It all started with a cough – Sara* was previously fit and healthy, but found herself having a cough which would not go away. Then the cough got worse, and sometimes Sara found herself short of breath after exerting herself.
She had never smoked, so lung disease was not something on her mind. But the cough and breathlessness kept getting worse, until she had to be admitted to hospital after several weeks of being unwell.
The medical team in Sara’s hometown found fluid around one of her lungs. Some fluid was drained out, but after several days she was still waiting for answers.
Sara was 50 years old, married with grown-up children. It is a precious time in the life of a parent – the children are independent, with the prospect of grandchildren along the way. But Sara was ill, and not getting better. What should have been the prime of her life was now clouded with uncertainty.
So she had come seeking a second opinion from us. Sara arrived at Mount Elizabeth Novena Hospital at lunchtime on a busy day, and we attended to her.
Looking at her previous scans, there was a tumour growing in Sara’s lung. The rest of the lung was surrounded by fluid, with deposits on the lining of the outside of the lung (the pleura). Cancer was a very real concern – and lung cancer can affect people who have never smoked. To confirm the diagnosis and guide treatment, a biopsy would be needed.
Biopsy is an important part of the cancer treatment journey. By taking cells from a tumour, a biopsy helps confirm which organ the cancer has started from. In many cases, different subtypes of cancer can arise from the same organ; a biopsy also helps us understand how the cancer works, and which targeted treatments may be suitable. In today’s molecular and genetic era of medicine, it is crucial to know the cancer as well as we can.
We mobilised a team of experts: a respiratory specialist inserted a temporary pleural catheter at the side of Sara’s chest to drain off all the remaining fluid, to help Sara’s breathing.
MRI brain and PET-CT scans were arranged to confirm the stage of cancer and how far the cancer cells had spread.
A CT-guided lung biopsy was done to obtain a large enough specimen of cancer cells for comprehensive testing.
Within 48 hours of touchdown, we knew that Sara had Stage 4 adenocarcinoma of the lung. Twenty years ago, that summary would have been enough information to guide treatment.
But today, lung cancer specialists know that there are many types of lung cancer. Even a lung adenocarcinoma can have different molecular targets, and this information helps the oncologist choose the best treatment for the patient.
For example, there are targeted therapies available which help lung adenocarcinoma patients with EGFR, ALK or ROS1 targetable mutations. So it is important to ascertain early on if the cancer has these mutations. It helps to have a pathology team with the equipment and training to conduct molecular testing.
The molecular pathology team quickly came back with a readout of Sara’s lung cancer mutations. Her cancer had a mutation which allowed targeted therapy to control her cancer – with just a single tablet once a day.
At Sara’s follow-up appointment a few weeks later, she was neither coughing nor short of breath. She felt much better, and had returned to her regular daily routine as an energetic homemaker.
Without treatment, Sara would likely have had only a few short months to live. With the appropriate treatment, she now has a chance to see her children get married and start their own families too.
We were able to help Sara get answers to her illness within a few days. Time is precious, especially when racing against a fast-growing cancer.
We will continue doing our best for Sara and all our patients.
Written by Dr Tan Wu Meng*Name has been changed to maintain patient confidentiality.