Oncologists are like bookies, I would tell my patients during prognosis. 'We study the natural history of different cancers, understand the odds and what is likely to happen if we were to treat, not to treat, or to modify the treatment programmes.'
Recently, I saw a patient who played the odds and lost.
She had noticed a small lump in her breast some time last year and immediately saw a doctor who confirmed that she had breast cancer. She rushed down from Kuala Lumpur and was delighted to hear, after the surgery, that she had stage 0 breast cancer.
Most are familiar with breast cancer stages I to IV but few have heard of stage 0.
Stage 0 is an optimistic name for intraductal carcinoma.
This is used to describe tumours in which the cells become abnormal and divide without control but have not started invading. The cells stay within the confines of where they should inhabit and have not started penetrating to deeper layers.
This patient was referred to see a senior medical oncologist who assured her that her chances of cure were excellent. As the tumour had not started invading, the chances of a cure were estimated to be about 99 per cent. She did not need chemotherapy. She was elated.
Six months later, her joy turned to despair when she detected a small swelling in her neck. A biopsy confirmed her worst fears - her cancer had recurred. In fact, within those six months, it had spread to involve many sites within the body.
When she came to see me, she wanted to know why: Why did the cancer recur when she was told that her cancer was diagnosed early and she had an excellent chance of cure?
I wasn't sure how to console her. The cruel thing about those odds is that some patients end up in that 1 per cent. If science could predict who will be in that 1 per cent and why, it won't be a chance but a certainty.
As the cancer had spread, I advised her to consider chemotherapy which had a greater than 60 per cent chance of killing the cancer cells and prolonging her life. She saw me once and never came back.
Her odds had been 99 to one and she lost. I guess the new odds I gave her (60 to 40) did not sound too appealing but she could have been in the 60 per cent.
As a doctor, I do not go into philosophical discussions of odds with my patients. I explain what I can and also the limits of scientific knowledge. I tell them what I think works best.
However, the reality is that there is a great deal about cancer that we do not understand. I have a good number of breast cancer patients who were diagnosed with advanced stages of the disease - with more than 10 lymph nodes affected. Medical literature suggests that these patients have dismal outlooks.
Yet some of these patients of mine are still alive and well.
One of the first patients I saw in 1990 when I came back from my oncology fellowship was this anxious woman who had breast cancer with more than 10 lymph nodes affected. I remember well our lengthy discussion, with me emphasising the lack of data to suggest chemotherapy. However, her husband was adamant that we should just go ahead with the treatment and hope for the best. With her, we played the odds - and won.
We know data and probabilities. We know who has a good chance. However, patients must not rejoice too wildly when they appear to have good odds, just as they should not give up when the picture seems bleak.
I say we play the odds because it is an easy way to explain data to patients and even to myself. Of course, medicine is not a game of roulette: There are no odds on the final outcome, no winners or losers. Death eventually comes to us all.
Cancer doctors have one rare privilege. We walk with our patients on their final journey and I have seen true courage and love in the face of impending death.
I recently held the hand of a cancer patient in her 80s, with very advanced stage cancer. I had to break the news that her husband had gone through an emergency surgery and was critically ill. She had a rare moment of lucidity, which allowed her to grieve.
'Oh dear, oh dear,' she murmured and started to tear.
I asked: 'Is there anything you'd like me to tell him?'
She sobbed. She had been married to him for more than 50 years. I just stood there, completely wretched.
Then she said clearly: 'Tell him I love him.'
Walking this final mile is an exhausting and heartbreaking part of medicine, but regardless of the odds and outcome, I have seen the victory we gain, even in death.
-Dr Ang, the medical director of Parkway Cancer Centre, has been treating cancer patients for nearly 20 years. In 1996, he was awarded Singapore's National Science Award for his outstanding contributions to medical research.
This story was first published in Mind Your Body, The Straits Times, on July 30.
