Cancer makes a dramatic and life-changing impact on patients’ live, but treating cancer, for me, on most days, is a matter of routine – breast cancer patients who have been referred for treatment after having had their surgery; lung cancer patients who have just been found to have stage four disease; patients with cancer of the colon or rectum seeking an opinion on the best way to manage the disease.
But once in a while, a patient with a really exciting and challenging medical problem will walk through the door.
Alexander, aged 45, was one such patient that I saw in June this year. His problem began in March, when he noticed a swelling in his abdomen.
He saw doctors in Jakarta, who diagnosed that he had a cancer inside his abdomen. After a computed tomogram (CT) of his abdomen, the doctor suspected that he had a malignant lymphoma (cancer of the lymph nodes), and suggested that he should have surgery.
Upon hearing the diagnosis of cancer, he decided to head to Penang for a second opinion. After all, he had been there before in November 2011, for surgery to remove a liver abscess. He was hoping that they would be able to solve his problem.
A CT scan was repeated and this showed a large mass inside his abdomen – nearly the size of a basketball. The doctors attempted to get the diagnosis by passing a biopsy needle into the tumour under CT guidance. Unfortunately, all they managed to get was some blood and necrotic (dying) tissue.
The doctors subsequently recommended that he should have surgery, which he promptly agreed as the abdominal swelling was getting worse from day to day.
In end May, he underwent surgery. Much to his disappointment, the doctors did not manage to remove the tumour. Instead, he ended up having a long mid-line surgical wound that was gaping because the tumour was so large. All the doctors did was to remove a small piece of the tumour for analysis.
Two weeks after the operation, the doctors were still not even sure if this was a malignant tumour. Tests and more tests were being run on the tumour sample.
In the meantime, the patient’s condition was getting worse. The growing tumour was accompanied by a severe throbbing pain that prevented him from having any sleep at night.
Desperate, he decided to come to Singapore for further management.
When I saw Alexander, he looked absolutely miserable. He was brought into my consultation room on a wheelchair. His cheeks were hollowed-out and sunken, looking like a malnourished war refugee. The abdomen was distended to the size of a near full-term pregnant woman.
He came to see me because he was told that since the tumour could not be surgically removed, he should consider the option of chemotherapy.
But I felt differently. Before any treatment, I explained to him, I needed a firm diagnosis. The only way to do that was to get a tissue sample from the tumour for analysis. He was initially worried at my suggestion because he thought that meant that another operation.
However, I reassured him that we were often able to reach a diagnosis without open surgery. The trick in patients with large tumours is to know where to get the tissue from.
Contrary to common understanding, a tumour is not homogenous (meaning that not all parts of the tumour mass are made up of the same tissue). Some parts of it are cancerous, while other parts may be made up of dying cells and fibrous tissue.
This is where a PET-CT can be useful. A PET-CT scan allows us to identify the part of the tumour that is metabolically active – the part of the tumour that contains the cancer cells.
A PET-CT scan followed by a CT guided biopsy was carried out the next day. Within 24 hours, our pathologist was able to put out a report that this is a Gastro-intestinal Stromal Tumour (GIST).
This is a rather uncommon cancer that has gained much prominence since the approval of a drug called imatinib (Gleevec) in 2001.
Before that, the only treatment option for patients with GIST is surgery. This tumour is not responsive to chemotherapy and patients with inoperable GIST often die within six months of diagnosis.
By taking four tablets of Gleevec a day, the tumour literally melts away and leaves behind a liquefied mass that slowly disappears.
Alexander was started on Gleevec and within two months, his health was restored back to normal. A repeat PET-CT confirmed that tumour had halved in size and was no longer metabolically active.
We were all elated.
I wish this could be an unadulterated good news story but there is an enormous fly in the ointment – the high cost of treatment. One-month course of Gleevec costs nearly $5000. While the medical mystery is solved, the battle for Alexander has just begun.
There are complexities in funding cancer research, including the great need for private capital to take high risks in investments, with the promise of future patents. At the same time, there is a tussle between private profits and the vital task of saving lives. There are no easy answers – indeed the problems in this arena make my medical mysteries rather pale in contrast.
For me though, there is one clear reality – what I have done is not to cure the patient, but to find an expensive way to return him to good health. I may have given Alexander a reprieve but the real challenge for him is to find the funds to continue taking this drug.