When cancer makes an unexpected return

SINGAPORE - It is always a nerve-racking time for patients when they come for their annual health review. Some patients tell me that they become exceptionally irritable, while others experience sleepless nights or frequent loose stools for days before the full health evaluation.

It is understandable. After all, the annual review is a red letter day of sorts.

Routine follow-up visits involve taking a clinical history, doing a physical examination and reviewing blood test results.

To confirm whether the cancer has returned, however, I need radiological scans. But it is impossible to perform scans on patients every month or every time they visit the doctor.

Aside from the cost, excessive exposure to radiation may carry with it long-term adverse effects.

But once a year, we conduct a thorough check.

For Mario, the news was exceptionally good.

"All clear," I happily declared as Mario waited patiently for me to finish reviewing all the scans.

It has been 4.5 years since he had surgery and chemotherapy to treat lung cancer.

The 74-year-old Indonesian comes to Singapore every year for a positron emission tomography- computed tomography (PET-CT) scan and magnetic resonance imaging (MRI) of the brain.

When he first saw me in April 2009, he had lung cancer with a single lesion in his brain.

He had surgery followed by six cycles of chemotherapy.

Mario's "metastasis" disappeared after three cycles of chemotherapy.

It was agreed that medical scans to the brain, which exposes it to radiation, would stop after he was done with chemotherapy, given that the lesion could no longer be seen.

Instead, we opted for close surveillance.

Mario has been making it a point to visit me once every two to three months for his medical review.

After one such visit in October last year, Mario and his family left my consultation room feeling reassured that all was well.

Three months later, Mario came back for another medical review.

As usual, I greeted him with a bright smile and a hearty "good morning".

But as I looked at his latest blood test results, my face fell.

His level of carcino-embryonic antigen (CEA), a cancer protein, was 24.8 micrograms per litre (mcg/l).

This is much higher than the normal rate of less than 5mcg/l. I glanced at the results of the same test that he did in October. Then, Mario's CEA level was 1.5mcg/l, well within the normal range.

How could it be?  Perhaps it was a laboratory error?

Was it possible that his cancer had returned when his results had been normal less than three months ago?

I immediately sent Mario for a PET-CT scan.

To my horror and astonishment, there were cancer metastases in the lymph nodes as well as in the liver. The joy that we felt a few months ago was replaced by disappointment and frustration.

The top question in our minds was how and why this happened.

His daughter was certain that it was due to the stress that Mario had been feeling. There had been many family problems in the past few months, she said.

Mario decided that he wanted to go ahead with palliative chemotherapy.

More gloomy news

More gloomy news

Even as I sat reeling from this blow, on that same day, I had to break bad news to another patient.

Yi, a 39-year-old Chinese woman, has been under my care since October 2012. She had cancer in her left breast which had spread to the lymph nodes in her armpit.

Her surgeon had performed a biopsy on the tumour, confirmed that her cancer was an aggressive one and that she also carried a cancer-promoting gene called HER-2.

She received four cycles of chemotherapy and registered marvellous results on subsequent medical scans.

She went on to have a mastectomy and another four cycles of chemotherapy. This was followed by 17 rounds of treatment with the chemotherapy drug Herceptin.

Yi endured her chemotherapy sessions with minimal fuss.

Her last dose of Herceptin was scheduled for Dec 31.

She was eagerly awaiting that special day to mark the end of the year and, at the same time, the end of her year-long treatment.

That day, she complained of discomfort in her upper abdomen. It had been bothering her for several weeks, she said.

She was scheduled for a full health evaluation in three weeks' time. I decided to bring forward her tests - not because I suspected anything was wrong, but rather, to reassure her that all was well.

Results showed that the cancer had unexpectedly returned.

On Jan 6, Yi started on palliative chemotherapy.

That day, I went home feeling emotionally drained and spiritually exhausted.

To deliver bad news is never easy.

To deliver bad news when I did not expect it and when I could not account for it scientifically makes it even more difficult.

Why is it that nothing makes sense?

Then I remembered what King Solomon, who was famed for his wisdom, wrote: "I returned, and saw under the sun, that the race is not to the swift, nor the battle to the strong, neither yet bread to the wise, nor yet riches to men of understanding, nor yet favour to men of skill; but time and chance happened to them all."

For cancer patients, three things matter the most - their own will and spirit; the care provided by their doctor; and time and chance, which affect us all.

We cannot explain, we may not understand but if life is to have any meaning, we must gather our strength and continue the journey, wherever it may lead us.


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.

Get a copy of Mind Your Body, The Straits Times or go to straitstimes.com for more stories.