I sat dumbfounded as I stared at my patient’s positron emission tomography (PET) scan result. It showed at least three bony sites that lit up with the contrast dye, indicating that an active cancer had spread from somewhere else in the body to these areas, called metastatic sites. This meant that my patient had stage four cancer, which could not be cured.
Just a little earlier, I had breezily assured him that he could. Mr Chew, a Chinese man in his mid 40s, was diagnosed with nasopharyngeal cancer (NPC) about four months ago. He, upon the recommendation of a friend, came to see me immediately after he was told by an ear, nose and throat specialist that the biopsy of his nasopharynx – a procedure to remove tissue sample for analysis from the top portion of the throat – confirmed he had cancer.
NPC is a common cancer among the Chinese in Singapore. The three most common symptoms associated with it are nosebleed or blood in the sputum, blocked ear with a hearing impairment and a lump in the upper neck. He had all three. ‘Not to worry,’ I had reassured him, before sending him for a PET scan to determine the stage of the cancer. ‘NPC is very responsive to chemotherapy and radiotherapy.
So long as the disease is confined to the primary site and the lymph nodes in the neck, there is a good chance that you’ll be cured,’ I had said. I can still recall the awkwardness that I felt as I broke the bad news.
I then focused on the fact that NPC was very sensitive to chemotherapy – no less than 80 per cent of patients will respond favourably. Mr Chew proved to be no exception. After the third cycle of chemotherapy, the post-treatment PET scan showed that all the bony lesions had resolved and there was only minimal activity left in the nasopharyngeal tumour.
Upon completion of the sixth and last cycle, the PET scan showed no residual disease in his body. ‘What’s next?’ he asked as we reviewed the PET scans, after his last cycle.
The big question left was what to do for these patients after the chemotherapy is completed. Although his scans showed a marvellous result, the cancer had completely disappeared, the natural history of the disease has shown that it would almost always return with a vengeance. However, when it would recur remains unknown.
Much of the advances that we have seen in treating incurable cancer is the ability to control the disease and delay recurrence. It is for this reason that we often consider some patients with metastatic cancer to have more of a chronic illness than a life-threatening disease. In hormone-sensitive breast cancer, the manipulation of the body’s hormones has been shown to be effective in retarding the growth of cancer cells. Drugs such as Tamoxifen, Arimidex, Femara and Aromasin have been shown to be effective.
By switching from one drug to the next as the disease becomes resistant to a particular drug, the lifespan of breast cancer patients can be extended by years, sometimes even decades, even for those with stage four breast cancer.
Some chemotherapy drugs can be used for a long time. I have metastatic colorectal cancer patient who have been on programmes based on 5-fluorouracil for more than five years. This drug is relatively safe and has no significant cumulative toxicity, which means the side effects do not get worse with continued use of the drug. One of the big advances in treating incurable cancer is the use of targeted agents in controlling cancer.
Herceptin and Iressa are drugs which can remain effective for years in patients with metastatic cancer. In the past, it would be difficult to find stage four lung cancer patients who lived beyond two years of their diagnosis.
Nowadays, it is not unusual to see similar patients who are alive five years later. More important than just being alive, many of these patients are able to preserve a good quality of life. Mr Chew had metastases in the bones (NPC cells that had spread to the bones) when he saw me. He will continue to be treated with a biphosphonate to strengthen his bones and retard the progression of his metastatic bone disease. As for the remaining cancer cells, there was nothing further to do about them at this time.
To offer him more chemotherapy would not be sensible. ‘Don’t worry. Be happy!’ I assured him. And this time, I was indeed sure. I told him the story of a retired army major with metastatic NPC with bone metastases, who has remained alive and well for more than 10 years. I offered to get him acquainted with this ‘cancer warrior’. ‘No need, doc!’ he smiled as he left, happy in the knowledge that there are others who have been down this road and are alive and well.
This article first appeared in “Mind Your Body”, a Straits Times Supplement.
Tags: nasopharyngeal cancer