Complex jargon may prevent patients from understanding diagnosis
Q: After many bouts of pain in my left leg, I was referred for an MRI. They diagnosed me with left lumbar radiculitis, spondylolisthesis and lumbar spondylosis. There are many people in my independent living facility who have gotten similar diagnoses. As an RN with a masters in nursing education, I have a question: When the diagnoses are made, do doctors not explain the problem in layman’s terms?
I only found out my list of diagnoses from a physical therapist to whom I was referred.
A: Doctors certainly should explain their diagnoses in language appropriate for their patients. We can forget that the language we use is sometimes incomprehensible, but that’s not an excuse. A patient should always feel comfortable saying they don’t understand a diagnosis, or any other word or phrase their doctor uses, and ask for more explanation. Many of the most effective communicators I have seen not only ask the patient whether they understood but have made sure their patient can explain it back.
In your case, these specific diagnoses are generally not well known by nonexperts, and I am disappointed that they did not give you an explanation. Lumbar radiculitis is essentially sciatica — it’s an inflammation of the large bundle of nerve roots, which usually causes pain down the leg into particular locations based on which nerves are being affected. It is not a specific diagnosis, as it doesn’t say what is causing the damage to the nerves.
Spondylolisthesis is a condition where one vertebra overlaps another one below it (front to back, not side to side). Very mild spondylolisthesis will not cause any symptoms, but more severe cases can cause damage to the nerve roots. Spondylosis of the lumbar vertebrae is a nonspecific term signifying degeneration of the spine, usually due to osteoarthritis and often including degeneration of the disks in between the vertebrae.
So, these diagnoses together suggest that you have osteoarthritis of the spine, along with a displacement of one vertebra over another, causing damage to the nerve roots of the spine. These conditions would be likely to cause the back and leg pain you have on your left side.
Q: What are the risks for long-term usage of metformin for prediabetes?
A: Metformin is a commonly used treatment for Type 2 diabetes but has also been proven to prevent, or at least delay, the onset of diabetes in people who are at risk. This includes those who already have abnormal blood sugar but don’t yet meet the diagnostic criteria for diabetes — called “prediabetes” or “impaired glucose tolerance.”
Metformin works mostly by preventing the liver from making sugar. This allows the insulin a person makes to work on dietary sugar instead, which in turn lowers insulin levels, thus promoting weight loss.
Metformin is a very safe drug with few long-term side effects. Side effects are often gastrointestinal — nausea and diarrhea are the most common. These usually go away after time and can be minimized by using the long-acting form of the drug. Vitamin B12 deficiency happens in about 20 percent of people over a span of five years. The most severe side effect is called lactic acidosis. This is extremely rare and happens when metformin is only given to people with normal kidney function. Kidney function and blood sugar levels should be periodically checked when on metformin, whether for diabetes or prevention.
Q: I had been on hormone replacement therapy for 20 years or so and was diagnosed with breast cancer last year. I had a lumpectomy (stage 1) and radiation (external, five days a week for 21 treatments). Now, the oncologist is saying I need to start taking tamoxifen indefinitely. I have read online that it can cause memory loss, liver injury, stroke, blood clots and/or endometrial cancer. What are the chances of any of these happening? These possibilities seem potentially worse than the original cancer spreading.
A: Tamoxifen for breast cancer is indeed associated with a risk of serious medical issues, but you need to consider the benefits as well.
Memory loss was seen in some studies of tamoxifen. Verbal memory was decreased in one study (by about 0.2 points on a 45-point scale), and executive function speed was reduced by about 0.2 seconds. These results were statistically significant but small.
Women with breast cancer may develop fatty liver disease on tamoxifen treatment. This rarely causes symptoms and does not seem to increase the risk of severe liver damage. The risk can be reduced by about 50 percent through exercise.
Because tamoxifen acts like an estrogen in some ways, the risk of blood clots and stroke is increased. It is estimated that about 3 women per 1000 will have a stroke due to tamoxifen. However, tamoxifen protects against heart disease. So, about 3 women per 1,000 will not get a heart attack who otherwise would have, making the net effect of combined stroke and heart disease almost none. However, women at high risk for blood clots should probably not take tamoxifen.
The risk of endometrial cancer in postmenopausal women after five years of tamoxifen is approximately 3 women per 1,000, whereas it is less than 1 woman per 1,000 for premenopausal women treated with tamoxifen.
The risks of tamoxifen are real but small, and so you must weigh them against the benefits. I don’t have enough information to estimate your risk of a recurrence of breast cancer, but your oncologist does. As an example, a low-risk woman with small stage 1 cancer might have a risk of recurrence of 10 percent. Tamoxifen would be expected to reduce that by 30 percent to 40 percent, meaning an absolute risk reduction of 3 percent to 4 percent. For most women, the benefit in breast cancer recurrence is greater than the combined risk of stroke, blood clot, endometrial cancer and serious liver disease. Most women are on tamoxifen for five years, though some high-risk women will benefit from 10 years — but not indefinitely.
Your oncologist should be able to give you more-personalized risk and benefit estimates than I can give, in order to give you the best information to make your choice.
Q: Can I take testosterone replacement if I have benign prostatic hypertrophy?
A: Because prostate tissue can grow with testosterone treatment, it’s a reasonable question. But, in a large study comparing men who were on testosterone treatment versus an inactive placebo, there wasn’t any difference in the symptoms of an enlarged prostate (among the most common symptoms are a slow urinary stream and increased urinary frequency). That’s probably because the testosterone replacement just gets men back to normal levels of testosterone, not to excessively high levels.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Drive, Orlando, FL 32803.