STI: Weight gain a red flag

April 9, 2009

Doc talk

Weight gain a red flag

By Dr Ang Peng Tiam 

 

It was one of those mornings when I decided to drop by the doctors' lounge to have a quick bite. I sat beside a senior gynaecologist and our conversation drifted to Madam Loi, a mutual patient on whom he carried out surgery in October 1998.

 

When she first saw him more than a decade ago, she already had a swollen abdomen for several weeks. At the time of surgery, he found that the cancer, which started in her ovaries, had spread throughout the abdominal cavity.

 

There were many tumours - big and small, which carpeted the omentum (an apron of fat inside the abdomen), intestines, ovaries, the uterus and pelvic cavity.

 

'Besides removing the uterus, both ovaries and the omentum, I even had to remove the appendix,' he recounted.

 

In most cancer cases, whether breast, lung or colon, there is little or no role for surgery once the cancer has spread extensively. We rely on other measures such as chemotherapy to tackle the disease. Ovarian cancer is the only cancer where surgery can play an important role even though the cancer is at an advanced stage.

 

The surgeon needs to remove as much of the cancer as possible (this is referred to as debulking surgery) in order to optimise the patient's chances of a cure.

 

This has to be followed with chemotherapy to kill the remaining cancer cells and hopefully cure the patient. The good news is that ovarian cancer is highly sensitive to chemotherapy. Even large tumours tend to melt away when chemotherapy is administered.

 

The bad news is that despite initially encouraging results with chemotherapy, only 15 to 25 per cent of patients with stage III ovarian cancer are cured.

 

Chemotherapy then adopts a palliative role - to control the disease, preserve quality of life and prolong life. It often goes on for as long as the disease is controlled and the patient finds the treatment tolerable with acceptable toxicities. This maintenance treatment can go on for years.

 

Ovarian cancer is the fourth most common cancer among women in Singapore. It has no known cause but genetics play a role. There is some vague evidence that it may be associated with the use of talcum powder (which I do not believe).

 

The majority of patients consult doctors only when the cancer has already spread, causing swelling of the abdomen (stage III). Many mistakenly think that they have gained weight and put on inches around the waist when, in fact, there is accumulation of fluid in the abdominal cavity.

 

Symptoms of ovarian cancer include feeling a lump and experiencing pressure or fullness in the lower abdomen. Patients may also complain of changes in bowel and urinary habits such as urgency and frequent urinating.

 

Not all types of ovarian cancer run a similar 'chronic' course as it depends on the sort of ovarian cancer cells. Each time I come across an ovarian patient with the 'clear cell carcinoma' variety, I am reminded of an incident back in 1999.

 

I was referred a middle-aged Indonesian woman who had just undergone debulking surgery. She had come to Singapore for a routine check-up when she was found to have a mass in the ovary. At the time of surgery, more than a litre of bloody fluid was drained from the abdomen and the cancerous tissue removed.

 

She had clear cell carcinoma of the ovary.

 

As she was totally unprepared for an operation and extended stay, I agreed that she should go back to Indonesia and return two weeks later for her chemotherapy.

 

To my horror, she looked like a full-term pregnant woman when she came back for the scheduled follow-up. When the computed tomogram was repeated, there were large tumour masses with re-accumulation of fluid in the abdomen.

 

Despite best efforts, which included chemotherapy and repeated drainage of abdominal fluid, she died within a year of diagnosis.

 

The lesson I learnt is to show the greatest respect for anyone with this particular sub-type of ovarian cancer. These patients should have chemotherapy initiated early and be treated with the most aggressive, even unconventional, chemotherapy programmes to try and optimise their chances of a cure.

 

As for Madam Loi, she is still going strong. Each time she comes for her monthly review, she buys me my favourite bak kut teh from Balestier for lunch. So, I have had a decade of free lunches so to speak. Much as I appreciate her thoughtfulness though, the real treat is seeing her doing so well.

 

angpt@parkwaycancercentre.com

 

Dr Ang, the medical director of Parkway Cancer Centre, has been treating cancer patients for 23 years. In 1996, he was awarded Singapore's National Science Award for his outstanding contributions to medical research.