KOCHI: Christmas is always the perfect time for family reunions. Sara Thomas eagerly awaited the arrival of the families of her doctor son , Jacob from the US and daughter, Meena from the UK. But somehow this year even the bright smiles of grandchildren could not reduce the pain in her joints and the breathlessness which was making it difficult even to walk short distances. For the last few months, her husband, Dr Thomas had consulted various colleagues who were trying their best, subtly putting the blame on her crossing the 70th year milestone also.Sara was somehow not convinced how she could become 15- 20 years weaker in a span of a few months. Jacob who was my classmate, also noticed this and called me on December 24 and we chalked out a plan after Christmas.
When our team first saw Sara after admission on December 26, there was no doubt that she had a serious, possibly life threatening illness. Haemoglobin was just 6 gm % , ESR more than 100 and the Oxygen levels in the blood maintained only with supplemental oxygen. It was a wonder how an experienced and senior doctor like her husband could miss the evolving danger, blaming most of the symptoms on rheumatism and ageing. We see this quite often in cancer cases because mind has the strange capacity to mask reality and rely on false hopes when the danger seems too big! CT scan confirmed that there were several masses in the lung and we immediately performed a biopsy from one. A brave woman, Sara also agreed for a bone marrow biopsy the very next day in view of low counts.
As her condition was deteriorating, we speed tracked the reports within three days. In the multidisciplinary meeting, the radiologist had no doubt about the shadows being of lung cancer.
Pathologist named the same as adenocarcinoma of lung. The surprise came when the haematologist put up the bone marrow slides showing Acute Leukemia. Breaking bad news is a routine for us clinicians in cancer care. We try to focus on the good points even in an incurable cancer. But Sara was a unique one with two serious issues diagnosed together. As I knew the family well, there was an open discussion about the expected outcomes. The main aim we kept was to reduce her symptoms and prolong life span. Usually oncologists avoid answering the How Long? Question. As a friend, I told Jacob “few months”, BUT...As Sara was a retired college professor, she also wanted clarity about the issues. With a smiling face she agreed to go through the treatment, leaving the rest to God. Being deeply religious surely helped her to face the illness with confidence.
Sara’s lung cancer was driven by a genetic mutation in EGFR domain which makes the cells to divide without control, leading to cancer. In such cases,a simple tablet, Geftinib or Afatinib can block this mutation, arresting cancer growth. The leukemia was also amenable to control through a new class of drugs, Azacytidine which again modified the DNA of cancer cells. Both of these could be called as “designer drugs “which are being increasingly used in Oncology.
They target the cancer cells specifically. Collateral damage to normal tissues which causes side effects of chemotherapy are minimal with these drugs. As these can be taken at home, Sara was discharged .Within a few weeks, there was symptomatic relief. It is indeed fulfilling when a patient who was critically ill walks in to OP and talks like any other person. There was some skin rash, joint pains and she still required blood transfusion, but overall tolerance was good. First place she visited was the church and in her words “I had to thank the Lord who gave you the medicines to make me better!”
Jacob and Meena went back and they knew very well that their mother was enjoying a temporary reprieve. Scans done at 3rd month and 6th month showed that lung cancer had dramatically shrunk. Blood counts also recovered and we could stop transfusions. Sara resumed the spoken English classes she was conducting at home. Then suddenly the fever started. The fatigue returned and pains increased. This time the lesions were there in liver and spleen, lungs mostly normal. In a routine case, we would have termed this as cancer progression and advised palliative care. But Sara was a fighter and she asked us a sharp question- Is it cancer or something else? The liver biopsy confirmed tuberculosis which was a relief as there was a treatable disease now. Being immuno compromised due to leukemia, Mrs Sara was prone for developing tuberculosis also. Jacob had come all the way and he jokingly scolded his mother for raising a false alarm! Maybe this positive spirit in the family was the real drug which seemed to work well for Sara. Repeat tests confirmed that TB in addition to lung and blood cancer was under control.
Clinical research has shown that EGFR inhibitors work for an average of 1 -1 ½ years and Azacytidine for close to 1 year. This scientific fact was always nagging me whenever Sara came for review. However there were outliers, living for many years and we always want our patients to be among them reaping the exceptional benefits of modern medicine. We have many such patients who are aware of the inevitable but continue taking treatment with a smiling face. Their families also play an important role in taking them through this phase. A year had passed. Jacob and Meena were planning for an elaborate celebration by inviting their extended family. Being a different person, Sara just asked them the budget for the planned function. The next instruction was very clear- “Give it to the old age home for terminally ill patients”. Sure she came to Oncology OP with a home baked cake and has promised me one for next Christmas also!
The author is a Consultant , Medical Oncology, Aster Medcity
The views expressed by the author are his own.
(A real life case- all names changed to protect privacy*)