His tummy was bloated, resembling a woman in her final term of pregnancy, and he had swollen legs. Mr Anthony Koh, yellow with jaundice, entered my consultation room with his wife.

His was a sad story.

In June, he was not feeling well and went to see a doctor. One test led to another and he was told he had cancer of the liver.

Primary cancer of the liver (called hepatocellular carcinoma) is a serious medical condition and often occurs in patients who are hepatitis B carriers.

What Mr Koh had was even worse. It was a very rare type called high-grade angiosarcoma, an aggressive cancer that arises from the blood vessels.

A senior liver surgeon advised him to have surgery and his cancer was successfully removed.

He was told he did not need further treatment.

Then about two months after his surgery, he began losing his appetite and he also developed jaundice.

The cancer had recurred and it spread to other organs.

"The surgeon referred me to an oncologist, but explained that chemotherapy was not likely to be effective against this type of cancer," he said while looking at me expectantly, hoping that I would disagree.

I did not. Instead, I said: "Let me see what I can do to help you."

While examining him, I struggled within on how best to tell him the bad news.

Angiosarcoma is indeed very resistant to chemotherapy and the odds of getting a meaningful response are less than one in six (and even that is being optimistic).

Should I offer him treatment or should I just tell him to adopt "best supportive care" (BSC)? This is the term physicians coined to describe treatment intended to minimise symptoms rather than prolong life.

Judging by his physical condition and the pace of the disease, it was unlikely that he would live beyond weeks.

If I were to proceed with treatment, what drugs would I use? With his poor overall condition, what would his family and my peers think if he died from treatment?

When this last thought surfaced, I took myself firmly in hand.

What was most important was that the patient knew all the available options and was given every possible chance to live.

What does it matter what people thought?

"So, what do you think, Dr Ang?" his wife asked as I finished the examination. I explained the severity of the condition and described BSC as an option. I sensed their disappointment.

I then told them of chemotherapy as another option. Mr Koh asked: "Have you treated angiosarcoma with chemotherapy successfully?"

Indeed I had. I showed him pictures of an elderly woman with recurrent angiosarcoma of the head; she had responded well to chemotherapy.

Without hesitation, he decided to proceed with treatment immediately.

In the five weeks since, Mr Koh has thrived. His jaundice subsided, the swelling in his abdomen and legs disappeared and he was up and about - his normal self.

During his last visit, he asked me why I merely presented options instead of insisting on treatment. More seriously, his wife asked if the surgeon had denied him a cure by not referring him to an oncologist after the surgery.

I assured them that the surgeon did no wrong. There is indeed no proven role for chemotherapy after surgery for patients with angiosarcoma because there was no data to prove that it would make a difference.

At the same time, I conceded that I would have given him the option of chemotherapy despite the lack of data.

I offered him treatment despite knowing that chemotherapy has reportedly dismal results in patients with metastatic angiosarcoma.

My philosophy is that it should be left to the patient whether he wanted to take a chance.

He said he definitely would, as he had nothing to lose.

To be honest, I am not so sure. For one, he had to spend a considerable sum of money on treatment. This might lead some to think that oncologists in the private sector offer useless treatment purely for financial gain.

And, if his disease had not responded as marvellously as it did, perhaps he too would think likewise.

This is entirely post facto justification. That is, whether I did the right thing is justified wholly by whether it worked or not and we would not know this until we have tried it.

While I shudder to think of the consequences if the treatment did not work, I share in the motto that "who dares wins".

Doctors rely on evidence-based medicine; we do not gamble with patients' lives.

However, if it is a choice between certain death and a very small chance at life, I would take the chance every time, with any patient who chooses it.

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.

angpt@parkwaycancercentre.com

This article was first published in Mind Your Body, The Straits Times.