May 21, 2009
A worthy risk
By Dr Ang Peng Tiam
I have known Peter and his family for more than 10 years. He is a loving father, a keen sportsman and a religious man.
Unlike me, he is very disciplined where diet is concerned. I remember being invited to his house for dinner where, to my horror, the chicken served had no skin and the 'kong bak pao" (braised pork belly bun) had no fat!
Late last year, he had abdominal discomfort with loss of weight and appetite. Investigations confirmed that he had a very advanced cancer involving the liver. The consensus was that the cancer did not arise from the liver but had probably spread from some part of the gastro-intestinal tract.
The liver surgeon felt that it was not worthwhile removing it as the cancer was advanced.
Peter initially underwent chemotherapy at a government restructured hospital. After three cycles of chemotherapy, the tumour grew and almost doubled in size.
When he saw me after Chinese New Year, the cancer had extended well below his navel, occupying the upper half of his abdomen. We both knew he was in serious trouble as he was experiencing increasing pain and his weight kept falling.
After careful consideration, the chemotherapy programme was modified and intensified - in the hope that it would control the disease. Initially, there appeared to be some improvement as his pain got better.
After a short overseas holiday with his family, he complained that the pain had recurred and intensified. Repeat computed tomograms (CT) showed that the tumour had grown even bigger.
It was obvious we were losing the battle. Further chemotherapy at this time was not likely to benefit him.
I sat down with Peter and his wife and explained the CT findings. We were pretty desperate as the tumour was growing with impunity.
I suggested going ahead with surgery to remove what we could of this rapidly growing tumour. Based on the surgeons' assessment, this was going to be a major operation with limited chances of success, high likelihood of morbidity and of questionable benefit.
They were fully prepared to remove the cancer together with parts of whatever organs may be involved - which they suspected would include the liver, stomach, duodenum, pancreas, and small and large intestines. We suggested that there was a 10 per cent chance Peter would not make it out of the operating room alive.
Most of the time, the role of surgery in cancer management is fairly straightforward - when it is needed and when it is not. For example, a patient with localised breast cancer would definitely need some form of surgery with the expectation of cure.
However, in this case, Peter's surgery was likely to be debilitating, fraught with risks and yet may or may not be beneficial. Somehow, I felt that it had to be attempted. Talk about being unscientific!
Our discussion included wide-ranging issues: getting his family affairs in order, the option to sign an Advanced Medical Directive (also called a living will which stipulates that we must abandon unreasonable life-sustaining efforts if he is deemed not likely to survive) and the cost implications of surgery and hospitalisation.
Also, there was the option of stopping treatment and focusing instead on preserving and perhaps improving his quality of life.
What impressed me was his decisiveness - he agreed to surgery and left it to me to choose the earliest convenient date.
The surgery was carried out on the Monday after Easter. The surgeons assessed that the surgery was likely to take more than six hours. An hour into surgery, they messaged me: 'We are winning. Dinner is on you!"
The tumour was apparently attached to the inferior aspect (lower surface) of the liver. It was stuck but did not invade neighbouring structures, allowing it to be 'peeled off" quite easily. The surgery took only two hours and Peter was discharged on the sixth day.
While the bulk of his cancer has been removed, the war is far from over. The wonderful news is that he is so much better - able to lie flat in bed and able to eat again.
In due course, the remaining smaller tumours need to be tackled. For now, we are just thankful that he is recovering - and getting ready to do battle some other day.
Recently, there has been debate on whether doctors here should participate in the separation of a pair of conjoined twins from India. The Health Minister has voiced his concerns.
As doctors, we have the responsibility of guiding patients in whether or not to undergo major high-risk operations. In most instances, the decision-making process is quite simple. But in some, it takes perspicacity, balanced with courage and humility.
Often, there are differences of opinion. However, after all the debate and discussion, we must respect the patient's decision, for the life is his to live.
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.