Most likely: Carcinoma of the oesophagus (long history of oesophagitis; progressive dysphagia sensation; weight loss; reduced appetite).
Open questions — give freely:
For the last month: can feel food go down the food pipe (does not actually stick). Usual heartburn medication has not helped. Reduced energy and poor appetite for about a month.
Only if asked directly:
Ideas: Related to longstanding heartburn.
Concerns: Not really worried about anything serious.
Expectations: Stronger antacid prescription.
Feelings: Plays things down; not overly worried.
Nil of note (adopted).
Intelligent, cheerful, slightly worried but plays down symptoms. Does not like being ill.
Management Part 1: Reassurance not appropriate. Explain negative exam does not exclude serious problem. 2WW referral for dysphagia (gastro / upper GI). Agree bloods (FBC, CRP, LFTs). Advice: softer food, well chewed; increase fluids/milky drinks. Follow-up after endoscopy.
Returns ~10 days after endoscopy. Feels much better; swallowing improved after procedure. Had discussion with consultant but “didn’t take anything in” — recalls waiting for biopsy results.
Hospital letter (patient may demand to see):
Extensive tumour lower one-third of oesophagus; histology confirmed adenocarcinoma. LFTs grossly abnormal — strongly suggests hepatic secondaries. Radical excision may not be possible. Next: MRI + MDT (surgeon + oncologists). Options may include stent for swallowing; chemotherapy may improve prognosis somewhat. Consultant had not fully discussed findings with patient pending histology.
Full letter (show if the patient asks to see it):
Hospital letter
Dear Dr X
RE: MRS MARGARET / MR MICHAEL ASHBY, AGE 60 YEARS
Thank you for referring this patient for endoscopy. I found an extensive tumour at the lower one-third of the oesophagus and histology has now confirmed an adenocarcinoma. Unfortunately, liver function tests are grossly abnormal strongly suggesting hepatic secondaries.
Radical excision may not be possible, the next step would be to organize an MRI and refer him/her to the multi-disciplinary team which includes myself and the oncologists to discuss the treatment options. This may include placing a stent to improve swallowing. However, the oncologists are likely to recommend a more aggressive approach with chemotherapy which may improve the prognosis somewhat.
I have not fully discussed these findings with the patient as I had not had the confirmation of the histology at the time of endoscopy. I told him/her I would be writing to you, however, so he/she may well come to see you in the near future.
With kind regards
Yours sincerely
Breaking bad news principles: Find out what patient was told; indicate letter does not contain good news; allow response. Explain obstruction due to growth; let patient use word “cancer” if ready. Acknowledge distress, denial and anger. Offer support for patient and spouse (same-day / home visit). Realistic discussion of outcomes (lower-third oesophageal cancers have poor prognosis).