Man On Hormone Treatment for Prostate Cancer Told He Has Osteoporosis — Free SCA Practice Case

Character Overview: You are Cedric Lamptey, a 70 year old retired tax inspector. You live with your wife Hortense in a semi detached house, and your son Kofi lives in Leeds with his two young children, whom you visit most months. You were diagnosed with prostate cancer about two years ago, had a course of radiotherapy, and have had a hormone injection implant every twelve weeks since, which the nurse here gives you. Your last cancer results were good and the plan is to carry on until you have had three years in total. The hospital arranged a bone scan because of the injections and sent you a letter saying the result was low and you should see your GP. You are a precise, courteous man who likes things explained properly and writes things down. You are surprised and a little unsettled, because you always assumed brittle bones was something that happened to older women. Your voice is polite and measured, with a worried edge when you mention your mother or the injections.

Opening Sentence: "Good morning, doctor. I've had a letter from the hospital about my bone scan and it says my bones have come out low and that I should speak to my GP. I have to say, I'm rather surprised, I thought that sort of thing was for women."

History if Asked (Data Gathering Phase)

• ●Why the scan was done: "The cancer doctors said the injections can thin the bones, so they sent me for a scan to check. I didn't think much of it until the letter came."
• ●The cancer treatment: "Radiotherapy finished about twenty one months ago. I've had the implant every twelve weeks since, the nurse here gives it. I'm told the PSA is undetectable. They want me to carry on for a year more, to three years altogether."
• ●Symptoms from the treatment: "Hot flushes, mostly in the evening. I'm tired a lot of the time. I've put on about a stone. My drive for anything, well, that has gone, and I'd rather not go into it."
• ●Fractures: "None. I've never broken a bone in my life."
• ●Falls: "No falls. I tripped on a kerb once last year but I caught myself on a lamp post."
• ●Back pain and height: "No back pain. I don't think I've got shorter, though Hortense says I look a bit rounder in the shoulders than I used to."
• ●Bone pain or other symptoms: "No bone pain anywhere. No weight loss, my appetite is normal, no fevers and no infections."
• ●Family: "My mother broke her hip at 82 when she slipped in the kitchen. She never really walked properly again and died within two years. My father had nothing like that."
• ●Smoking and alcohol: "I gave up smoking about twelve years ago. I smoked about fifteen a day for thirty years. I have a pint, sometimes two, most evenings with my tea. Perhaps ten to fourteen units a week if I'm honest."
• ●Diet and sunlight: "I don't like milk. I have a yoghurt now and then, a bit of cheese, and I eat fish. I get outside a fair amount in the garden, but I don't take any vitamins."
• ●Activity: "I used to walk five miles. Now I manage about twenty minutes, to the shops and back. I've never done anything with weights."

Ideas, Concerns, Expectations

Gating note: Cedric does not raise any of the following himself. Each part comes out only when the doctor asks what he makes of the result, what is worrying him, or what he is hoping for.

• ●Ideas: He believes brittle bones is something that happens to women after the menopause. He wonders whether the injections have caused it, or whether he is simply old. "I thought that was a women's complaint. Is it the injections? Or is it just age?"
• ●Concerns: His first fear is that the doctors will stop the injections and the cancer will come back. His second is ending up like his mother, who never recovered from her broken hip. His third is that his friend Ambrose told him that Ambrose's wife took bone tablets and "ended up with a rotten jaw". "I'm not stopping the injections, am I? I don't want the cancer back. And Ambrose's wife had a terrible time with her jaw after those tablets."
• ●Expectations: He wants to be told what the result means in plain terms, whether the cancer treatment carries on, and what can be done. He would prefer to avoid anything that means more hospital trips. "I'd like to know where I stand, and what you'd advise. I just don't want to lose my place in the cancer plan."

If Asked: Medical History and Medications

Gating note: Cedric answers each of these plainly when the doctor asks about it.

