Mdm. Loh is a 60 year old mother of 11 children, one of them is a Mongoloid child. She married at the age of 18 to an employee of her family business. She assisted the husband to run the family business manufacturing noodles. At the age of 45, she had per vagina bleeding and was found having squamous cell carcinoma of cervix, stage 3. Her doctor had told her that she had advanced cancer. She and her husband are anxious to explore all avenues to achieve a ‘cure’. She was offered radiotherapy and chemotherapy but she refused both. She sought my advice with regard to this matter. I recommended her to a University Professor who years ago did a successful Wertheim’s hysterectomy on my mother. So, she sought a second opinion from the University Professor, a gynaecology oncologist who reviewed the case as stage 2a. She was offered Wertheim’s hysterectomy. After a successful Wertheim’s hysterectomy, she became very religious and volunteered religious work on a regular and compulsive basis. Her husband died of carcinoma of colon with liver and peritoneal metastasis 10 years ago. Her mother died of lung carcinoma with brain metastasis 15 years ago. Her eldest child, a daughter died of brain cancer at the age of 19, twenty two ago. (Both her mother and eldest daughter had underwent radiotherapy and chemotherapy and died shortly after that.) 

I am a General Practitioner (GP) practicing in a small town in Malaysia. Mdm. Loh saw me in my clinic complaining of backache and occasional burning and aching pain in the buttocks with radiation to her thighs when she stood for more than ten minutes or walked for more than ten meters. She had this pain for the last three months and this problem limit her activities of daily living. 

Although she had been well for the last fifteen years I suspected that she could still have recurrence of carcinoma of cervix. She might have spinal cord compression with early nerve root compression as the pain was localised to the vertebral column and occasionally radicular. However, she did not have any symptom of hypercalcaemia. Her bladder and bowel functions were normal. I referred her to a hospital-based physician who requested a MRI (magnetic resonance imaging) of the lumbar spine. The MRI ‘confirmed’ that Mdm. Loh had recurrence of carcinoma of cervix causing compression from L3 to L5.  

The following discussion would aid in deciding:

1. Whether Mdm. Loh is a suitable patient for surgery
2. The most appropriate therapy and the outcome of the therapy.

In this case, the FNA (fine needle aspiration cytology) was not done. The use of FNA guided by CT scan is readily available and should be the procedure of choice to establish a definite diagnosis as well as to exclude other diseases such as lymphoma or sarcoma. Failure to obtain material for diagnosis may lead to laparotomy or open biopsy. 

Bone metastasis is particularly rare for cervical cancer. However, bone metastasis, while uncommon, can have a dramatic clinical presentation, with severe pain and hypercalcaemia-induced confusion the most frequent findings. The most common mechanism of bone involvement is direct extension of the neoplasm from involved para-aortic nodes to the adjacent vertebral bodies, although haematogenous spread is possible. The treatment of bone metastasis consists of localised radiotherapy for symptomatic relief of pain as well as treating hypercalcaemia where present. Late recurrence is rare but may be found 10 or more years following initial diagnosis. Van Herik & Fricke examined the records of 2107 cases of cervical carcinoma for evidence of recurrence at least 10 years after initial therapy. 16 patients (0.7%) developed recurrences 10 to 26 years after initial therapy. (Manetta, Bernam & DiSaia, 1992, p719). 

I had previously put her on paracetamol 1 g four times daily. She had some but inadequate pain relief. Based on the diagnosis of spinal compression, the hospital-based physician started her on morphine 15 mg b.d. together with dexamethasone 4 mg b.d. There was no neurosurgical consultation. There was also no consultation with pain specialist. These have been the normal practices as these resources are not readily available in Malaysia. 

A course of radiotherapy with concurrent chemotherapy was recommended and her morphine was gradually increased to 30 mg q.i.d. After radiotherapy and on a dose of morphine 30 mg q.i.d. she was feeling comfortable, slept well and was able to sit up for several hours. As she complained of pain on walking, a NSAID, Naproxen 550 mg b.d. was added. Her pain was well controlled.  

Over the next three months, her condition deteriorated. Investigations showed bowel, peritoneal and liver metastasis. She was no longer able to sit up. She complained of abdominal pain and backache. The physician recommended a further course of 5-FU (5-flourauracil). The BIP (Bleomycin, Ifosfamide and cisplatin) program was not used. She chose to go through the course of chemotherapy but returned home after each course. She felt better after each course while the side effects of chemotherapy continue to worsen. 

Recurrent carcinoma of cervix has a 1 year survival of only 10 to 15% and 5 year survival of less than 5%. Because the majority of these patients usually have pelvic wall involvement or local spread to lymph nodes or distant metastasis by haematogenous route or bone metastasis, there is no indication for ultra radical therapy. Hence, the greatest number of recurrence are suitable for palliative care only. (Manetta, Bernam &DiSaia, 1992, p720). 

