Keep looking ahead

An articulate man in his late 40s, he had a lot to get off his chest.

‘Please give me some time to tell my story from the beginning,’ Mr Lim said as he sat down on the chair across from my consultation desk.

Despite a queue of about 10 patients waiting to see me, I knew that it was important to allow him to tell me what had happened in his own way, even though his medical records already told me what I needed to know.

His story began in March, when he went for a routine check-up with a general practitioner.

He was found to be mildly anaemic – his haemoglobin (oxygen-carrying protein attached to red blood cells) concentration level was 13g/dl, lower than the normal level of 13.5g/dl.

He was reassured by the doctor that this was ‘quite common’ and did not justify further investigations.

Unconvinced, he went to a government polyclinic to have it rechecked.

Again, the check showed that he was merely mildly anaemic. Again, he was reassured that this was ‘normal’ and did not require further action.

In August, he developed some body aches after helping his sister to move house.

He went back to the polyclinic doctor and asked for a blood test. The test found that his haemoglobin concentration level had dropped to 11g/dl.

At his insistence to be seen by a specialist, he was referred to a colorectal surgeon for routine colonoscopy.

One of the most common causes of anaemia in a man is occult blood loss from somewhere within the gastrointestinal tract. Bleeding piles, peptic ulcers and cancer of the stomach or colon can often account for anaemia which does not have any symptoms.

After the colonoscopy, Mr Lim was told that he had some small polyps in his colon and these had been removed.

The surgeon explained that these polyps were not cancerous but showed lymphoid hyperplasia.

Mr Lim related: ‘When I asked him what lymphoid hyperplasia was, he told me that the lymphatic cells were just reactive and these were not of concern.

‘I pointed out to him that I had some swollen glands in my neck.’

Mr Lim was referred to another doctor who carried out a test on one of the lymph nodes.

The diagnosis again came back as lymphoid hyperplasia and no treatment was recommended.

Months later, he decided to go and have a blood test again. To his surprise, the haemoglobin concentration level had dropped even further.

He immediately made an appointment to be reviewed by the colorectal surgeon. He pleaded for repeat colonoscopy although it had been less than six months since the previous procedure.

‘I purged the whole night to clear my bowels. I went the next day, signed the consent form and they injected me with an anaesthetic in preparation for the colonoscopy,’ he said.

When he woke up, he asked if the procedure was over and was told it had been cancelled because it was not necessary.

This was because the surgeon had looked through his medical records and found that the final diagnosis of the polyp removed months ago was malignant lymphoma.

Malignant lymphoma is a type of cancer of the lymphoid tissue.

As it turned out, Mr Lim had one of the more aggressive forms of lymphoma called mantle cell lymphoma.

‘That’s how I ended up coming to see you,’ he explained.

That same day, he underwent a positron emission tomography scan which showed that his cancer had spread to the lymph nodes in his neck, chest, abdomen and spleen.

The bone marrow biopsy also showed the presence of lymphoma cells, indicating that he had stage four cancer.

‘How could this have happened?’ he lamented.

It was difficult for me to explain what happened.

How it happened and why it happened is unimportant at this point in time. What matters is that he had an aggressive form of cancer and he needed treatment as soon as possible.

Mr Lim began his chemotherapy the day after he saw me. By the fourth day, most of the lymph nodes in his neck were already smaller.

While I expect the response to treatment to be good, his road ahead is a long and tortuous one.

‘One day at a time,’ I reminded him. ‘Look ahead and not back.’

This is easier said than done and perhaps rather tepid consolation for his ordeal.

However, as doctors, the end of the year is a good time for us to reflect on what we could have done better.

It is only by constantly glancing at our rear-view mirror that we can travel safely ahead.

This article first appeared in "Mind Your Body", a Straits Times Supplement.