It was a nail-biting decision – my patient was likely to have only one chance left and we had to get the treatment right. As it turned out, we did not.
It was at 10.30pm on 11 August that I received an email.
“My sister is diagnosed with cancer arising from the cervix. We are still waiting for the final diagnosis to determine the exact type of cancer cell.”
The sender’s sister, Hui Fen, had been had been admitted to another hospital for massive vaginal bleeding five days earlier. Examination by a senior consultant gynecologist confirmed an advanced cancer of the cervix. The cancer had spread beyond the cervix and there were metastases in the lungs and the liver.
I responded to the email immediately and arranged for the patient to see me the next morning.
When I met Hui Fen, she looked very ill. She was pale and jaundiced, with a swollen abdomen and a markedly enlarged liver.
She noticed post-coital bleeding (meaning some blood from the vagina after sexual intercourse) since June 2014. However, the problem was intermittent and she did not think much of it.
However, on 6 August, she started to bleed profusely. She lost so much blood that she nearly blacked out and had shortness of breath.
She was seen at the emergency department and admitted immediately for blood transfusion and packing of the vagina to stem the bleeding.
What was unusual about Hui Fen was the type of cancer cells that was found – a malignant melanoma arising from the cervix.
Melanoma is a type of skin cancer that arises from the pigment cells. It is by far more common among Caucasians living in sunny climates. It is rather unusual amongst Chinese and even more unusual to arise from the cervix.
This type of cancer was rare enough for a young doctor, who happen to have seen her in hospital, to contact me expressing interest in writing up the case for publication in a medical journal.
There has been a great deal of interest, research and advances in treatment for patients with melanoma.
After all the investigations were completed, we came up with two treatment options.
One was to treat with a cocktail of four chemotherapy drugs – an established method and one I was familiar with, and the other was to deploy immunotherapy with a new monoclonal antibody called Ipilimumab.
The patient had very advanced cancer and that there was evidence that the liver was on the verge of failing.
It is possible that Hui Fen had only one chance to get it right. If we chose an option that did not work, it was likely that Hui Fen would be too ill to try anything else.
Ipilimumab was considered as the safer of the two options as it had minimal toxicity. The chemotherapy cocktail I had in mind was potentially more toxic and even possibly fatal.
As Ipilimumab is a new drug, Hui Fen would be the first patient we would have used the drug on. Based on the reports in the medical literature, the drug is very effective as awakens the immune system to kill the melanoma cancer cells.
After careful deliberation, we came to a consensus to treat with Ipilimumab.
Despite the relative safety of the treatment, Hui Fen ran a stormy course. She became increasingly weak and drowsy as her liver failed. Her serum bilirubin (a measure of the degree of jaundice caused by accumulation of biliary fluid) rose to a high of 440 umol/l (normal is less than 26).
A PET-CT scan done soon after treatment showed that the cancer was growing in size and spreading to other new sites.
I gathered the family together after the second PET-CT scan to explain that the treatment was not working. Obviously, everyone was distraught. The question was whether to continue with the same treatment or to consider alternative options.
Hui Fen was only 39 years old and she has a 2 year old son. An accountant by profession, she lived a healthy life, neither a smoker nor a drinker. Her parents are still alive in their 70s.
By that time, Hui Fen was very ill and barely able to get out of bed.
I encouraged the family to proceed with the cocktail of chemotherapy drugs. The family understood that chemotherapy was potentially fatal but they agreed to try.
Almost immediately after we started the first cycle of chemotherapy, Hui Fen became less jaundiced and we saw a gradual drop in the serum bilirubin. Ten days after treatment, her appetite returned, she was able to ambulate on her own and was discharged from hospital.
Six weeks after the chemotherapy, we repeated the PET-CT scan and the results were most encouraging as most of the tumours in the lungs and liver had gotten smaller or disappeared.
Hui Fen was fortunate – even as our first choice of treatment did not work, she had a second chance. Others may have died from disease progression.
While we are always thrilled at the discovery of new drugs in treating cancer, we must also remember that new therapies are not always better. Most times though, we only have one shot, and we must strive to get it right the first time.