Lin (T498) is a 50-year-old female. Sometime in March 2006 she felt nauseous and was unable to eat. Every time she ate, she vomited. Lin was admitted to a private hospital. The medical report written by her surgeon dated 6 April 2006, revealed her problems. "She was referred to me on 10 March 2006 for upper GIT obstruction and Ix revealed D3 obstruction. By pass surgery had been done on 14 March 06 … with biopsies of nodes and tumor. She has recovered surgically and now eating well and stable."

The histopathology report dated 16 March 2006 stated: "The primary site is not apparent … any adenocarcinoma from the gastrointestinal tract, hepatobiliary system or female genital tract could be possible." It was suggested that Lin had cancer - D3 retroperitoneum and (?) body pancreas.

After the surgery, Lin was referred to an oncologist for chemotherapy. This is what her oncologist wrote on 8 February 2007. "The patient suffers from locally advance cancer of pancreas. She was referred to me … for treatment of her disease in 2006 April. Patient was then told of her illness with her husband and agrees to palliative chemotherapy 5FU/FA based for a total of 6 cycles."

"Post chemotherapy she was well and disease was under control till she come back again to see me with abdominal fullness on 18 September 2006. Investigation showed that the disease has again recurred."

"Patient was then started on II line chemotherapy Ciplatinum and Gemcitabine for her illness. She had so far 2 cycles. She was admitted to the ward again on 7 February 2007 for abdominal fullness and I had performed a therapeutic tap for her. Took out 1.8 liters of serous fluid and started patient on Spironolactone."

"Patient had been told about her illness but did not seem understand it well."

"I hope you can help follow her up for her palliative care as I think her disease is resistant to the IInd line chemotherapy."

Lin and her daughter came to see me on 22 December 2006 and told me that so far Lin already had four cycles of the second line chemo-drugs and she still had two more cycles to go. Each chemo-shot cost her about RM 3,000 plus.

Lin was prescribed some herbs and a week later she came back and reported that:

1. She was able to sleep better.
2. She was more energetic.
3. The problem of her stomach wind (which bothered her very much) had improved.
4. Her breathing was better.

She came to see us again on 19 January 2007 and that was the last time we saw her. Unfortunately she did not continue taking the herbs.

On 2 April 2007, Lin's daughter came to see me again and she appeared very upset. She explained that due to lack of money she continued to receive the 5th cycle of chemotherapy at a government hospital in Kuala Lumpur (KL). After this shot of chemotherapy, Lin's condition deteriorated and as a result she had to be warded in the KL hospital for about a month. Lin had severe pains and this made her cry all the time. Her stomach was bloated and both legs were swollen. She was not able to eat at all and she also vomited very frequently. After a month in the KL hospital the family requested that she be transferred to the Palliative Care Unit of the government hospital in her hometown. In this hospital she was on painkillers and injections of antibiotics. The anti-vomiting medication administered to her was not effective and she still continued to vomit frequently.

The daughter came to seek my help again. The family was told that as far as the doctors are concerned they could not do anything anymore. At present the immediate problems that need attention are: to stop the vomiting, swelling of the legs and severe distension of the abdomen.

Comments: This is indeed a sad case. If we were to read the reports written by those who cared for her, it is most frustrating to say the least. A surgery was carried out. Perhaps there was some justification to do this procedure given the fact that the tumor was blocking the food passageway. But what about all the follow up treatments? It is not for me to say or judge. The answers much depend on your perception, bias, personality and educational upbringing. But let me point out some salient facts:

1. It is almost always the case that after surgery you will be asked to do chemotherapy! This is because after surgery there is nothing else that medicine can offer except chemothrapy or radiotherapy.

2. Now, ask this question: "chemotherapy for what cancer?" Is it for pancreas cancer? The pathological report put a (?) against this. The primary cancer that Lin had can be from any source - biliary system, ovary, colon, etc. So, is the chemo-drug used in the treatment a shot in the dark?

3. Did chemotherapy work for this patient? Yes, it seemed to work - but only for two months! After the first round of six cycles of chemotherapy, Lin was well for a while and then according to Lin's daughter, her mother had pains again after two months - meaning, the cancer recurred. Why did I say chemotherapy worked for her? The doctor said so! Read what the oncologist wrote: "Post chemotherapy she was well and disease was under control till she come back again to see me with abdominal fullness on 18 September 2006." Yes, according to the oncologist, she was well and the disease was under control! This is the perception of the medical people - the chemothrapy made her well for two months and the disease was also under control for two months and then it recurred.

4. The oncologist also wrote: "Patient was then told of her illness with her husband and agrees to palliative chemotherapy … but did not seem (to) understand it well." Sad. Again this is a problem of perception. To the oncologist the treatment is only palliative. I wonder how many patients fully understand what this word means! Obviously even the doctor sensed that the patient and her husband did not understand the meaning of this word. To the patients, to undergo chemotherapy is to cure the disease! Yes, that is the perception of most (or all?) patients.

5. Anyway, second line chemo-drugs were used after the first liner had failed (oop, it did not fail. It worked for two months, remember?). These drugs, Ciplatinum and Gemcitabine, are very toxic! When Lin and daughter came to see me, I did caution her on this but they said they wanted to proceed with the additional two cycles of chemotherapy. We respect that decision. But it was not to be. That additional shot of chemotherapy sent Lin rolling downhill.

6. Question: After the surgery, Lin had chemotherapy and the disease was under control for two months, said the oncologist. If Lin did not have chemotherapy after the surgery, do you think the disease is NOT under control for 2 months? To be more blunt do you really think that chemotherapy controlled the disease at all?