Wk 2 Day 3 with Dr Chen Hem/Onc by Heidi Pang

We started the morning with patient rounds. It was a difficult and emotional morning as 3 of the patients we saw were at terminal stage and we have been following their case the past 3 days. Patient on BiPaP machine with hx colon cancer and liver metastasis continues to worsen and her infection is not clearing.  Dr Chen sadly informed the patient’s family that her vitals are not promising. We had a discussion afterwards on when we should perform invasive/aggressive procedures on patients. Dr Chen believes that treatment of choice depends mainly on the prognosis and chance of survival, and it is often the most difficult decision to make as a physician. The age and treatment response are also key factors to consider before any procedures (ex: intubation, BiPAP, CPR).

We then moved on to the patient with MDS who continues to refuse treatment and would only want symptomatic relief. She presented with old petechiae on her lower limbs. Dr Chen showed us a standard procedure on checking petechiae and stated that it is important to know how to perform physical findings since we can’t be drawing patient’s blood daily. First, old petechiae tend to be mildly red/pinkish while new ones will be purple. You should also always check oral mucosa as well to look for signs of petechiae. If bleeding is found in oral mucosa, patient has to receive immediate platelet transfusion. Platelet count is usually at around 20-50K if petechiae is newly found on limbs only, and <10K if also visible in oral mucosa.

Our patient with newly diagnosed terminal esophageal cancer with lung metastasis had made his decision with his elder brother to not receive any therapy. He will be discharged today from the hospital. It is unfortunate and sad to witness this decision and we can only provide him with symptomatic relief (for his constipation mostly) at this time. The vitals of our other patient with gastric cancer are also worsening with continuous intermittent bleeding. It was a rather difficult morning today and I can finally experience the emotional stress that an oncologist has to go through on a daily basis.

We returned to the outpatient clinic in the afternoon and saw 20 patients. It will take me forever to explain each case so I will try to keep this short.  

We had a 54 y/o female with invasive lobule carcinoma of the breast, PH of thyroid cancer (w/ subtotal thyroidectomy), DM and Htn. Patient is on adjuvant treatment that includes Tamoxifen. MC side effect of Tamoxifen is endometrium thickening, so it is necessary to have gynecology visit annually. Tamoxifen is a estrogen-R-1 selective inhibitor, Dr Chen explained that it may possibly stimulate the ER-2 receptors in the endometrium leading to proliferation of cells.  He also mentioned that studies have shown increase chance of thrombosis from taking tamoxifen but occurrence in Asia is relatively low so oncologists in Taiwan are not recommended to put patient on prophylactic anti-coagulants. CXR was ordered and showed RML patch with unknown etiology. Dr Chen does not believe that it is possible pneumonia since patient was not presenting with any clinical symptoms. She will return in 2 weeks for a f/u CT scan.

Another interesting case is a 64 y/o female patient with newly diagnosed mixed mucinous and residual invasive ductal carcinoma of the breast. Dr Chen stated that it is pretty rare to find a mixed type carcinoma of the breast. She was PR (+), ER (+) and HER (+1) with a tumor size of 1.5x1.1x1.0cm (relatively large tumor). He staged it as early stage 2. He suggested 4 sessions of adjuvant chemo with radiation after chemotherapy (patient had partial mastectomy). He explained that even though patient is PR and ER (+), adjuvant therapy is more suitable as her tumor size is large and she has mixed prognosis.

We ended our day with a 64 y/o female with DCIS (ductal carcinoma in situ). Dr Chen believes that DCIS has no relationship with invasive ductile carcinoma. It is often multi-focal and can grow up to 2-10cm.  Current treatment primarily is surgical resection and adjuvant treatment with tamoxifen was suggested to the patient to prevent relapse. Successful survival rate for DCIS patient with this treatment procedure is up to 98% for 5 years according to clinical trials. It was nice to end the day with some more positive prognosis after having a tough morning…

Some Other things that I have learnt today:

Dr Chen had encountered a few patients who refused chemo and choose to seek for treatment from TCM doctors. He said that there are some patients that have returned and ended up receiving conventional chemotherapy at the end. Currently there are some clinical trials that have been done in China but no systematic search and analysis have been done to show the effectiveness of TCM in treating cancer. I did encounter many patients who seek for TCM physicians to treat the side effects of chemo and cancer related surgeries, but I have yet encountered any patient that visited a TCM doctor as a main treatment for their condition during my 1-week rotation at the department. 

One may think that a BiPAP machine is a simple procedure and is non-invasive, but putting a terminally ill patient on BiPAP machine may not be the best option since it often leads to poor digestion function after 2-3days of usage (so if a patient is already having CO2 retention, he/she is pretty much trapped both ways). 

Cancer bleeding often occurs when intra tumor pressure is high, can occasionally stop bleeding by physically constricting the arterials

1^st presentation of recurrence of nasal T cell lymphoma is fever.  To determine whether fever is infectious vs tumor fever:

1.          Patient must have tumor (MRI, CT to diagnose)
2.        Trial and error to exclude infection
3.         NSAID is usually effective in reducing tumor after only 1 dose

Radiation therapy causes a lot of SE, some include:

• Hearing loss – usually first high pitch, then low pitch
• Sputum production due to damage of cilia function – this will influence future diagnosis as physician will have to distinguish between cough induced due to radiation SE vs infection such as pneumonia

Diagnosing Breast Cancer often involve checking HER2, ER, and PR makers to determine chemo treatments. Aromatase inhibitor is more effective in treating post-menopausal women in general when compared to Tamoxifen (both considered as anti-hormone/hormonal therapy).

Herceptin is usually DOC for non-metastatic breast CA (usually in combo with another drug for adjuvant therapy)

Check bone marrow density for osteoporosis annually if Patient is put on Aromatase Inhibitor

To check for possible bone metastasis clinically, physician can use a fist to knock along patient’s spine. If patient complains of pain after “knocking”, possible metastasis; if patient feels better after, most likely muscle ache.

Patient can take Emend (substance P/NK1 antagonist) to prevent nausea and vomiting from chemo for 1-3 days (but it’s self-paid at the hospital, ~700NT/pill). This Rx works directly in the CNS so it’s much more effective than conventional 5-HT3 antagonist.

Standard treatment of partial mastectomy is to receive radiation after chemo to prevent reoccurrence. Patient generally cannot start chemotherapy until 6 weeks after mastectomy.  

Lastly, remember to ALWAYS relate diagnostic results (imaging, labs) with CURRENT CLINICAL symptoms to determine differentials!