Today was the first day of Heme/Onc with student doctor Christine Le. We shadowed Dr. Chen on the 7th floor of the hospital. The area where his patients were was markedly different from other wards of the hospital. There was a statue of guanyin pusa, a goddess in Buddhist belief, and the lights were a little dimmed. It was a much more calming atmosphere than the rest of the hospital.
Case 1
75 yo female who has Myelodysplastic syndrome presenting with neutropenic fever and thrombocytopenia. Originally put on vancomycin with a fever a week ago, but she reacted to medicine with petechiae (red man syndrome). She also had wet purpura (bleeding from mucosa) due to thrombocytopenia. Dr. Chen explained to her that she had bacteremia and was still unable to find the infection focus. She is now on Ceftazidime.
Case 2
57 yo female with IDC (invasive ductal carcinoma) breast cancer with HER2/neu (3+). There are two types of breast cancer: invasive ductal carcinoma and lobular carcinoma in situ. Invasive ductal carcinoma begins growing in the duct and has invaded the fatty tissue of the breast outside of the duct. Pt had a mastectomy last November and refused adjuvant therapy. There are four different immunhistochemical staining diagnoses for breast cancer:
1. Estrogen receptor or Progesterone receptor positive - these are more likely to respond to hormone therapies.
2. HER 2 receptor positive
3. Triple positive (ER+, PR+, and HER 2 +)
4. Triple negative (no ER, PR, or HER 2)
She is given paclitaxel, capecitabine + trastuzumab C2D1. Dr. Chen states that if she hadn't refused adjuvant chemotherapy at the time of her mastectomy, she would not have progressed to terminal breast cancer so quickly. Adjuvant chemotherapy is given after treatment to reduce the risk of recurrence.
Case 3
65 yo female with colon cancer who has a colon resection. She presents with liver metastases and has an elevated CEA (marker for certain cancers such as lung, liver, colon, and rectal cancers). She is being treated as a stage 4 disease so insurance will cover the therapy. Dr. Chen stated that if she was not treated with target therapy initially, insurance will not cover it later.
Case 4
55 yo male who is a heavy smoker came in a few months ago for odonyphagia. He lost 15 kg in 2 months and was unable to eat solid food. He was admitted for exertional dyspnea and LAD was found at the left supraclavicular space. He has cachexia and looked extremely skinny upon examination. He also has stage 4 lung metastases and needle aspiration showed that it was squamous cell carcinoma. An EGD (esophagogastroduodenoscopy) showed upper esophageal mass. Palliative chemotherapy was initially refused, but patient changed mind later when he found it becoming more and more difficult to breathe. Palliative chemotherapy is used to lessen symptoms of the tumor. Unable to put in NG tube due to tracheal stenosis. Surgery for tracheostomy delayed because the intubation necessary for anesthesia is difficult with stenosis. He is now on parenteral nutritional supplement.
Case 5
95 yo female with gastric cancer last November. Dr. Chen recommended surgical treatment but the family could not agree and she was only put on chemotherapy. Chemotherapy response was poor and she was unable to tolerate the side effects of chemotherapy. She is not consciousness and now receives intermittent blood transfusions with no treatment at all. Dr. Chen said that he does not do anything for this patient besides stopping in and greeting the family members there.
Dr. Chen explained to us the nature of being a doctor in this particular hospital as well as an oncologist in this particular hospital. Taipei Hospital is a medium sized hospital that often refers patients to Taipei's medical centers. If a patient needs radiation therapy or target therapy, they are referred to medical centers that offer them. There are 20 medical centers in Taiwan, and Taipei alone has 11 of them. He believes that many of these medical centers only offer the bare minimum of services or none at all to get more government funding.
From these cases we have seen many patients use a conservative approach to chemotherapy and surgery, often to dire consequences. For his breast cancer patient, Dr. Chen expressed that had she accepted adjuvant chemotherapy, it would not have progressed to such a terminal level. He also expressed the same sentiment with the 95 yo gastric cancer patient. Unfortunately, the nature of the disease is that quick decisions need to be made once there is a diagnosis. Cancer moves fast (sometimes) and is deadly.
Another thing I noticed is that Dr. Chen frequently cites journal articles or papers, often prefacing his treatment plan with "there is a trial done..." or "studies say...". It seems like oncology is still a growing field that is constantly changing. Often times Dr. Chen has to make up his own treatment regimen since there haven't been studies done for a specific patient's cancer. Dr. You (from pulmonology) said that he hopes that cancer will one day be as well understood as a chronic disease. For now, it seems like a deadly and difficult field to work in.
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