In my experience, one of the hardest things for a doctor to do is to tell a patient to stop treatment. It takes a good deal of courage and not a decision that we take lightly. The battle has been lost, and we are just waiting for the end to come.
Siew Khin’s battle with cancer started in March 2012. At that time, she had undergone surgery to remove her uterus as well as both her ovaries. She was diagnosed to have malignant mixed Mullerian tumour.
This is a fairly rare cancer that occurs in only 2 to 5% of all the cancers of the uterus. It is called a “mixed tumour” because the malignant tissue contains both carcinoma (malignant cells arising from epithelial tissue) as well as sarcoma (malignant cells arising from connective tissue).
After the surgery, Siew Khin went through six cycles of chemotherapy. However, less than a year after her chemotherapy, the cancer recurred. She went through more rounds of chemotherapy till June this year.
Then, she was advised by her doctor that the disease was getting worse. It was time to stop all active treatment and focus on preserving her quality of life. Siew Khin accepted the doctor’s decision.
Within three months, the cancer grew with a vengeance and the disease destroyed her liver and other organs. She needed a wheelchair and someone to assist her in getting around as her abdomen swelled to the size of a pregnant woman and the legs doubled in size from water retention.
When I first met her in October, she was jaundiced (the skin turns yellow because the liver fails to get rid of the bile juices) and she tipped the scale at 64kg, 10kg more than her usual weight because of fluid retention.
Accompanied by her grown-up children, she had come to see me because she was desperate for any form of treatment which might give her a chance of getting better.
Although she had been heavily pre-treated with three lines of chemotherapy, I did have something up my sleeve.
There is a fairly old chemotherapy drug called doxorubicin, which I have used many times in the past for treating patients with malignant mixed Mullerian tumour.
The only problem is that the medical literature is emphatic that doxorubicin must be used with extreme caution in patients with jaundice (meaning patients with raised serum bilirubin levels).
When the serum bilirubin level is slightly raised (1.5 to 3 mg/dl), the dose of doxorubicin must be halved. If the serum bilirubin level is moderately raised (3.1 to 5 mg/dl), 75% dose reduction is recommended.
When the serum bilirubin is above 5mg/dl, the medical literature clearly states that doxorubicin must not be initiated or should be immediately discontinued if the patient is already on treatment.
When Siew Khin came to see me, her serum bilirubin was 6.5 mg/dl.
The PET-CT scan showed that the cancer had spread extensively throughout the liver. There was disease recurrence in the pelvis where the original cancer had been. There was also spread of the cancer in the fat apron inside the abdomen and along the abdominal wall.
I was in a real dilemma. To treat or not to treat?
As I stared blankly at the results of the blood tests and PET-CT scan, I muttered a silent prayer.
I explained the seriousness of the cancer, the option of doing nothing versus treatment with a doxorubicin-containing chemotherapy program. Most importantly, I highlighted the potential dangers of treatment which included death from drug-induced liver failure.
With little hesitation, Siew Khin consented to treatment and chemotherapy was started the same day. One week later, she walked into my consultation unaided. She had lost 11 kg from massive diuresis (passing out lots of urine).
But her serum bilirubin had risen further to a hair-raising 10.2 mg/dl.
When I reviewed her before her second cycle of chemotherapy, her weight had stabilized and the serum bilirubin settled down to 2.6 mg/dl. She has just had a follow-up PET-CT scan and all the metastases have reduced in size as well as in metabolic activity.
Today, amazingly, Siew Khin’s serum bilirubin is 1.4 mg/dl – within the normal range.
The practice of medicine is thickly covered by rules to ensure that we do not put patients at undue risks. I know these rules, and I know the consequences of breaking them. As a result, I shudder to think what could have happened to the patient (and to me) if things had not turned out well.
The end, of course, will come for Siew Khin – as it does for all of us. But as this is the season of peace and joy, I shall set aside that thought and simply thank God that we have made it through another year filled with His grace.
By Dr Ang Peng Tiam