Today marks the 2nd wk of my summer internship at Taipei hospital with student Dr Jonathan Go. This week I will be with Dr Chen, a hem/onc specialist. I have always been interested in oncology so I was especially excited to be placed in this department. Dr Chen generally only encounters cancer patients and rarely have hematology patients. He began the patient rounding by de-briefing us on the 2 main patients that are currently under his care on the cancer ward.
Case 1 85 y/o female w/ colon cancer with liver metastasis, PMH: htn and ischemic stroke
The initial workup for the patient was colon rupture and large liver tumor. Patient was reacting to chemo at first but during her f/u visit after receiving 6 mo of chemo, the tumor has enlarged. She is now only on supportive care since she is no longer responding to chemo. She is currently admitted in the hospital for fever with unknown etiology. Bacterial culture is (-) and Rx are given for pseudomonas and fungal coverage but her fever is still fluctuating a lot. Dr Chen suspects some sort of pleural effusion that is causing her CO2 retention even though the initial x-ray didn't show any signs. The patient is put on a BiPAP machine (also known as CPAP), causing excessive trapped-gas in her stomach so the team will change her BiPAP to PM use only.
Case 2
72 y/o female patient admitted for fever and chills. She was previously diagnosed with MDS as Dr Chen found myeloid blast and normal blasts cells in her PBS. BAS and cytology also confirmed the diagnosis of MDS. We generally use Giemsa stain in the States but pathologist in Taiwan utilizes Liu-stain instead for cytogenic studies. Advantage of the Liu stain is that you can obtain 3 lineage dysplasia results in 2-3 minutes (fastest for Giemsa stain is 5-10mins). It was a technique developed by Dr Liu of National Taiwan University in the 1950s. Dr Chen had previously advised the patient to start on new generation of de-methylating agents such as decitabine, but patient refused to receive any chemo at the moment. I asked him how likely her MDS will progress to AML, he replied with "100%" since blasts cells are found in her PBS already. Hopefully Dr Chen can eventually persuade the patient to begin treatment before her condition worsen, and in the meantime the team is only trying to provide her w/ better quality of life by controlling her anemia and infection along with some Rx for dyspepsia.
We also saw a new patient with transverse colon cancer who was previously treated with 5-FU but has just started on a new target therapy regimen due to abnormal findings in the CT with liver tumor. She is put on target therapy only instead of adjuvant treatment (ex 5-FU) simply due to insurance reasons. Insurance will also only allow imaging studies every 3 months and the hospital will normally perform abdominal ECHO first since abdominal CT is very costly. It is difficult to witness the fact that patient care is controlled so much by insurance policies even when Taiwan has adopted the national universal healthcare system. Our last patient is a 95 y/o female patient who has been admitted in the hospital since last November for intermittent bleeding and gastric cancer. Her family refused surgical intervention so the main goal of care can only be controlling her iron deficiency anemia. Patient had tachycardia and Afib last week and was put on CBB and amiodarone. Generally we will be putting the patient on anticoagulants as well to prevent thromboembolism due to her Afib but since the patient has been bleeding chronically, the team can only stabilize her condition with anti-arrhythmic drugs. According to Dr Chen, unlike people in the States, people in Taiwan mostly refuse hospice care. To them, hospice care indicates loss of hope and that they have given up trying. However, he believes that ultimately the quality of life of the patient should be the most important.
It seems like colon cancer/GI cancer are pretty prevalent here in Taiwan for elderly. It is difficult to come to a conclusion by seeing only a few patients on the first day but it seems like there is a commonality, leading to my prediction of possible environmental factors contributing to the prevalence of the disease.
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