21 APRIL 2011

Time Difference

The first question my patient asked after I finished examining him: ‘Will the delay in surgery make any difference?’ Mr Yee’s ordeal started last November, when he was told that he might have pulmonary tuberculosis (TB) after a routine pre-employment chest X-ray.

He was referred to the TB Control Unit and after the usual skin test and sputum analyses, he was told that he did not have tuberculosis. In January, he was referred to a public hospital for further evaluation of the ‘shadow’ seen on his chest X-ray. A computed tomography (CT) scan – a more detailed X-ray – of the lung was carried out on Jan 15 and a biopsy of the lesion – a procedure to remove tissue sample for analysis – was performed on Feb 11.

He was given the dreaded news that he had lung cancer. After a brain scan and a bone scan, he was given the ‘good news’ that his cancer had not spread beyond the lung.

He said: ‘They told me that I had early stage cancer and I really wanted surgery to be done as soon as possible.’

Unfortunately, the hospital had a waiting list for patients needing lung surgery. ‘They told me that the delay would not make any difference,’ he said. After waiting for more than a month, he was finally admitted on March 21 for surgery to remove the cancerous part of his lung. ‘I changed into hospital baju (clothes) and got into bed.

Barely two hours later, the nurse came and told me that I was being discharged because the hospital did not have a bed in a special ward to monitor me after the operation. ‘I changed back into my own clothes and went home,’ he said. ‘Every day, I waited for them to call me to go in for surgery.’

On March 28 – his 39th birthday – he could not wait any more and decided to come see me to find out if the delay in surgery was detrimental to his illness. I explained to him that surgery was indeed the treatment of choice for patients with early stage lung cancer. I suggested that he should go for a positron emission tomography (PET) scan to confirm that the cancer was indeed localised before we went further to expedite surgery for him.

The PET scan – which involves injecting the patient with radioactive isotopes bound to a dye that can flag the diseased cells on the scan – was done the same day. When he came by the next day to collect his results as scheduled, he said, beaming with joy: ‘I just got a call from the hospital to say that I can be admitted today and have the surgery tomorrow.’

His wife was also smiling enthusiastically, imagining that their long ordeal had finally come to an end. I said: ‘I’m sorry but you won’t need the surgery because the PET scan shows that the cancer has spread to many parts of your bones.’ He argued: ‘But they said that the bone scan was normal.’ Mr Yee had many questions, not the least of which was how a bone scan could be normal when cancer had spread to the bones.

My only answer was that PET scans are different from other scans, and different tests are useful for different things. A study has been done on the value of the PET scan in evaluating lung cancer patients for surgery. In that study, after all the routine tests that included scans of the lungs, liver, brain and bones, patients found to be suitable for surgery were also given a PET scan.

Half of these patients were found not to require surgery as they either did not have cancer or that the cancer had already spread to distant sites. Mr Yee then asked: ‘Was the cancer spread due to the delay in surgery? The interval between the initial detection of an abnormality on the chest X-ray and the biopsy results confirming that it was cancer was 21/2 months.

The interval between the biopsy results and the confirmation from the PET scan that the cancer had spread was another six weeks, making it four months in total. There is no way to be certain but, in any case, it was a moot point for Mr Yee. His disease was already in the fourth stage, and his options were either palliative chemotherapy or do nothing and wait his time. With tears brimming in his eyes, he reminded me that he had a 31/2-year-old child.

After three days of considering his options, he came back and started chemotherapy. It is mean recompense but I think that it is fortunate that his operation had been cancelled.

If the operation had gone through, it would have been a wasted effort as the cancer has already spread. It is a difficult truth to accept, but there is no way that we can turn back the clock and take another path. What we can do now is to battle on, the best we can, and with all possible speed.

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