29 JANUARY 2014
The limits of reason
It is always a nerve-wrecking time for patients when they come for their annual full evaluation. Some patients tell me that they become exceptionally irritable, have sleepless nights, or frequent loose stools for days before they are due for their annual review.
It is understandable. After all, the annual review is a red letter day of sorts. The more routine follow-up visits involve taking a clinical histology, physical examination and reviewing blood test results.
To confirm cancer recurrence, I need radiological scans. It is not possible to scan patients every month or every visit. Quite aside from the cost, excessive exposure to radiation may carry with it long term adverse effects.
But once a year, we do a thorough check. For Mario, the news was exceptionally good.
“All clear!” I happily declared as Mario waited patiently for me to finish reviewing all the scans. It has been four and a half years since his surgery and chemotherapy for lung cancer. Every year, this 74 year old Indonesian from Pangkal Pinang, has been coming for a PET-CT scan and MRI of the brain.
When he first saw me in April 2009, he had a lung cancer with a single lesion in his brain. He completed his treatment, consisting of surgery followed by six cycles of chemotherapy. Mario’s “metastasis” disappeared after three cycles of chemotherapy and never recurred.
The consensus, after he completed his chemotherapy, was not to carry out radiation to the brain as the lesion could no longer be seen. Instead we opted for close surveillance. Mario has been making it a point to come by to see me every two to three months for his medical review.
After that visit in October 2013, Mario and his family left my consultation room feeling reassured that all was well.
Then three months later, Mario came again for his medical review. As usual, I greeted him with a bright smile and a hearty “Good morning!” As I looked at the results of his blood tests, my face fell. His CEA (Carcinoembryonic antigen), a cancer protein, had risen to 24.8ug/l (the normal being less than 5).
I quickly looked back at the results in October. The CEA at that time was 1.5ug/l, well within the normal range.
How can it be? Perhaps it was a laboratory error? Is it possible that his cancer had recurred when the scans were normal less than three months ago?
I sent Mario for a PET-CT scan on the same day. To my horror and astonishment, there were cancer metastases in the lymph nodes as well as in the liver. The joy that we felt a few months ago was replaced by disappointment and frustration.
One of the foremost questions in our minds was how and why this happened. His daughter is certain that it is due to the stress that Mario has been feeling. There had been many family problems over the past few months, she said. Mario decided that he wanted go ahead with palliative chemotherapy.
Even as I sat reeling from this unexpected blow, on that same day, I had to break bad news to another patient.
Yi, a 39-year old Chinese woman, has been under my care since October 2012. She had sizeable cancer in her left breast with spread to lymph nodes in her armpit. Her surgeon had biopsied the tumour and confirmed that it was a high grade cancer (meaning that it was aggressive) and also carried a cancer gene called HER-2.
She received four cycles of chemotherapy and responded marvelously to MRI and PET-CT. She went on to have a mastectomy and another four cycles of chemotherapy. This was followed by continuation of trastuzumab for a total of 17 treatments.
Yi went through her chemotherapy sessions with minimal fuss. She understood the seriousness of her condition and simply did whatever needed to be done.
Her last dose of Herceptin was scheduled for 31 December. She was eagerly awaiting that special day to end the year as well as end her year-long treatment. That day, she saw me and complained that she was experiencing some discomfort in her upper abdomen. This discomfort had been bothering her for several weeks.
She had already been scheduled for a full evaluation in three weeks’ time. I decided to bring forward her scans, not because I suspected anything was wrong but rather to reassure her that all was well.
The PET-CT results unexpectedly showed that the cancer had recurred. On 6 January, Yi started on palliative chemotherapy.
That day, I went home feeling emotionally drained and spiritually exhausted. To deliver bad news is never easy. To deliver bad news when I did not expect it, and when I could not account for it scientifically, makes it even more difficult. Does nothing make sense? I railed.
Then I remembered what King Solomon wrote in Ecclesiastics: “I returned, and saw under the sun, that the race is not to the swift, nor the battle to the strong, neither yet bread to the wise, nor yet riches to men of understanding, nor yet favour to men of skill; but time and chance happeneth to them all.”
For cancer patients, three things matter – their own will and spirit, the care of the doctor, and time and chance, which happen to us all. We cannot explain, we may not understand but if life is to have any meaning, we must gather our strength and continue the journey, wherever it may lead us.
Dr Ang Peng Tiam