A CANCER STORY By Dr ALBERT LIM KOK HOOI Despite the best of preparations, dealing with death is no easy matter,

especially for those who are grieving. An 81-year-old man was diagnosed to have an advanced pancreatic cancer. He was in fairly good physical shape. He had good insight to his problem. Of one thing he was sure. He wanted chemotherapy if it would mean a prolongation of good quality life. That put me in a quandary. Pancreatic cancer is a deadly disease. The average life span, even with state-of-the-art chemotherapy for the younger patient, is six months. Luciano Pavarotti (the maestro Italian tenor) and Patrick Swayze (the Hollywood actor) survived less than a year with the best possible treatment. My patient, Mr A, was two decades older.

Pancreatic cancer ... Luciano Pavarotti and Patrick Swayze survived less than a year with the best possible treatment.

I told A that a good quality life was very realistic without chemotherapy. We could treat the symptoms as they arise. I tried to dissuade him from undertaking chemotherapy. The chances of him living a year, (even if he responded favourably to chemotherapy) was remote, say 1% to 2%. Moreover, he was 81, and whatever we can say about biological age (actual physical condition) versus chronological age (how many years since birth), he was still 81. He would not budge. Reluctantly, I agreed. I first ascertained his cardiorespiratory, liver, kidney, and bone marrow functions. If one of these functions were inadequate, I would be on solid ground to refuse him chemotherapy. As it turned out, all his functions were adequate as far as chemotherapy went. Moreover, he was self caring, mobile, and mentally acute. I estimated his survival to be between three and six months. Accordingly and delicately, I prepared him and his family for the eventual outcome. With each visit, I reinforced my message about his short survival time. I wanted A to have an opportunity to sort out his affairs (the sooner, the better) and his family members to go through anticipatory grief. In this way, A will be better prepared for his last journey and his family will have a smoother bereavement. That was all simple textbook stuff. Most oncologists would have done the same. The chemotherapy programme began with the anti-cancer drug gemcitabine. There are a few other regimes available consisting of two, three, or even four, chemotherapy agents. Even with one agent I was wary. I told my oncology nurses to keep A within their telescopic lens. I advised him and his relatives to tell me as soon as something was amiss. To the relief of all parties the patient, relatives, doctor, nurses A tolerated

chemotherapy well. The side effects lethargy, occasional low blood counts were tolerable and self-limiting. To the joy of all parties, the CT scan two months after commencing chemotherapy showed that the pancreatic tumour had shrunk by 50%! I continued A on the same chemotherapy regime. At six months, the CT scan showed that the tumour had almost completely disappeared. I decided to stop chemotherapy at that juncture and kept him on close surveillance. I tried to communicate a realistic picture to the patient and his relatives. I told them this was truly exceptional (he was well at six months!) but we would have to prepare for the worst. By the worst, I meant that A would not survive beyond a year. Again, simple textbook stuff. All the relatives seemed clued in. They nodded their assent and made agreeable noises like it is more than we can expect and hope for and quality of life matters, not quantity. It was eight months since chemotherapy started. The inevitable happened. The tumour started to regrow and caused A to feel bloated and listless. A repeat CT scan confirmed my clinical impression, i.e. the disease had become worse. A was insistent that we embark on second-line chemotherapy. Again, I tried to dissuade him from doing so. I tried even harder this time. I told him of the very remote chance that second-line chemotherapy will be of any benefit. He was adamant. I reluctantly started him on gemcitabine, combined with a second drug, erlotinib. After two months on this regime, he felt better. The CT scan showed that the tumour masses had shrunk by about 25%, not quite as good a response as when chemotherapy was given the first time. This was not unexpected. Treatment went on for another two months. He soon became very ill as the disease had worsened once again. This was 12 months after he began treatment.

His tumour had spread to the liver, lungs and the abdominal cavity extensively. Coincidentally, he developed a stroke and became comatose. We gave him oxygen and put up an intravenous drip of normal saline. This treatment was more a salve for the relatives than anything else. You could not have asked for a better medical story. We have an intelligent, wellmotivated patient who knew what he wanted. He had no regrets about undergoing two lines of chemotherapy. He had lived a good quality life with cancer, easily six to nine months more than expected. The relatives were counseled repeatedly and had apparently accepted it all. We had the textbook all played out according to script. All honky-dory, or so you would have thought. For three days, A hung on. He appeared peaceful in his comatose state. His breath became shallower and his blood pressure slowly dropped. A Do Not Resusitate order was issued. During those three days, some of his relatives (there were 30 in his room), became agitated. They made unreasonable demands. One suggested CT scans; another even suggested a transfer to the Intensive Care Unit. All this happened even though counseling went on for a year. A.s heart stopped beating. Two relatives vehemently insisted on calling t he crash team. The code blue button was pushed by one of the relatives and an announcement was made over the public address system of the hospital. Ten doctors and nurses rushed to the patients side and started cardiopulmonary resuscitation. Of course it was all in vain. There was only one outcome. Perhaps, the reaction of the relatives was not that unexpected or bizarre. At least not for a minority of us. There were 30 of them acting out roles determined by complex social dynamics. Each was trying to vie with the other on who cared and loved papa and grandpa more. Was it the one who denied his death? Was it the one who cried and mourned the loudest? Could it be that this outward show of filial piety was therapeutic to them? Did the bedside charade make their bereavement easier?

BIBLIOGRAPHY

The Star, (2011). Health. Retrieved on 20th February 2011 at http://thestar.com.my/health/story.asp?file=/2011/2/20/health/8086137&sec=healt h The Star, (2011), Health. Retrieved on 21st February 2011 at http://thestar.com.my/health/story.asp?file=/2011/2/21/health/8095837&sec=healt h