Sudden onset of appendicitis reveals potential cancer
BY KEITH ROACH, M.D.
DEAR DR. ROACH: Recently I had a sudden onset of appendicitis and was operated on the following day laparoscopically. The surgeon explained to me that the surgery took longer than usual because of scar tissue from a total hysterectomy 10 months earlier. He said my appendix was enlarged and inflamed around the site and had some samples sent for testing on the chance of cancer. This blindsided me. He said if I were positive for cancer, I would be sent to an appendix oncology surgeon. This was totally unexpected and very upsetting. The doctor said not to worry and that I would get the results in two weeks. Of course, I can’t stop worrying. How common is this, and what is the likelihood of this coming to pass? — I.B.
ANSWER: Cancer of the appendix is very rare, found less than 1% of appendectomies. Sometimes, all the cancer cells have been completely removed in the appendectomy, while other times, further surgery is done to make sure the cancer is completely gone. Many experts recommend further surgery on all patients with appendix cancer, but this is debated.
I.B. wrote back to say the test result was negative for cancer and noted: “I have always wondered if patients need to know in advance if cancer is a possibility or if the doctor should wait until tests come back and break the bad news only if that comes to pass. I’m not sure which way I lean.” In general, I favor giving my patients as much information as possible, and while in this case there was some reason to suspect cancer was more likely, I don’t feel telling people about a minuscule risk is helpful. It certainly leads to greater anxiety. I’m curious what readers think and invite comments at my Facebook page, facebook.com/keithroachmd or by email.
DEAR DR. ROACH: A recent column advised topical corticosteroids in patients with sinusitis. I have been told that corticosteroids lower defenses against an infection. Do steroids make infection harder to treat? — D.V.
ANSWER: In any infection, there is danger from the infection itself as well as danger from the body’s response to infection. Sometimes, the body’s overly vigorous response causes more problems than the infection. In the case of sinus infection (both viral and bacterial), the inflammation in the sinuses can keep the sinuses from draining, which is a fundamental way the body has of curing the infection. Corticosteroids decrease the swelling around the entrance/exit of the sinuses, which speeds relief of symptoms. Using topical steroids decreases any adverse effect on the immune system. In fact, a comparison trial of nasal steroids alone versus antibiotics alone found that steroids work better than antibiotics.
Systemic corticosteroids are very dangerous in some infections. In a person with severe tuberculosis, oral corticosteroids like prednisone can have a fatal effect. This is thought to have contributed to the death of Eleanor Roosevelt. On the other hand, in some cases of sepsis, meningitis and severe cases of COVID-19 in people with low oxygen, steroids decrease the fatality rate. We have much better data now on when steroids are helpful and when they are harmful in severe infections.