Cancer patient gets to see her daughter graduate

SINGAPORE - For most of us, July 16 this year is just going to be another day.

But for Madam Low, it is going to be a day of heady excitement and grand anticipation - a day that she thought she would never see.

I first met Madam Low, 53, in November 2011.

She complained of her abdomen being bloated with gas and an upper abdominal pain that radiated to her mid-back.

She had been investigated at another hospital and was suspected to have cancer of the pancreas with metastatic spread to the liver.

A liver biopsy (test of tissue sample) was carried out but the results were inconclusive.

At that point, her family decided to see me for a second opinion.

The clinical suspicion of metastatic cancer of the pancreas was high because the level of the cancer marker called CA19-9 was markedly elevated at more than 100,000 units, when the normal is less than 37.

I often see patients with modestly raised CA19-9. This is a very sensitive but non-specific tumour marker.

Many non-malignant conditions can cause a spike in the level of this marker - including inflammatory conditions such as arthritis, bronchitis or even skin eczema.

Instead of conducting a barrage of expensive and often inconclusive tests, I usually suggest monitoring the marker over time.

However, in this case, there was little doubt that Madam Low, a part-time sales promoter, had cancer. The clinical history, blood tests and radiological findings all pointed to it.

A repeat computed tomography-guided biopsy of the liver metastasis was carried out under direct imaging.

Bleak prognosis

Bleak prognosis

The biopsy confirmed that Madam Low had adenocarcinoma of the pancreas with spread to the liver.

Of the several types of pancreatic cancer, adenocarcinoma is the most common and aggressive, and often deadly.

In patients with metastatic pancreatic cancer, the average life span is often quoted as three to six months.

For a patient with stage 4 pancreatic cancer, the options are either to opt for the best supportive care or palliative chemotherapy.

Treatment with palliative chemotherapy has only modest success.

Furthermore, the chemotherapy is associated with side effects, risks of complications and high cost.

Because of these reasons, many doctors would recommend the best supportive care for these patients.

This rather bleak picture was presented to Madam Low and she had to exercise her personal choice.

Each patient, presented with the same scenario, will take into consideration different factors in making his decision.

Madam Low was clear about what she wanted.

"I really want to make it for my second daughter's graduation. I missed my elder daughter's and I really regret it," she said.

The graduation day would be July 16, about 11/2 years later.

With that sole consideration in mind, Madam Low and her family decided to embark on treatment.

Even before the chemotherapy could start, she started vomiting after every meal.

Further evaluation confirmed that the primary cancer in the pancreas had increased in size, resulting in the blockage of the duodenum (the first part of the small intestine connected to the stomach).

The ingested food was stuck in the stomach, which could not empty.

To overcome the obstruction, a stent was placed in the duodenum to stretch open the lumen and allow food to pass through.

Weekly chemotherapy started on Nov 16, 2011.

Thankful to make it this far

We watched with both trepidation and joy as the CA19-9 level swung like a seesaw. We watched as the marker came down to as low as 4,000, rising back to 80,000, and then coming back down to 50,000 units.

As the marker level came down, we documented a good response in both the pancreatic primary cancer as well as in the liver metastases.

As the marker level rose, the scans showed progression of her cancer.

Through all the ups and downs, Madam Low remained focused on the graduation day.

"What are we going to do after your daughter's graduation?" I asked her.

"I don't think about it. I am just thankful that I am going to make it," she said.

She recently told me what the doctors said to her when she was first suspected to have metastatic pancreatic cancer two years ago.

"Very fast one, you. What you want to eat, go and eat," she was told.

That was medical shorthand for "the end is nigh" as far as she was concerned.

Although she knows that the end is not very far away, she also knows that she has come a long way.

More importantly, she will get to mark an important milestone - on a date she thought would be well past her time.

Dr Ang Peng Tiam is the medical director of Parkway Cancer Centre. He has been in practice for 30 years. In 1996, he was awarded Singapore's National Science Award for outstanding contributions to medical research.

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