It was one of those rare days when my daughter happened to drop by at the clinic on her way to run some errands in town.
Christmas was just round the corner and there was joyful music playing in the clinic.
“Sit with me while I see the next patient,” I said.
She is a relatively new doctor and I was keen to obtain her views, as well as to share my work with her.
The next patient was a new one – Mr Tan, a 57-year-old who used to work as a foreman at a sand yard. He was married with four children and his brother died several years ago of nasopharyngeal cancer (NPC).
As he related his clinical history to me, it appeared that he was heading down the same route.
In August 2011, he had a blocked nose. His general practitioner referred him to an ear, nose and throat (ENT) specialist who quickly diagnosed that he, too, had late-stage NPC. He was then referred to a medical oncologist who put him on an aggressive chemotherapy regimen.
He responded well to the chemotherapy and went on to receive concurrent chemotherapy and radiation therapy.
I often describe the concurrent chemo-radiation therapy phase of treatment as a “living hell”.
Patients have to go for radiation treatment daily from Monday to Friday. The standard programme for treating NPC requires patients to undergo 33 treatment sessions.
To maximise the effectiveness of the radiotherapy, chemotherapy is administered once a week too. In the first two weeks, there are hardly any side effects. However, the problem kicks in from the third week onwards. The inner lining of the mouth literally sheds off and the pain becomes excruciating whenever the patient tries to swallow his saliva, talk or drink.
It is like a person going sunbathing without applying any sunblock. As the minutes and hours go by, the skin gets terribly burned and blisters form.
Anyway, Mr Tan survived the ordeal and finished his treatment in January 2012.
Barely two months later, he suffered a relapse of his cancer. This time, the situation was a great deal more serious as the cancer had spread, with a vengeance, all over his body.
Between March 2012 and October 2013, Mr Tan tried eight different chemotherapy programmes and one course of palliative radiation to relieve some of his bone pain.
Looking at the records that he had brought along with him, I counted nine different chemotherapy drugs used alone or in combination. Every one to three months, he switched from one chemotherapy programme to another because nothing seemed to work.
By the time I saw him, he weighed only 54kg. His voice was hoarse and barely audible. One of his vocal cords was paralysed because of cancer compression on the nerve. He had a persistent cough and complained that he felt very tired. He suffered from a loss of appetite and was in constant pain from the metastases (cancer spread) in his bones. His doctor had given up on treating him.
The positron emission tomography-computed tomography (PET-CT) scan showed that his lungs were studded with “cannon-ball” metastases. There were metastases in his bones, water around his heart and the cancer had also spread to the lymph nodes in his neck, chest and abdomen.
The scans painted a dire picture. But I saw something that could not be captured by the scans – Mr Tan’s fighting spirit. Most people would have given up long ago.
Mr Tan was well aware that the odds were stacked against him, but he wanted to give treatment one more try. His determination made me want to try harder.
As most of the active agents in treating NPC had already been used, all I could offer was to alter the combination of drugs.
However, I had one trick up my sleeve. It has been well reported that up to 80 per cent of patients with very aggressive NPC carry a particular genetic mutation. My experience with adding the targeted agent called Cetuximab has almost always been positive.
Despite the potential side effects and risks, Mr Tan was adamant that he wanted the treatment that I was proposing. He started the treatment on the very same day.
After he left the room, my daughter frowned at me. She clearly did not think that this man, who had already been so heavily treated, had any chance of a meaningful response to further treatment.
I stuck my neck on the chopping block and jokingly said: “Don’t worry! Sure work one!”
She shook her head in disbelief and said: “Remember to tell me what happens to this patient.”
Nine weeks have since passed and Mr Tan has completed three cycles of chemotherapy.
I saw him again. He was eating well and his voice was stronger and clearer. The follow-up PET-CT scans showed that his tumours responded in all the affected sites.
I had the pleasure of scanning his PET-CT pictures myself and sending them to my daughter.
I guess the lesson I want her to learn – a lesson which goes beyond medicine – is to never give up when there is still some fight left.
Written by Dr Ang Peng Tiam
Tags: cancer diagnosis, cancer mutation, cancer positive thinking, cancer relapse, chemo-radiation therapy, chemotherapy, head & neck (ENT) cancer, metastatic cancer