PAYING THE PRICE

Paying the Price

Pain, however unpleasant it might be, is a survival instinct. It helps us recognize any damage to our body and take prompt action. My patient had noticed a painless swelling in his neck a month ago. He had ignored it till he developed daily fever with profuse sweating. 61- year- old retired principal of a reputed high school came to my OPD accompanied by his wife, also a teacher herself.

The patient was short, stocky, bald, and more importantly, anxious. The most striking feature in the physical examination was the neck swelling, the size of a lemon. His family physician had already done a needle test from the swelling and had raised suspicion of cancer. That explained the anxiety. I explained him that a biopsy# would confirm the presence or absence of cancer and redirected him to the surgeon. The couple revisited me 3 days later, even more anxious than ever. The biopsy said it was a high-grade lymphoma. Lymphoma is the cancer of lymph nodes. Lymph nodes are part of our immune system and help us fight infections. Lymphomas are of different types. Further testing was required to classify and to give a name to it. Also, now that the diagnosis of cancer was confirmed, we needed to know the stage of cancer for which I advised PET scan*.

They returned with all the necessary tests. The neck swelling was just the tip of the iceberg. Lymphoma had spread all over the body and it was stage 4. The subtyping of lymphoma suggested that it was not any ordinary lymphoma, it was Burkitt lymphoma, the fastest growing cancer ever. Sometimes, one’s strength can be one’s weakness too. Because the cancer cells are multiplying fast, they also get killed by chemotherapy which targets rapidly multiplying cells. That is the reason, Burkitt lymphoma is one of curable cancers when treated with chemotherapy.

I broke the bad news that it is a notorious cancer in stage 4 and it required treatment with chemotherapy. I also discussed addition of immunotherapy to improve cancer control. His wife asked me, “Can he withstand the side effects of chemotherapy?” I explained that we can use medications to prevent side effects of chemotherapy and start with a low dose and escalate the dose as he tolerated. After patients reach this stage, “stage of diagnosis” in their cancer journey, they go through subsequent stages like discussing with their children, family members, neighbors, well- wishers and practically anyone willing to offer free advice regarding cancer! They hold debates whether the patient should opt for chemotherapy at all. Even if he must undergo chemotherapy, whether he should take it in Shimoga or he should go to big branded hospitals in bigger cities, would be contested. Sometimes I do not hear from patients after this stage as they either shun away from chemotherapy or drift to metropolitan cities.

I was surprised when the couple turned up the next morning willing to take chemotherapy. They did not have children and did not care about their relatives. Patient’s wife found it convenient to opt for treatment in home town as she had to manage her exam duties. I appreciated that they did not bother about naysayers. Administering chemotherapy is not everyone’s cup of tea. Chemotherapy is a double edged sword. Giving very low dose would not control the cancer and cancer would soon sneak in causing recurrence/relapse. Giving a high dose may end the patient’s life right away due to side effects. Giving the right dose, balancing the effects and side effects, determines winning or losing. I was apprehensive whether this man would fare well or not. Praying lord Ganesha in my mind, I admitted him for treatment$.

The first two courses of chemotherapy had been manageable. Patient had hair-fall, nausea and fatigue which he had been managing well. He was reporting promptly for his follow up visits with blood tests. The tumor in the neck was shrinking in size and the couple was happy about this whole exercise of chemotherapy. The shrinking tumor and the comfortable patient made me more ambitious and grandiose. I set out for the conquest of this infamous lymphoma. I would not settle for anything less than cure. I hit the accelerator and increased the dose of chemotherapy in third cycle. Patient got discharged happily and I was beaming with pride.

One week later the patient’s wife called me that he had fever and was not able to breath well. He was rushed to the emergency huffing and puffing. His Blood pressure was low, his hands were cold and clammy, which made me perspire and tremble. His oxygen level was low and was started on oxygen immediately. He got admitted to ICU. I explained his wife that he was having the side effect of chemotherapy, his white cells were knocked off and he may require life support with ventilator. His life was in danger. At this stage in cancer journey, “stage of side effects”, patients and their family react in different ways. Some families had blatantly abused me that it was my mistake to increase the dose of chemotherapy. Some had threatened me that they will get media and disclose my mistake. Some others cursed that my family members should become ill. This patient was different. With tears welling up in her eyes, she said, “Doctor, please do everything possible to save him. I do not have anyone other than him as my support. I have trusted you and started treatment with you. Please do something.” I was dumbfounded. I felt sorry to have put her in this situation. I felt ashamed. Why did I have to increase the dose of chemotherapy? Why was I greedy for cure? Was I overconfident? Was it a mistake or a misadventure? Why did this couple had to pay the price for my miscalculation? I could not reason anything. I started the patient on medications to improve his white blood cells, to improve his BP and to control the infection in his lungs. I felt miserable the whole day. My mind was cluttered. I felt guilty and slept with a heavy heart.

The next day morning, patient was breathing comfortably, but was still on oxygen. 3 days later, patient was off oxygen and his white blood cells back to normal.  I felt sorry that he had to go through all of this due to the chemotherapy. His wife said it was their karma that they had to go through this crisis but she was grateful that he survived. I was astonished at her spirit. Now that he had completed 3 cycles of chemotherapy, I advised him to come back 2 weeks later with PET scan to see the tumor shrinkage. I was not worried about whether cancer is controlled well or not. I was thankful to the divine spirit for saving this soul from the iron fist of chemotherapy.

Two weeks later, the patient did the PET scan and met me. The report was not yet typed. I was curious to know what happened to his tumor. I called my colleague nuclear physician and asked him about the response to treatment. He said, “Mam, his previous scan had tumor in his neck, chest, abdomen and bone marrow. This time I am searching everywhere. There is no sign of tumor anywhere.” All the tumor had melted away like butter. Misty eyed, I announced to the couple that he had 100% regression of all the tumor he had at the time of diagnosis. Technically, this type of response to treatment is called “Complete metabolic response”, usually seen with combination of chemotherapy and immunotherapy in fast growing tumors. Complete metabolic response is a harbinger of Cure, the complete elimination of cancer. The couple was overjoyed. The patient completed 3 more cycles of chemotherapy with dose reduction off course. He managed them well, though he had fatigue and nausea. He is in follow up for more than 5 years. Every year he undergoes PET scan to search for tumor recurrence. Our nuclear physician keeps searching for the tumor and fails to find traces of it year after year. The couple lived happily ever after!

Cure comes at a cost. There are innovations in the field of cancer like immunotherapy which are sophisticated and improves survival, yet patient has to endure the uncertainties, frustration and melancholy during treatment. This couple had faith in me, endured the tough times and emerged triumphant. It is the success of chemotherapy, the success of doctors who give hope to patients about cancer cure and the success of patients and families who are willing to pay the price.

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Footnotes

# Biopsy: Biopsy is a test to take out a small piece of tissue from the body for examination.

*PET Scan: Positive Emission Tomography is a scan which examines the entire body for presence of abnormalities. It not only detects tumor mass and its size but also the activity in the tumor. This is used to assess response to treatment. If the tumor responds, the size reduces and also the activity.

$ Treatment this patient received was combination of chemotherapy and immunotherapy, Dose adjusted R-EPOCH, Rituximab is the immunotherapy, EPOCH consists of chemotherapeutic agents Etoposide, Prednisolone, Vincristine, Cyclophosphamide and Doxorubicin. In this treatment doses are adjusted (escalated/decreased) based on tolerability in previous cycles.