Hard to predict when cancer will recur

SINGAPORE - It is never easy to tell someone that his cancer has relapsed.

This is made more difficult when it is totally unexpected. It is also difficult to predict how patients would react to the news.

Rudy was diagnosed with colon cancer in 2001. At that time, he underwent surgery to resect the affected part of his colon.

As a few of the lymph nodes near the colon cancer contained cancer cells, his cancer was classified as stage three.

It is accepted that patients with stage three colon cancer should have adjuvant chemotherapy (treatment given in addition to the main or initial treatment).

The main purpose of the chemotherapy is to eradicate the microscopic cancer cells that cannot be seen or detected.

Studies have shown that post-surgery chemotherapy helps to lower the risk of the cancer recurring.

Without chemotherapy, about half of the patients with stage three colon cancer will suffer a relapse. With chemotherapy, one in four patients will still suffer a recurrence.

Rudy had chemotherapy after his surgery. He sailed through the treatment with no discernible side effects.

There was no hair loss, nausea or vomiting. He did not have any diarrhoea, mouth sores or fatigue.

His only complaint was that of mild numbness in his hands and feet.

In the large majority of patients with colon cancer, this is a very common side effect.

It is caused by the drug oxaliplatin, sold under the brand Eloxatin, which damages the peripheral sensory nerves.

I have observed that older patients and those with diabetes tend to experience more numbness in their hands and feet.

After completing treatment, Rudy followed up with regular check-ups.

The issue of what is an appropriate follow-up period, and for how long this should go on, remains unresolved.

The minimalists suggest that the patient does not need any follow-up except for routine colonoscopy once every three years. There are others who recommend three-monthly reviews.

These often include a clinical examination and some blood tests.

Annually, the patient has a chest X-ray with either an ultrasound or computed tomography (CT) scan of the abdomen. Rudy opted for the reviews.

Five years came and went.

Many patients in a similar situation would have been discharged from follow-up.

After all, surviving five years without a relapse, after completion of treatment, is deemed to be the equivalent of being cured.

The visits to my clinic have become so much a part of his life that Rudy felt "safe" coming back for his reviews twice or thrice a year. The visits were usually brief. A short chat and a quick physical examination to make sure that all was well.

And, of course, a review of the blood tests.

Then, one day, I had a shock.

More than 10 years after his initial diagnosis, Rudy's carcinoembryonic antigen (CEA) was raised. CEA is a cancer protein that is often found in patients with metastatic or advanced colon cancer.

"Are you sure there is no mistake?" he asked.

A repeat blood test and a positron emission tomography (PET) scan confirmed that the colon cancer had indeed recurred - but in the liver.

Despite the unexpected bad news, Rudy and his wife were outwardly calm.

Their main questions were "why" and "what do we do next?".

No one can really explain why the cancer cells remained dormant, yet alive, in the body for 10 years.

And, more importantly, no one knows what triggers these sleeping cancer cells to reactivate.

My hypothesis has always been that the body's immune system keeps the cancer cells at bay and somehow, when the immune system is weakened, these cells re-emerge.

To me, stress plays an important role in the body's immune system.

However, by his own account, Rudy lives a stress-free life.

He has an ongoing business that runs very much by itself. He has a happy family life and his children are doing well.

Rudy completed three cycles of chemotherapy and the CEA has returned to normal.

A PET scan confirmed that the cancer had become smaller and less active.

Rudy's options were either to have surgery to remove the cancer or to undergo radio-frequency ablation of the lesion. He opted for the latter.

The lesion was ablated using high-frequency ultrasound waves, which heats up the lesion, thereby destroying any remaining viable cells in the area.

Rudy is still on chemotherapy and is well on the road to recovery.

One can never be certain whether or not he has truly beaten the cancer. Only time will tell.

In the meantime, besides completing the planned chemotherapy, there is little we can do except to remember the old dictum "carpe diem" (seize the day, in Latin).

Live each day to the fullest and not count the many, or few, that may not come to pass.


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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