After she completed the chemotherapy, the liver enlarged at an alarmingly fast rate. She refused further chemotherapy because she felt too ill. She was referred by her hospital-based physician to the palliative care unit. In the Palliative Care Unit, the patient’s condition continued to deteriorate.  Unlike in developed countries, DNR (do not resuscitate) order or a healthcare proxy is not yet an issue in Malaysia. Her major concern was her children. According to her, the children were reasonably successful and ambitious, but they were not religious enough. For those who were still single, she would like to see them settled down, starting their family and be more religious. She would also like them to look after the only dependent Mongoloid child (Down’s syndrome). She believed that whatever fallibility of being human would be taken care off by being religious. As she chose to live her last days at her home, I was asked to visit here daily until she died peacefully 7 days later surrounded by her children, relatives, friends and religious colleagues. 

PSYCHOSOCIAL AND SPIRITUAL ASPECTS

This patient does not suffer from depression and terminal confusion. However, caring for this patient touches me because her personal and clinical scenarios were very much similar to my own mother. This case highlights the issue of IDENTIFICATION and PROJECTION. (This patient and her caregivers and relatives do not know that I had a mum with similar problems. They only knew that I showed unusual holistic interest in her case).

The similarity of the patient to the doctor’s mother might more starkly face the doctor’s grief of losing his mother. Hopefully, doctors will develop ways of dealing with this experience with both intrapersonal and interpersonal resources at both personal and professional levels. In other words emotional maturity in these areas is necessary to deal with this experience.

Mdm Loh, being a devoted Buddhist, did not have much problem in this area. Despite the pain and restricted mobility that affect her activity of daily living, she was able to maintain a good quality of life. Being religious, she ‘chanted’ ( religious rituals) a few times a day and meditated occasionally. She had good general psychological supportive care from her friends, neighbours, religious colleagues and relatives. Her coping skills and stress management techniques were satisfactory. These people love to visit her very often and enjoyed talking to her. She enjoyed talking to these visitors for hours. She could even confide very private and intimate topics with many of them. 

I found Mdm Loh lucky in the sense that she usually expressed her spirituality through her religion. She acknowledged that she would have a peaceful exit through a helpful society because of her close and dedicated association with Buddhism and the various temples in town. During the last few months she had been preparing herself psychologically, socially, culturally, and spiritually for a peaceful exit surrounded by her children, relatives, friends and religious colleagues. 

MALAYSIAN WORK ENVIRONMENT 

In Malaysia, Palliative Care is still at its infancy. The Malaysian experience is best illustrated by the article “PALLIATIVE CARE: EXPERIENCE WITH 156 CASES IN A GENERAL HOSPITAL” (Khoo, SB, 2002).  This is the first Malaysian report on a developing discipline. The author covers the experience of both the Palliative Care Team and the Palliative Care Unit. The study describes 156 patients referred for Palliative Care over a period of two and a half years. The author makes the point that the number does not represent the palliative care population or the prevalence of the types of cancer seen at the hospital as some disciplines in the hospital did not refer. As up to 70% of cancer patients are at stage 3 or 4 at diagnosis it is likely that the need for palliative care is enormous.  

Generally, the society sees Palliative Care as a bonus. These patients have simple needs. They do not ask the doctors to save them from death but if they are comfortable from day to day they would be most grateful. In addition, the clinical experience has proven to us that Palliative Care work equally well within the Malaysian environment to help them face death peacefully and with dignity.

At this stage of development, it is essential to have a Palliative Care ward and a home program to improve the clinical skills and to ensure good Palliative Care services. The support of all the other doctors is needed to reach out to this group of patients. Hopefully, Palliative Care would soon be considered as a basic need for all advanced cancer patients who should have the autonomy to request for such care and not to be deprived of it just because their doctors refuse to refer.

However, as Palliative Care and Oncology go hand in hand, it is very important that their close relationships must be adequately addressed. Beside early detection and treatment of cancer, there must be adequate resources. The priorities for Malaysia include training of more oncologists and allied health staff, upgrading and replacement of the aging machines in the various government cancer centres, strengthening of programs for palliation and consolidation of existing treatment programs. While overseas training in clinical oncology is being continued, it is heartening that the Master in Clinical Oncology  has started in University of Malaya since 2002.

Treatment and care of cancer patients require a multidisciplinary team. Close networking between oncologists, surgeons, radiologists, pathologists, palliative care physician and other relevant disciplines optimises cancer treatment and care as well as facilitates the development of management policies that favour the outcome in patients.

Apart from reducing the incidence and mortality due to cancer, programs for the control of cancer must also improve the quality of life of cancer patients. Issues about accessibility to reliable data on cancer, appropriate dissemination of information to the public, measures for prevention, screening and early diagnosis of cancer, rehabilitation, palliative care, inter-agency cooperation, training programs, research in cancer and legislative changes must all be addressed effectively. 

CONCLUSION

Ideally all doctors should be capable of delivering basic palliative care to their patients in whatever work environment. Continuing medical education is the closest answer to this philosophy. 

REFERENCE

1. Manetta, A., Berman, M.L., & DiSaia, P.J. (1992). Advanced and recurrent carcinoma of cervix. In M. Coppleson (Ed.), Gynecologic oncology (2^nd ed., Ch 45, p 719). U.S.A.: Churchill Livingstone.

2. Khoo, S.B.,(2002). PALLIATIVE CARE: EXPERIENCE WITH 156 CASES IN A GENERAL HOSPITAL. In MJM, Volume 57, Number 4, December 2002.