What's in a name?

I was engrossed in my thoughts and my mobile phone, when a patient slowly walked into my outpatient department. I missed the sight of him entering and he was already seated in front of me. According to classic medical teaching, a doctor can diagnose the neurological disorder of the patient just by observing how the patient walks into the consultation room. I sensed something was wrong with his gait but wasn’t sure.

He was a 65 year old retired civil engineer and was accompanied by his wife. She narrated the history that he had a tumor in his right kidney which was operated a year back. It was an advanced stage and he was advised by the oncologist to take some medications to prevent further spread of cancer. Patient refused to take chemotherapy wary of its dreaded side effects. Six months later patient developed severe debilitating back pain and was found to have cancer spread to his back bones, lungs and brain. Two months back, right side of his body became paralysed and he was haunted by daily headaches, severe back pain and unable to sleep due to pain. ?Patient consulted another oncologist who advised some medications for the control of cancer but the patient had sworn not to take chemotherapy. After listening to the story, I stood up to examine him. His right hand was lying limp by his thigh. I wanted to assess the severity of the paralysis. In this simple test, the doctor asks the patient to squeeze her fingers. I held together my right index finger and middle finger ?and asked him to squeeze them?with his right hand. The strength of grip is a measure of the muscle power of patient’s?fingers. My patient used his left hand and tried to bend his limp fingers of right hand in a futile attempt to grab my fingers. I asked him to try and move the fingers of his right hand. He made another attempt but in vain and started wailing. ?I was perturbed by his emotional outburst and pacified him saying I have seen worse patients who have improved after taking treatment from me. His wife wiped his tears and they composed themselves.

I decided to tell the patient what he wanted to listen. I explained that chemotherapy is one of the oldest forms of cancer treatment but is notorious for its side effects and I would not suggest chemotherapy to him. Instead I suggested that he should opt for a new form of therapy called targeted therapy and said that it works like Lord Rama’s arrow. ?I told him the story of Lord Rama’s arrow from the celebrated Hindu mythology Ramayan. Lord Rama was a valiant archer and possessed a magical arrow. Rama could tag a particular demon to be slain and the arrow once shot would target only the demon. It guaranteed success every time it was shot and did collateral damage to no one else. Many of my patients are spiritual and believe in the miracles from heaven. I could see that Lord Rama’s arrow could elicit a sparkle in my patient’s eyes and eased the wrinkles on his forehead. I explained that targeted therapy is a refinement over chemotherapy and specifically targets cancer cells. It does not cause classic side effects of chemotherapy like hair fall, nausea and vomiting. I told him that I would prescribe medications for symptom relief like headache and back pain, he should think about targeted therapy and come back if he is interested. The patient stood up with the help of his wife and limped out of my OPD. This time I did not miss the way he walked. It was classic hemiplegic gait due to paralysis of one half of the body affecting his right upper limb and lower limb.

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Three days later, his wife returned to my OPD and said that he was feeling better and pain has reduced. He had decided to try targeted therapy. I wrote a prescription for Sunitinib which was the same medicine suggested by the previous oncologist!?Sunitinib is a targeted therapy to be taken in the form of daily tablets. After 15 days, patient came to my OPD limping. I asked him to squeeze my fingers and he grabbed my fingers with a childlike grin. His muscle power had definitely improved, though not entirely normal. His early morning headache was gone as was the back pain. I wanted to jump with joy but I behaved myself. He said, “Madam, your medicine seems to be doing some magic.” I said, “Yes definitely, in your next visit I would challenge you with arm wrestling!” Believe it or not, the patient continues to take Sunitinib and is living happily ever after for 12 months. His cancer is not cured but is controlled. It is co-existing with him without causing any painful symptoms.?

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Often patients think that every tablet or injection prescribed by an oncologist is Chemotherapy. In today’s world, there are multiple different agents available for treatment of cancer other than chemotherapy. Unlike chemotherapy which is non specific and kills all rapidly dividing cells of tumor as well as normal cells, agents like targeted therapy, immunotherapy and hormone therapy are more refined. This patient had assumed that he was prescribed chemotherapy and had refused treatment earlier. Sometimes patients are scared of discussing with doctors or they are snubbed by snobbish doctors. This may lead to mistrust, misinformation and non-compliance with the proposed treatment. A detailed discussion along with the analogy of Lord Rama’s arrow seemed to have solved the problem of misinformation and compelled this patient to try targeted therapy. This saga reminded me of the quote from Romeo Juliet by Shakespeare, “What’s in a name? That which we call a rose by any other name would smell as sweet”. The names themselves neither hold worth nor meaning and they simply act as labels to distinguish one thing from another.