Case Study: Behind the scenes of “streamlined” care

By Joseph Rosales, MD 

This study presents the case of a 37-year-old woman diagnosed with tongue squamous cell carcinoma. The patient first noticed a feeling of fullness in her tongue in October 2022, which progressively worsened over the next couple of months. She presented to the Emergency Room in December 2022. An ENT evaluation revealed a large tumor on her tongue, originating from the left side and crossing the midline, involving the entire tongue. Additionally, a palpable mass measuring 2 x 3 cm was detected in her left neck, consistent with lymphadenopathy. A biopsy confirmed the diagnosis of poorly-differentiated squamous cell carcinoma. A PET/CT scan in January 2023 identified increased uptake in a 4.1 cm mass occupying the entire tongue, along with necrotic-appearing left-neck level 1 and level 2 lymph nodes, up to 3cm in diameter. No distant metastases were detected. A tumor board recommended resection followed by adjuvant therapy. 

In March 2023, the patient underwent surgery which included a total glossectomy, tracheostomy, right and left modified radical neck dissection, and pharyngoplasty with an anterolateral thigh free flap. The pathology report classified the tumor as pT4aN3b. Following the surgery, the patient received adjuvant chemoradiation, which included radiation therapy of 66 Gy in 30 fractions with a boost to the tumor bed, ending in June 2023, and three cycles of Cisplatin every 21 days from May to June 2023. 

The patient had recently relocated to Seattle from the Marshall Islands. She and her husband were unemployed, on food stamps, and living with family in Des Moines, WA. She was covered by Medicaid under her maiden name and had no transportation. The patient missed an appointment in December 2023 and faced a denial for a CT scan in February 2023. In April 2023, she had a feeding tube inserted. Between May and June 2023, she missed multiple radiation therapy doses. The study highlights the complex interplay of medical and socio-economic factors in managing cancer treatment.