June 4, 2009
Never too old to live
By Dr Ang Peng Tiam
Mr David Chen is more than 70 years old and he looks his age. He has Parkinson's disease, walks with tottering steps and has a bit of a stoop.
However, his appearance belies the fact that he remains mentally sharp and well-informed. He reads the newspapers, is aware of what goes on in the world and enjoys his food.
He consulted a doctor because he had a change in bowel habits and there was blood in his stools - the two most frequently reported complaints of patients with cancer of the colon and rectum.
Sadly, in the case of Mr Chen, the cancer had already spread beyond the colon to the liver by the time it was diagnosed.
When the diagnosis was made, the colorectal surgeon operated on him to remove the part of the colon where the cancer was located. Afterwards, the surgeon gave him a medical report 'for consideration of chemotherapy'.
'What about the cancer metastases in the liver?' Mr Chen's daughter, who lives in Canada, asked her father. (Metastases are growths or tumours that have spread via lymph or blood to other areas of the body.)
Neither Mr Chen nor his wife could give a satisfactory answer so she flew home to Singapore to find out what was going on.
Instead of confronting the surgeon, she brought her father to see me for an assessment of his cancer and an opinion on further management. The review of the pre-operative computed tomogram (CT) scans clearly showed several metastases in the liver.
It was obvious to me that the surgeon had decided to do the surgery and take a non-committal stand for the rest of the treatment. I have not spoken to this surgeon, but I can guess his reasons, which are admittedly numerous.
Mr Chen is elderly, chemotherapy is toxic and associated with many side effects, it is costly and may or may not effectively control the cancer. After all, this was stage four colon cancer and he would eventually die of it anyway.
In my younger days, I considered anyone over 70 years as being very old. Somehow, now that I am in my 50s, I no longer think so. My mother is in her late 70s and my dad is in his mid-80s. Both enjoy full active lives and I hope to see them live into their 90s and beyond.
The question, however, is not whether a patient is young or old, but whether doctors have the right to deny patients access to information and choice just because they are old. What is the basis when doctors make such decisions? If the patient were a VIP well into his 80s, would the surgeon have dared not to refer him to an oncologist for an opinion?
Two months had lapsed since Mr Chen's surgery and the initial CT scans, and we decided to carry out a positron emission tomography-CT scan to assess his current status. The results showed that the liver metastases had increased significantly in size. The cancer was now occupying no less than 80 per cent of the liver.
At the pace the cancer was progressing, if we decided not to do anything, I estimated that, on average, Mr Chen would live another three to six months.
On the other hand, there was the option of chemotherapy. While this had no curative potential, it had a 60 per cent chance of controlling the cancer and preventing it from spreading. With treatment, the average life-span of patients with stage four colon cancer is about two years.
There is a great deal of bias both in medical circles as well as among laymen against chemotherapy, especially when administered to the elderly.
It is important to realise that there are many types of chemotherapy, some more toxic than others. The dose of chemotherapy used also determines the severity of the side effects - the higher the dosage, the more serious the reactions.
In the treatment of colon and rectum cancer, there is a cocktail of drugs made up of 5-fluorouracil, oxaliplatin and cetuximab. This cocktail has been shown to be both effective and yet very tolerable.
The options were presented to Mr Chen and, together with his family, he made the decision to go with the treatment.
Mr Chen tolerated his treatment with minimal side effects. The main complaint was numbness in his hands and feet. This sensory impairment results from injury to the small nerves caused by the drug oxaliplatin.
The good news was that the latest PET-CT demonstrated a marvellous response - most of the liver metastases had disappeared.
I reminded Mr Chen that this was merely a temporary reprieve - a stay of execution, not a full pardon. In the meantime, he spends time with his family, takes two walks every day and eats dim sum at the Paragon mall when he comes to Mount Elizabeth Hospital to see me.
Mr Chen shows us how to live the good life - a useful lesson whether one is seven or 70 years old.
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.