Detecting cancer by chance

I was recently invited to speak at a seminar titled How To Fight Cancer? in Jakarta, Indonesia. Although the seminar had been scheduled to begin at 9.30am, people were lining up to register by 7am. Cancer talks almost invariably draw large crowds. This is partly because cancer has become so much a part of our lives – most people would know of a friend or relative who has cancer. It has become a disease feared by most.

The questions asked during the question-and- answer sessions in such seminars are almost always the same. This time, a man in his 50s asked: ‘What do I need to do to detect cancer early?’ I smiled and instinctively responded: ‘Pray for God’s grace.’ The audience cheered in appreciation of my candid response.

As usual, I related a real story to illustrate my point. Recently, I received a text message from an old schoolmate to ask if I could accommodate the father of his friend for a medical consultation. Of course, I agreed. Mr Chan, in his 60s, was a heavy smoker. He puffed 20 cigarettes a day for almost four decades.

He recently went to see his general practitioner, who suggested that he should have a panel of blood tests. This panel of blood tests, commonly referred to as multi-phasic blood investigations, is often prescribed as a screening panel.

Included in the panel are blood counts and tests for kidney and liver function, cholesterol, uric acid, calcium and antibodies against hepatitis B. The urine and stools are usually also analysed. Invariably, two cancer markers are included in this panel. One of these two cancer markers is called carcino-embryonic antigen (CEA). Mr Chan’s CEA was found to be mildly elevated at 5.5 (the normal being between 0 and 5).

It is well known that this marker is often raised in smokers. In fact, most accept that a CEA level of below 10 can be considered as normal among smokers. The use of CEA for cancer screening is not recommended by the Ministry of Health (MOH).

In the MOH Clinical Practice Guidelines on Cancer Screening dated January 2010, the experts said CEA is not recommended as a screening test. By carrying out a CEA test on Mr Chan, the general practitioner had disregarded the guidelines set by the ministry. The mildly elevated cancer marker had caused enough anxiety in this man that he had sought to see me urgently.

He was accompanied by a very concerned daughter and son-in-law. I gave them the option of just monitoring the marker over the course of time or proceeding with computed tomography (CT) scans of the chest and abdomen. I also explained to them that these further tests could find other abnormalities that might or might not be significant.

And these abnormalities might lead us to do even more investigations, I added. The patient and family decided that they did not want to leave things to chance and wanted to proceed with the scans. To cut a long story short, this man was found, on a CT scan of the chest, to have a 1.1cm nodule in the left lung. An interventional radiologist inserted a fine needle into the nodule and managed to aspirate a few cells for examination. These cells were seen by our pathologist and suspected to be cancerous.

A positron emission tomography (PET) scan was done to rule out any spread of the tumour to other parts of the body. Mr Chan then proceeded to have surgery for resection of the tumour. The final diagnosis was an early stage 1 lung cancer with an excellent outlook for cure. Mr Chan did not need to have any chemotherapy or radiotherapy as follow-up treatment.

Most types of lung cancer – about 85 per cent – are diagnosed at either stage 3 or stage 4. It is very rare to diagnose all types of lung cancer early because these tumours tend to be silent until they have grown and invaded into the nearby structures or spread to other parts of the body.

If Mr Chan did not see his general practitioner for a routine check up, if the doctor decided to strictly follow the cancer screening guidelines, if the patient did not come to see me and if the family decided on taking the wait-and-see option… There were so many ifs that could have delayed the diagnosis of lung cancer. And, at each stage, the alternative decision leading away from the diagnosis would not have been wrong.

Cumulatively though, they would have been disastrous. Today, the patient is alive and well. Mammography has been shown to be useful for early detection of breast cancer, colonoscopy for colorectal cancer and the Pap smear for cervical cancer.

But, there is no proven screening test for lung cancer. It is truly by the grace of God that we sometimes detect cancer early. This article first appeared in "Mind Your Body", a Straits Times Supplement.

POSTED IN Cancer Prevention, Cancer Treatments
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