Day 1, Megan and I started our Hematology/Oncology (Heme/Onc) rotation by accompanying Dr. Chen on his rounds. I chose to do the Heme/Onc rotation because I felt that my knowledge about the subject was lacking and I wanted to reinforce what I have already learned, as well as gain exposure to the clinical practice of Heme/Onc.
Patient 1 was a 57 year old female with left breast invasive ductal carcinoma (IDC) that was HER 2/neu (3+). She had a modified radical mastectomy (MRM) in November 2013, which revealed metastasis to the lymph nodes. However, she refused adjuvant therapy, which is additional therapy done after the primary therapy to decrease the risk that the cancer will return. In May of this year, her CT scan showed multiple lung tumors. Her cancer is now Stage IV and she is currently being given palliative therapy, which is designed to relieve symptoms. This made us (as well as Dr. Chen) wonder what were her reasons for not accepting the adjuvant therapy, since the adjuvant therapy would have prevented her cancer from progressing so rapidly.
Patient 2 was a 75 year old female with myelodysplastic syndrome (MDS). In MDS the bone marrow is not functioning normally, thus the blood cells are poorly formed or dysfunctional. She presented with neutropenic fever and malaise. Because she is immunocompromised, she is prone to getting infections.
Patient 3 was a 55 year old male with esophageal cancer (squamous cell carcinoma), stage IV, with lung metastasis and normocytic anemia. In March or April, he developed odynophagia and also experienced a weight loss of 15 kg in 2 months, and cancer cachexia. Dr. Chen told us that nutritional status is very important in the treatment, and since this patient was unable to eat solids, they tried to insert a nasogastric tube, however, due to stenosis, they had to use the parenteral route for feeding. They are waiting for approval for a gastrostomy tube insertion.
Patient 4 was a 95 year old female. A gastric tumor was found in November or December of last year, which turned out to be adenocarcinoma. The family refused a surgical resection and the patient was given palliative chemotherapy. However, the patient's response was poor and she could not tolerate the side effects. Currently, she is not receiving any treatment, but is only given blood transfusions. Since she has a blood loss of 300-500 ml/week, she cannot be discharged.
Patient 5 was a 65 year old female with a recurrence of colon cancer. 3 years ago the cancer was diagnosed as Stage III with 1 lymph node metastasis. It was removed and adjuvant chemotherapy was received. Upon follow up, liver metastasis was discovered and the tumor marker CEA was escalating. Dr. Chen told us he was deciding which regimen to give the patient because there is currently no data to support a specific treatment. This is where a doctor must use his knowledge and creativity to come up with a treatment regimen. Cases like this remind me that the field of oncology is constantly evolving and changing, as new research provides new treatments and when there is no evidence for a specific treatment, the doctor must come up with one based on his clinical expertise and knowledge of other regimens.
Day 2 began with outpatient visits. Many patients came for follow up after cancer treatment (mostly for breast cancer) or follow up for anemia. One patient that stood out to me was a 35 year old female who had 1) developmental disability, 2) seizures, 3) depressive disorder, and 4) nasopharyneal carcinoma with lung and bone metastasis. She was exhibiting rapid deterioration, as last visit she could still walk on her own, but this time, her sister had to carry her into the office. Dr. Chen suspected that the patient would pass away soon, so he suggested hospitalization, but her sister refused. The nurse told the doctor he should have pushed for the hospitalization, but he responded that she could pass away peacefully in her home. This case demonstrated to me the importance of respecting a patients' wishes, particularly in end-of-life care. While in some cases, it may be difficult to understand a patient's or his family decisions, physicians must respect those decisions.
After outpatient visits, we followed Dr. Chen on rounds where we saw many of the same patients from the day before. One new patient was a female who had colon cancer with liver and peritoneal metastasis. Because most drugs used to treat colon cancer are metabolized by the liver, use of these drugs would accelerate her liver failure. Therefore, Dr. Chen did not suggest palliative therapy.
Day 3: In the morning we did rounds. The patient with esophageal cancer had been approved for the gastrostomy, so he was being prepared for the operation. The patient with colon cancer that had metastasized to the liver had been given an increased dose of diuretic drug, but the edema and ascites did not improve. Dr. Chen suggested albumin, which is usually effective. However, if the inferior vena cava is being compressed by the liver tumor, then the venous return will be affected and the albumin may have little effect. But, the insurance will not cover the use of albumin because this patient does not meet the 4 requirements as stated by the insurance. Dr. Chen makes sure to explain the situation to each family member because lawsuits against doctors are, unfortunately, quite common in Taiwan. In the afternoon, we observed the outpatient clinic. As before, many of these patients came in for follow-up after completion of their cancer treatment or for follow-up of their anemia. Two patients came in for follow up of Idiopathic Thrombocytopenic Purpura. The doctor had recommended splenectomy for both patients and both were hesitant to undergo a surgical procedure. They had opted to remain steroid dependent, despite the risks. These cases were another reminder of how Taiwanese culture can influence patient perspective regarding surgical/invasive procedures.
Day 4: We started off the day in the outpatient department. Cases included macrocytic anemia, lung adenocarcinoma with meningial metastasis, ovarian cancer, ecchymosis, and colon cancer. After OPD we went on rounds where we saw some of the patients we had been seeing all week (myleodysplastic syndrome, esophageal cancer, colon cancer with liver failure, gastric cancer patient receiving blood transfusions). Other patients included a patient who was to receive a colon fibroscopy to determine if his anemia was due to GI bleeding, a patient who is receiving her first chemotherapy treatment, and an ovarian cancer patient who was admitted after her visit to the OPD earlier. This week in Heme/Onc has really expanded my limited understanding about the treatment of cancer patients. Practice in this field requires a physician to stay on top of all the new research so that he can provide the most appropriate care for his patients. And when there is no current evidence to help the doctor determine a treatment route, the doctor must combine his clinical knowledge with whatever data is available in order to create a treatment regimen for his patient. Additionally, I have gained more insight into the Taiwanese health care system.
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These past 4 weeks with the Taiwan International Healthcare Training Center at Taipei Hospital have been so great. This experience has really demonstrated to me that medicine is both a science and an art and has inspired me to learn more about medical fields that I may not have considered before. I have been able to see how social, cultural, and economic factors can affect healthcare delivery and have been able to learn about the triumphs and flaws that exist in one of the so-called best health care systems in the world. I will use what I have learned in this experience as motivation to pursue my academic and career goals. I would like to thank all the doctors for giving us their time and for their willingness to teach us. I would also like to thank the TIHTC staff for helping us throughout the internship.
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