Serene has been under my care since 1998. In her follow up visits these days, she spends no more than five or 10 minutes in the consultation room.
Most of that time is spent catching up with casual talk on family, recent news and local politics. Serene, with her an angelic smile and easy laughter, is always cheerful.
She almost always comes with her husband Richard, whose hair I’ve watched change from black to grey to almost all white. No one would guess that this petite 42 kg lady has gone through three battles with cancer.
Serene presented with complaints of “blocked ear” and tightness on the left side of her face. She was initially treated with a course of antibiotics by her general practitioner. When that did not work, he promptly referred her to an Ear, Nose and Throat (ENT) specialist.
He discovered a tumour in the posterior nasal space and a biopsy confirmed the diagnosis of cancer of the nasopharynx (NPC). The tumour had invaded the base of skull. It had also spread to the lymph nodes on the left side of the neck.
Serene was treated with chemotherapy and radiation. That particular treatment program is very tough because the inner lining of the oral cavity would be badly damaged by the radiation. The patient experiences severe pain in the mouth, especially when eating and swallowing.
Many need to have a feeding tube inserted through the nose into the stomach. Liquid diet can then be poured down the tube, bypassing the painful parts of the throat and directly into the stomach.
Serene too experienced severe pain but she continued eating. After the harrowing days of treatment was over, she enjoyed a respite that lasted eight years. She was able to accompany her husband who was posted overseas to Canberra in 2001.
In 2006, Serene noticed a recurrent lump on the left side of the neck. A fine needle biopsy confirmed that the nasopharyngeal cancer had recurred in the neck. The PET-CT unexpectedly also showed that there was another tumour in the colon. A colonoscopy was carried out and this confirmed that there was another unrelated cancer in the right side colon.
Serene underwent surgery for colon cancer on 2 March 2006. To our relief, it was a stage one cancer that did not require any additional treatment.
This allowed us to focus on treatment of her recurrent NPC. Serene started chemotherapy on 16 March, exactly two weeks after her colon surgery. She later also had combined chemotherapy and radiation. She is now doing well.
Despite the advances we have made in treatment, cancer is still a dreaded illness because many patients do die from it. I am often asked the question why some patients make it, while others succumb.
In my experience, three factors are important in affecting outcome.
The first is medical. In Serene’s case, the GP who first saw her did not attempt to “hold on to the case” but promptly referred her to a specialist after one course of antibiotics failed to resolve her symptoms. The ENT specialist also did his job well. He saw the tumour, confirmed the diagnosis of cancer, and referred him to cancer specialists.
Then there are the backroom doctors that the patient almost never meet – the pathologists who make the final diagnosis by examining the tumour specimen under the microscope. The radiologists who review all the radiological images to determine the extent of cancer spread.
One must never under-estimate the important role played by these unsung heroes.
The second factor is the patient herself and the psycho-social support she receives. Serene is a fighter. Both in her first and second battle against NPC, Serene never thought of giving up. Richard, her husband, is testimony of true love. He was always there for her. I cannot recall any visit when he was not by her side.
Serene was a lab technician and Richard is an employee. The cost of medical care through the years must have been substantial. Thankfully, that never strained their relationship.
Herein lies the importance of early financial planning for one’s healthcare needs. The enhanced Medishield plans offered by all the major insurance companies in Singapore are truly good value.
The third factor is perhaps the most important. For those who believe in God, trust in His will and plan for each one of us will leave to a calm confidence that whatever happens is for the best.
Serene was blessed in many ways. Most patients with recurrent NPC do not do well. Serene responded well to the second round of treatment and has remained cancer-free for seven years since her relapse.
She went for a PET-CT scan because she had a cancer recurrence on the left side of the neck. As a result, her colon cancer was detected fortuitously early.
So, faith, a strong heart and good teamwork from primary to acute care doctors made the difference for Serene.
But really, who knows? In life, so many things can go wrong. Thankfully for Serene, she is alive today because everything went right.