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When Patients Refuse To Comply
Being a doctor can sometimes be quite frustrating. You tend to get upset when patients fail to accept established clinical practices but instead choose unconventional options.
This happens of course, and not infrequently too – when patients do not believe what you are telling them, when they have unfounded fears of treatment risks, and of course, when there are circumstances beyond the patient’s control. I have a patient, let us call him Mr Choy, who is a government officer from another country.
I started looking after him, when he was diagnosed to have Stage 4 cancer of the colon with spread to the liver.
He had initially undergone surgery in China for his colon cancer. In June 2011, he was referred to see me when he discovered the cancer had spread. He is always accompanied by a physician from his home country, who served both as his counsel as well as his interpreter.
Communication with him was difficult as he spoke no English or Chinese. It is never easy to develop a rapport with patients when you do not speak their lingo. I tend to do well in this area because my usual speech is very animated. Whenever I talk, I have lots of facial expressions and I gesticulate a lot.
Anyway, Mr Choy and I hit it off well from the first time we met. The long-term outlook for patients with Stage 4 colon cancer is not good. Most cannot be cured.
When Mr Choy saw me, his metastatic disease appeared to be confined only to the liver. In the oncology community, it is now accepted that colon cancer patients who had metastatic disease confined to the liver may have a chance of being cured. Treatment with aggressive chemotherapy combined with judicious use of local treatment can actually cure 25 per cent to 40 per cent of the patients. Mr Choy responded well to the chemotherapy.
After we demonstrated that the liver tumours had shrunk in size, we went on to “burn” the lesions through radio-frequency ablation. In this procedure, a probe is inserted, under radiological guidance, into the tumour. High frequency ultrasound waves are then generated to heat up the tip of the probe and literally burn the cancer cells in the vicinity.
The problem with Mr Choy was that he could not stay in Singapore beyond a couple of months. As such, he often had to abandon treatment and return home whenever his time was up.
Two months ago, Mr Choy turned up in the clinic because the cancer was getting worse and had spread to various parts of his body. As he had been heavily pre-treated, the choice of chemotherapy drugs used this time were more toxic and had more side effects. After three rounds of chemotherapy, the latest PET-CT scans confirmed that he is getting better.
Unfortunately, I have been informed that he has to return home soon. I am not sure whether I should look forward to seeing him again because I know that if he appears, it means that things have turned bad again. I feel as though I am just placing a plaster on an infected wound, knowing that the plaster will fall off as the infection festers and spread. It does not mean that non-compliance always ends up badly.
Viggo is a Norwegian in his mid-60s, who saw me for the problem of cancer of his left tonsil with spread to the lymph nodes in the neck in May 2012. The diagnosis was made when he underwent a tonsillectomy for what was initially thought to be tonsillitis. After discussion on various treatment options, we embarked on chemotherapy.
Viggo tolerated the chemotherapy very well. After the third cycle of chemotherapy, we carried out a PET-CT scan which showed that all the cancer had disappeared. He was feeling good and had regained the weight he had lost earlier. The second phase of the planned treatment involved daily radiotherapy to the neck.
The plan was to treat him for seven weeks. Chemotherapy is administered weekly to enhance the effectiveness of the radiation treatment. The side-effects of radiotherapy vary depending on the dosage, the extent of the area treated and the treatment site. Radiotherapy to the head and neck areas often has the worse side effects.
I often warn my patients that it is like a “living hell” that they have to go through before they are cured. The initial two weeks are often fairly easy. From either the third or fourth week, the inner lining of the mouth breaks down and ulcers form, resulting in great difficulty with eating, drinking and talking.
After the third week of radiation, Viggo was suffering badly and his weight dropped from 86.6 kg to 80 kg. The pain was severe despite liberal use of painkillers. I admitted him to hospital for intravenous hydration and feeding. The radiotherapist and I coaxed him as best as we could and the radiotherapy was briefly suspended to allow his ulcers to heal.
Despite our best efforts, Viggo decided to stop treatment after only 15 of the planned 35 fractions of radiotherapy. He understood the potential consequences but simply could not bring himself to carry on. I just saw Viggo on one of his regular three-monthly follow up visits.
His weight was back to normal and the PET-CT scan showed no evidence of cancer recurrence. We are both delighted that he is doing well. Mr Choy and Viggo remind me that I am just playing at being the scientist – doctors of course are not dealing with cultures in the lab which behave predictably, or at least can be contrasted with controlled experiments to study causation.
What we treat are people with very human instincts, different emotions, body weights and at the cellular level, varying responses to the chemicals we inject into their bodies. While we may rail and rant at non-compliance we really do not know how things will turn out. All we can do is play the odds, await the outcomes, and carry on the best we can.
Written by Dr Ang Peng Tiam
|PUBLISHED 07 NOVEMBER 2016|