Sep 28, 2008
The Straits Times
I was stunned when the patient calmly told me: 'They said that I have no cancer." Mr Didik had been on palliative chemotherapy for several weeks for metastatic pancreatic cancer when all of a sudden his son asked that the pathology material, medical reports and radiology films be sent to one of the top cancer centres in America.
After a week of thorough review, the American doctors had concluded that there was no cancer.
The earlier diagnosis had been made in Singapore, when Mr Didik underwent surgery for what appeared to be localised cancer of the pancreas. At the time of surgery, we saw that he had multiple nodules on the surface of the liver. These were not seen in the pre-operative computed tomogram (CT) scans.
One of the nodules was taken for a biopsy and confirmed on frozen section (this refers to rapid microscopic diagnosis of the specimen) to contain cancer. As this meant that the cancer had metastasised to the liver, the planned re-section of the pancreatic mass was abandoned. I was then called in to discuss the role of palliative chemotherapy.
As this was stage four - or end-stage - cancer, the goal of the treatment was to try and kill the cancer cells, control the disease and, hopefully, allow him to live longer. After careful discussion, Mr Didik started on chemotherapy. He was tolerating treatment well when this bombshell was dropped on me.
If the pathologists from America were right, Mr Didik did not have cancer. This meant that I was giving him chemotherapy that was unnecessary and potentially harmful to his well-being!
Mr Didik is 59 and owns a wig factory in Indonesia. We have a good relationship and he had given me one of his specimens for the lab.
As I sat there looking at a seemingly perfectly healthy man, three concerns came to my mind.
The first was whether or not Mr Didik had cancer. In his presence, I called up the pathologist who had done the earlier diagnosis in Singapore to request an urgent review of the case. To my horror, he told me the entire specimen (it was a very small biopsy), including the pathology blocks and slides, had been sent to the American centre for review. There was no remaining tissue for us to study or to send elsewhere for another independent review.
When we contacted the American pathologist, he declined to release the specimen as he needed to retain the tissue in the event that he needed to defend his position. There was not enough tissue for two sets of slides.
My second concern was whether we should push on with the treatment or abort it. As there was now doubt cast on the diagnosis, I suggested we stop the treatment till we were sure. To my surprise, Mr Didik wanted to carry on and was determined to complete the six months of chemotherapy as planned.
His logic was that he was tolerating treatment well and that one of the cancer markers, elevated at diagnosis, was gradually coming down with treatment.
What if he really had cancer? His concern - a sensible one - was whether stopping chemotherapy would increase the risk of drug resistance and compromise his survival.
The third issue was whether he was going to sue us if there was indeed a misdiagnosis. At that time, I really didn't know how (or dare) to ask him if he planned to take legal action or file a formal complaint against us. After all, we gave him chemotherapy when he apparently did not have cancer.
The 2007 annual report from Singapore Medical Council (SMC) has just been released. The number of complaints per 1,000 doctors has risen from 11.6 in 1997 to 15.6 last year. In total, there were 115 complaints received last year, an increase of 42 per cent compared to 2006.
Our society is becoming more litigious. Siblings are suing each other, as are children and parents. Patients are suing doctors.
For me, the practice of medicine is as much an art as it is a science. Each day, doctors make judgment calls on how best to care for their patients. They combine medical knowledge and experience with perspicacity in deciding what is best for each patient.
If Mr Didik had decided to lodge a complaint, it would have been difficult for us to defend ourselves at that time.
He completed his chemotherapy and remained well for a while. About a year later, his cancer markers started rising and there was radiological evidence of cancer progression. After an overseas review in Europe that confirmed that he had metastatic pancreatic cancer, he is again on palliative chemotherapy and responding well to treatment.
One day, I found the courage to ask him why he never complained or sought legal redress for the alleged wrong diagnosis. He replied: 'What for? All of you are trying your best to help me. If there was a mistake, it was not intentional."
He is a truly magnanimous man. I wonder if he told the American doctors that they were wrong.
Dr Ang Peng Tiam
angpt@parkwaycancercentre.com
- 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 Sept 25, 2008.
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