• ●Other health problems: "Blood pressure, tablets for that, and acid reflux. Nothing else. No diabetes, no thyroid trouble, no liver or kidney problems that I know of."
• ●Steroids and other tablets: "No steroid tablets or inhalers, ever. Only the amlodipine and the lansoprazole, which I've had for about six years."
• ●Reflux and swallowing: "I get heartburn now and then after spicy food, and the lansoprazole keeps it under control. I've never had trouble swallowing, never had an ulcer or a camera test, and I can sit up as long as I like."
• ●Bowels and stomach: "Normal. No diarrhoea, no coeliac, nothing like that."
• ●Teeth: "I haven't seen the dentist for about eighteen months. A lower back tooth is a bit wobbly and I've been putting it off. No dentures, otherwise my teeth are good."
• ●Mood: "A bit flat some days with the tiredness, but I'm not depressed."
• ●Allergies: "None."

Social History and Lifestyle Impact

• ●Home and family: Cedric lives with Hortense, who still works two days a week as a school secretary. He is close to Kofi's children and likes lifting his four year old grandson, which he now wonders about.
• ●Daily life: Retired for five years. He is on the committee of the local history society and drives to its meetings. He is happy to book appointments any weekday.
• ●Alcohol and exercise: If the doctor suggests cutting down, he thinks a pint with his tea is harmless but is willing to hear why. He is reluctant about gym work but would do walking or home exercises he could write down.
• ●Practicalities: He wakes early and has a cup of tea first thing. He is happy to change that habit if it is explained.

If Asked: Associated Symptoms

Gating note: Cedric answers these only when asked. Every one is negative unless stated.

• ●If asked about new back pain, pain in the ribs or hips, or a recent fall: "No, none at all."
• ●If asked about thirst, passing a lot of water, constipation or kidney stones: "No."
• ●If asked about night sweats, fevers or recurrent infections: "Only the flushes, which are the injections. Nothing else."
• ●If asked about weight loss: "No, the opposite. I'm heavier."
• ●If asked about testing his own balance, standing on one leg or checking his height: "I'd rather not try that on the phone. Can you check me in the surgery?"
• ●If asked about bone pain, muscle weakness or trouble getting up from a chair: "No."

Responses to Management (The Negotiation Phase)

• ●If the doctor explains what the result means and why it has happened:
  • ●Reaction: Interested and a little reassured to have an explanation. "So men get it as well, especially on these injections? Why did nobody mention that when I started?" He asks for it to be put simply. "So it's the treatment lowering my hormones that is thinning my bones? Right, I understand that." He asks, "Should I be worried I'll break something?" If told it is a raised risk and not a certainty: "Right, so it is a risk rather than a certainty."
• ●If the doctor discusses stopping, changing or continuing the injections, or involving the cancer team:
  • ●Reaction: Anxious and then relieved. "I don't want it stopped unless the cancer team agree." If told the injections carry on and the cancer team will be told: "Good, that's what I wanted to hear. Will you write to them?" If told that stopping is something only the cancer team would discuss: "Then I'll leave that with them."
• ●If the doctor suggests tests before treatment:
  • ●Reaction: Agreeable but wants the reason. "What are the blood tests looking for?" He agrees to bloods and to being seen in the surgery. "I'm happy to come in. I haven't had my bloods done since the hospital three months ago."
• ●If the doctor suggests a bone strengthening tablet:
  • ●Reaction: Cautious, asks practical questions. "How do I take it? I have my tea first thing." "I already have heartburn and take lansoprazole, will it make that worse?" "How long would I be on it?" Then, if the jaw is not mentioned: "Ambrose said his wife's jaw went rotten. Is that a risk?" He accepts a dental check and a tooth plan. "I'll book the dentist this week. Can I do that before I start?" If a yearly injection or a different treatment is offered instead: "I'd rather tablets if they are as good, but I'll listen."
• ●If the doctor advises on calcium, vitamin D, alcohol and exercise:
  • ●Reaction: Pragmatic. "I don't drink milk. Can I get it from tablets?" About alcohol: "A pint with my tea. Is that really a problem?" He accepts a sensible limit if the reason is given. About exercise: "Weights at my age? I could do a walking plan, if you write it down. Is lifting my grandson all right?"
• ●If the doctor gives outlook, follow up or safety netting:
  • ●Reaction: Wants specifics. "Will this ever go back to normal? How will I know it's working?" If safety netting is vague, such as "come back if you have problems": "What sort of problems? I'd like it written down." He repeats back clearly when given specific symptoms and what to do.