When patients refuse to listen

SINGAPORE - Dr Ang Peng Tiam, 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.

Being a doctor can sometimes be quite frustrating.

You tend to get upset when patients fail to accept established clinical practices, but instead choose unconventional options.

However, this happens, and not infrequently too - when patients do not believe what you tell them, when they have unfounded fears of treatment risks and, of course, when there are circumstances beyond the patient's control.

I have a patient called Mr Choy, who is a government officer from an Asian country.

I started looking after him when he was diagnosed with stage 4 cancer of the colon which had spread to the liver. He had initially undergone surgery in China.

In June 2011, he was referred to me when he discovered the cancer had spread.

He is always accompanied by a physician from his home country, who serves not only as his counsel, but also his interpreter.

Communicating with him was difficult as he did not speak English nor Mandarin. It is never easy to develop a rapport with patients when you do not speak their language.

I tend to do well in this area because my usual speech is animated. I display a lot of facial expressions when I talk and I gesticulate a lot too.

Despite the lack of a common language, Mr Choy and I hit it off the first time we met.

The long-term outlook for patients with stage 4 colon cancer is not good. Most cannot be cured.

When Mr Choy came to me for treatment, his metastatic disease appeared to be confined only to the liver.

In the oncology community, it is now accepted that colon cancer patients with metastatic disease which is confined to the liver may have a chance of being cured.

Treatment with aggressive chemotherapy, combined with judicious use of local treatment, can cure 25 per cent to 40 per cent of patients.

Mr Choy responded well to the chemotherapy.

After the liver tumours had shrunk in size, we went on to "burn" the lesions through radiofrequency ablation.

In this procedure, a probe is inserted under radiological guidance into the tumour.

High-frequency ultrasound waves are then generated to heat the tip of the probe and burn the cancer cells in the vicinity.

The problem with Mr Choy is that he cannot stay in Singapore beyond a couple of months each time. He often had to abandon treatment and return home whenever his time was up.

Two months ago, Mr Choy turned up at the clinic because the cancer was getting worse and had spread to other parts of his body.

As he had been heavily pre-treated, the choice of chemotherapy drugs used this time were more toxic and had more side effects. After three rounds, positron emission tomography-computed tomography (PET-CT) scans confirmed that he was getting better.

Unfortunately, I have been informed that he has to return home soon.

I am not sure whether I should look forward to seeing him again because I know that if he turns up, it means that things have taken a turn for the worse again.

I feel as though I am just placing a plaster on an infected wound, knowing that the plaster will fall off as the infection festers and spreads.

Non-compliance not always a bad thing

It does not mean that non-compliance always ends badly.

Viggo is a Norwegian in his mid-60s, who came to me two years ago as he had cancer in his left tonsil, which had spread to the lymph nodes in his neck.

The diagnosis was made when he underwent a tonsillectomy for what was initially thought to be tonsillitis.

After discussing various treatment options, we embarked on chemotherapy. Viggo tolerated the treatment well. After the third cycle, we carried out a PET-CT scan, which showed that all the cancer cells had disappeared.

He was feeling good and even regained the weight which he had lost earlier.

The second phase of the planned treatment involved daily radiotherapy of the neck. The plan was to treat him for seven weeks.

Chemotherapy is administered weekly to enhance the effectiveness of the radiation treatment.

The side effects of radiotherapy vary, depending on the dosage, extent of the area treated and treatment site.

Radiotherapy of the head and neck areas would usually trigger worse side effects.

'Living Hell' too much for some

I often warn my patients that they have to go through what is like a "living hell" before they can be cured.

The first two weeks of treatment is often fairly comfortable.

However, from the third or fourth week onwards, the inner lining of the mouth breaks down and ulcers form, making it difficult for the person to eat, drink and talk.

After the third week of radiation, Viggo was suffering badly and his weight had dropped from 86.6kg to 80kg. The pain was severe despite liberal use of painkillers.

I admitted him to hospital for intravenous hydration and feeding.

The radiotherapist and I coaxed him as best we could, and the radiotherapy was briefly suspended to allow his ulcers to heal.

Despite our best efforts, Viggo decided to stop treatment after only 15 of the planned 35 fractions of radiotherapy.

He understood the potential consequences, but simply could not bring himself to carry on.

Recently, I met Viggo again, during one of his regular thrice-monthly follow-up visits. His weight was back to normal and the PET-CT scan showed no evidence of cancer recurrence. We are both delighted that he is doing well.

Mr Choy and Viggo remind me, that as doctors, we treat people with very human instincts, different emotions, body weights and, at the cellular level, varying responses to the chemicals we inject into their bodies.

While we may rant and rail at non-compliant patients, we do not know how things will turn out.

All we can do is to play the odds, await the outcomes and carry on the best we can.

angpt@parkwaycancercentre.com

This article was first published on June 26, 2014.
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