Mr Mohammad Khan had everything going for him. A 38 year-old doctoral candidate, he had been living in Canada for the past four years. He was looking forward to completing his thesis and thinking about whether to stay on in Canada or returning home to Bangladesh. He was married to a doctor and they have a lovely eight-year-old daughter.
The future was looking bright.
But one day he found himself boarding a flight to Singapore – a high risk venture because by then, he was desperately ill.
“I was so breathless that I was gasping for air on the plane. I wasn’t sure I was going to make it to Singapore,” he said. It was no surprise as his blood oxygen saturation on room air was only 87% when he first saw me in the clinic.
The oxygen for normal people is well above 95 per cent. Once it drops below that level, most would experience shortness of breath. Considering that the air is thinner at high altitudes, it was likely that his oxygen saturation on the plane was even lower.
Three months earlier, Mohammad had been experiencing a bad cough. He saw a local doctor who diagnosed that he had some form of allergy. He was given some medication which did not seem to help.
A fortnight later, a chest x-ray was done which suggested that something serious was happening. For the first time, the possibility of cancer was raised. It took an additional month before a CT chest was done. By then he had frequent episodes of “cough syncope” meaning that he fainted from the violent bouts of coughing.
The CT scan revealed shadows on both sides of the lung. He was admitted to hospital where doctors thought that he could be suffering from tuberculosis but as one investigation lead to another, he was confirmed to have stage four stomach cancer with spread to the lymph nodes in the abdomen, to the lungs as well as throughout the abdominal cavity.
By then, he had much difficulty eating and had lost about 10kg of weight.
Although the diagnosis had been made, no treatment had been offered as the doctors were waiting for tests on the pathology specimen.
Mohammad was desperate as his condition was rapidly deteriorating. After discussion with his wife and family, he made the brave decision to fly from Canada to Singapore – a 19-hour journey.
When I first met him, he was wheeled in on a wheelchair. Breathing heavily, he could barely get onto the examination couch without assistance.
On that day, with blood tests and a PET-CT scan, we found that his cancer had gone from the stomach, to the liver, adrenals, bones, lungs, as well as lymph nodes from the neck all the way down to the lower abdomen.
He was breathless because there were bilateral pleural effusions (fluid accumulation in both chest cavities) which prevented the lungs from expanding. When we inserted chest tubes on both sides to take the fluid out, he could breathe normally again.
His stage four stomach cancer meant the disease had metastasized all over, and surgery was not an option. One of his cancer markers CA 19-9 was 15,130 units (normal being less than 37).
We could not cure him but we could offer palliative chemotherapy. The aim of treatment was solely to try and kill some of the cancer cells, control the spread of disease, preserve his quality-of-life and hopefully help to extend his life.
Left with little choice, he agreed and was started on chemotherapy two days after admission.
He felt better after drainage of the fluid from his chest and was well enough to be discharged from hospital. After one cycle of chemotherapy, he was well enough to fly home to Bangladesh to spend time with the rest of his family.
He has been flying back and forth between Dhaka and Singapore of cycle number two and three of his chemotherapy. On 30 December, Mohammad was seen for his “big exam”. He had a repeat PET-CT evaluation to assess the progress of his treatment.
The radiologist concluded that the cancer in the stomach, liver, bones and adrenals had resolved. The lymph nodes had either disappeared or become smaller in size. The abnormalities in the lungs were much smaller.
His CA 19-9 had come down to 516 units.
With cancer, one can never predict the response to treatment. This was a very good response indeed. After his brave journey from across the seas, a journey that would have broken a lesser man, I wish I could be happier for Mohammad.
It is true that he is feeling much better. The PET-CT photos also showed excellent response. But with cancer, we can be so near yet so far – it can look like a cure, feel like a cure but remains as aggressive as it ever was.
After we wished one another the best for the new year, I watched as he strode briskly out my clinic door. I thought of the gates a doctoral candidate must pass through – grueling exams, long nights writing papers – in hopes of a bright future to come. Mohammad, the young father, was so near – if only a medical cure were not quite so far.