread if Mr A did not have surgery. Following his physician's advice, Mr A tried to quit smoking before the surgery but was unable to do so. Despite this setback, the surgery went well overall and appeared to be curative.

Mr A spent 9 days in the hospital following his surgery. It was relatively easy to wean him from the respirator, but he developed a venous thrombosis in his neck because of an indwelling catheter. As a result, Mr A received anticoagulation for a month.

Since the surgery, follow-up colonoscopies and computed tomography scans have not shown any evidence of tumor recurrence. Mr A's health has otherwise remained stable, although there has been some exacerbation of his chronic obstructive pulmonary disease and a few brief hospitalizations. He developed cholecystitis, which was resolved with drainage. Because of his high operative risk, Mr A was not able to have an open or laparoscopic cystectomy.

Most recently, Mr A has developed a football-sized ventral hernia with some overlying skin breakdown, and both are very uncomfortable for him. Although the presence of the hernia has worsened Mr A's shortness of breath and greatly limited his daily activities, his cardiologist has advised Mr A against undergoing any other elective surgeries. There is concern among his physicians that Mr A would not survive surgery or that repair of the hernia could potentially decrease the room available for his lungs to expand.

After his tumor resection, Mr A began drinking more heavily. Although this problem was successfully addressed, Mr A's depression worsened. He consulted a psychiatrist close to his home and began taking higher doses of antidepressants. He is doing better and no longer has clinical depression. Nevertheless, Mr A remains quite discouraged by his health and the limitations on his daily life. He continues to smoke between one-half and one pack of cigarettes per day.