The battle against lung cancer

SINGAPORE - Do you want just the last volume or all his medical records?" asked my nurse, when I requested for Simon's case notes.

When I got the files, they came in three volumes that were three inches thick.

They detailed a long medical history for someone who, until recently, would have been given just three months to live - Simon was diagnosed with stage four lung cancer in April 2006.

Back in 1986, when I started training in medical oncology and, for years after, the consensus among cancer experts was that patients with stage four lung cancer should be given the "best supportive care".

That meant that they should be treated for the symptoms and not the cancer itself.

Oxygen, to relieve breathlessness.

Laxatives, for constipation.

Painkillers and liberal use of morphine, for pain control.

The main reason was that there appeared to be little difference in the lifespan of lung cancer patients, even if they were given chemotherapy to quell the disease.

I thought of writing about Simon's story after I was asked this question during a recent radio interview: "Are we seeing any advances in the treatment of lung cancer?"

In the 1990s, more data emerged to suggest that chemotherapy could help to prolong the median survival rate of stage four lung cancer patients by another three months.

To many, this tiny extension in their lifespan made little difference.

However, with time, we discovered more and more chemotherapy drugs which were effective against lung cancer. Instead of just going for the standard course of six chemotherapy cycles, patients were given the option of second-line or even third-line chemotherapy programmes.

This meant that these cancer patients got to live longer.

More importantly, we began to understand more about the molecular genetics of lung cancer and discovered targeted agents which were effective in blocking the pathway of cancer development.

By the time Simon came to see me, we had begun to understand so much more about the cancer.


Simon, who just celebrated his 65th birthday this month, is an estate manager at the Institute of Technical Education where he has worked for 40 years.

He started smoking from a young age but gave it up at the age of 42.

His problems began in November 2005, when he started experiencing pain in his left shoulder and arm.

The pain subsequently migrated to his back. Despite being treated by a general practitioner and a specialist at a hospital, his pain persisted and became worse.

When the diagnosis of lung cancer was eventually made, the disease had already spread to the bones and he was experiencing weakness in both legs. The cancer involved the spine and there was evidence of early compression of the spinal cord.

A "cord compression" is considered a medical emergency. Depending on the extent and level of the spinal cord that is affected, the patient can end up with paralysis of the legs, or both the arms and legs.

Treatment options include surgery to decompress the spinal cord and radiotherapy at the affected area.

But Simon was found to also have a blood clot in his heart, so he was deemed unfit for surgery.

When he came to see me in April 2006, he had just completed radiotherapy and wanted me to take over the management of his cancer.

Simon was started on palliative chemotherapy the same day he saw me. The term "palliative" is used when the treatment has no curative intent. Instead, it is intended solely to kill the cancer cells, control the spread of the cancer, relieve or prevent symptoms, preserve quality of life and prolong life.

Simon, a man of faith, chose not to focus on the fact that he could not be cured but rather on the hope that he would prevail against the disease and have a chance to live longer.

His lung cancer was found to carry a mutation in the epidermal growth factor receptor (EGFR). By simply taking the tablet gefitinib (Iressa) coupled with monthly injections of zoledronic acid (Zometa), he was likely to see a positive difference.

Thankfully, Simon responded well to the treatment. After six cycles of chemotherapy, the cancer marker called carcino-embryonic antigen (CEA) dropped from a reading of 385 to a normal level of less than 5.

Dr Daniel Tan, one of the leading lung cancer experts at National Cancer Centre Singapore, shared with me local data which showed that only 35 per cent of men who have smoked carried the EGFR mutation in their lung cancer.

In contrast, 75 per cent of those who had never smoked but who also contracted lung cancer had this mutation.

Therefore, it is important not to smoke - not even to start. A person who has never smoked in his life has a lower risk of developing lung cancer and he also stands a better chance of responding well to treatment.


Sadly, Simon's lung cancer developed resistance against the gefitinib and his cancer returned in March 2012.

Spirit unbroken, he went for more chemotherapy sessions and was also treated with other targeted agents.

While these have been effective in controlling his disease, the treatment has also taken a toll on his body. He gets tired easily, although he is well enough to continue full-time work.

Every time he walks through the clinic door, Simon would give me his brightest smile and say: "So, how am I, doc?"

At the last visit, before I could answer him, his wife interjected: "How can life be any better? You have a good son, wonderful colleagues who drop by every few hours to check on you, a fantastic medical team to look after you.

"And, of course, you have me. I won't say any more, lah…"

I laughed and winked at Simon. Medical advances and new drugs are useful to doctors, but faith, good humour and the indomitable human spirit - these things stand steadfast against cancer too.

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.

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