Looking forward and not back

"Please give me some time to tell the story from the beginning," Mr Lim said as he sat down on the chair across my consultation desk.

An articulate gentleman in his late-40s, he had a lot to get off his chest. Despite a queue of about 10 patients waiting to see me, I knew that it was important to allow him to tell me what had happened in his own way, even though his medical records had already told me what I needed to know.

His story began in March this year, when he decided to go for a routine check up with a general practitioner. He was found to be mildly anemic, his haemoglobin concentration being 13g/dl when the normal is 13.5g/dl.

He was reassured by the doctor that this was "quite common" and did not justify further investigations. Unconvinced, he went to the Government Polyclinic to have it re-checked. Again, it showed that he was merely mildly anemic. He was reassured that this was "normal" and did not require further action.

In August, he developed some body ache after helping his sister to move house. He went back to the Polyclinic doctor and asked for a blood tests. The repeat haemoglobin was found to have dropped to 11g/dl.

At his insistence to be seen by a specialist, he was referred to see a colorectal surgeon for a routine colonoscopy.

One of the commonest causes of anemia, in a male, is occult blood loss from the somewhere within the gastrointestinal tract. Bleeding piles, peptic ulcers and cancers of the stomach or colon can often account for anemia without any symptoms.

After the colonoscopy, he was told that he had some small polyps in his colon and these had been removed. The surgeon explained to him that these polyps were not cancerous but showed lymphoid hyperplasia.

"When I asked him what was lymphoid hyperplasia, he told me that the lymphatic cells were just reactive and these were not of concern," he related.

"I pointed out to him that I had some glands in my neck."

Mr. Lim was referred to another doctor who carried out a biopsy of one of the lymph nodes. The diagnosis again came back as lymphoid hyperplasia and that no treatment was needed.

Stage 4 cancer

Months later, he decided to go and have his blood test again. To his surprise, the haemoglobin had dropped to further.

He immediately made an appointment to be reviewed by the colorectal surgeon. He pleaded for another colonoscopy although it had been less than six months since the previous procedure.

"I purged the whole night to clear my bowels. I went the next day, signed the consent form, they injected me with an anaesthetic in preparation for the colonoscopy," he said.

When he woke up, he asked if the procedure was over and he was told that the procedure had been cancelled because it was not necessary.

This was because the surgeon looked through the medical records,and found that the final diagnosis of the polyp removed months ago was a malignant lymphoma.

Malignant lymphoma is a cancer of the lymphoid tissue. As it turned out, Mr. Lim had one of the more aggressive forms of lymphoma called mantle cell lymphoma.

"That's how I ended up coming to see you," he explained.

That same day, he underwent a PET-CT scan which showed that his cancer had spread to involve the lymph nodes in his neck, chest, abdomen and spleen. The bone marrow biopsy also showed the presence of lymphoma cells, indicating that he had stage four disease.

"How could this have happened?" he lamented.

It is difficult for me to explain what happened. I tried my best to re-focus the priority on treating the disease and getting better. How it happened and why it happened is unimportant at this point in time.

What matters is that he had an aggressive cancer and treatment needed to start as soon as possible.

Mr. Lim was started on chemotherapy the day after he saw me. By the fourth day, most of the lymph nodes in his neck were already smaller. While I expect the response to treatment to be good, the road ahead is a long and tortuous one.

"One day at a time!" I reminded him. "Look ahead and not back."

Easier said than done and perhaps rather tepid consolation for his ordeal. Although I didn't say this to Mr Lim, as we move towards the new year, it is a good time for us to reflect on what we could have done better. It is only by constantly glancing at our rear view mirror that we can travel safely ahead.

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