I wrote about the sad demise of my cousin in my last post. The
trauma faced by his family during the brief period between diagnosis and his
death was painful indeed. The diagnosis was metastasized renal cell
carcinoma.
He contracted cancer for the
first time five years ago. It was a growth in one of his kidneys. The kidney
was removed and all neighboring lymph nodes cleaned by the surgeon. He recovered
and started leading a normal life. Periodical followups were satisfactory and
went on for three years. He was declared cancer free. Normal life, with his
normal ailments of diabetes, hypertension and enlarged prostate, continued for
one more year. In the fifth year he developed another problem. He started
having bouts of dizziness and losing balance while walking. This was initially
thought to be vertigo. He was also diagnosed with CLL (Chronic Lymphocytic Leukemia.)
However the haemo-oncologist reassured us that it had nothing to do with
his renal cancer.
Unfortunately, what was thought
to be vertigo was later found to be a cancerous growth in the brain. Further
investigations showed a growth in one of the lungs too. Biopsy results
showed that it was renal cell carcinoma that had metastasized to other organs.
My niece is a doctor and member
of a WhatsApp group of doctors with varying specializations. She
consulted the oncologists in the group and they were almost unanimous that it
will be best to stop looking for a cure and go for palliative care instead.
They estimated the remaining life span at 3 to 6 months. They also
described the likely and frightening after effects of radiation and cancer
medication. In their opinion the treatment, even if it succeeded in prolonging
life, will also aggravate the misery. The alternative of palliative care was
likely to ensure a relatively better quality of life for the patient for
whatever span was left to him. Needless to say that this group had no
commercial interest in the matter.
My niece also spoke with some
of the families that had lost an aged member to cancer. All of them
regretted having gone for the treatment and were of the opinion that the
patient would have been better off without it even if it had meant a shorter
residual life. Much later, after we were in the middle of treatment, I
learnt of the sad death of a friend; again due to cancer. His wife sorely
regretted having gone for aggressive treatment thereby prolonging and
intensifying his misery. She strongly advised us to ignore oncologists
and go for palliative care only.
It was too stark an advice to
be fully shared with the patient and those closest to him. Carefully
worded soft disclosures and hints at the alternative course led to a state of
indecision. The local medical oncologist insisted that the patient be
put through entire regimen of treatment which could extend his life by an year
or more. He ordered umpteen tests too. Finally he prescribed radiation
therapy for the brain. The radiologist decided in favor of whole brain
radiation instead of one focused on the tumor only. As the family could
not decide on the option of palliative care, my cousin, the patient, underwent
10 radiation sessions. He was also put on a heavy dose of steroids for the
duration of radiotherapy.
The steroids did wonders to
improve the patient's sense of wellbeing and he sailed through radiotherapy
without much visible adverse effects. Though, hair loss did start by the
end of the therapy. We thought that those advising against radiation were
a bit of alarmists. Thereafter steroid was gradually withdrawn leading to
progressive worsening of condition. Next the cancer drug Votrient was
started. Oncologists in my niece's group again advised against it.
The attending oncologist had
prescribed the maximum dose of 800 mg. However in view of the concerns
expressed in online consultations, it was decided to reduce the dose to 400 mg.
From here it was downhill all
the way. Many of the after-effects of radiation started showing.
Votrient seemed to do little to slow down the growth of the cancer while
it aggravated the downfall. The patient suffered from hypersomnia
(sleeping most of the time,) severe weakness in limbs and loss of control over
bladder and bowel movements. Other complications like urinary tract
infection (UTI) and thrombosis developed and required hospitalization for
treatment.
No improvement was noticed even
after a month of taking Votrient and other treatments for infection and
thrombosis. The doctor finally decided to stop Votrient for a few days
and we prevailed upon him for discharging the patient. We made
arrangements at home for administering intravenous drugs, started using adult
diapers and finally arranged an oxygen kit too. In the last two-three
days the patient stopped interacting with people altogether, ate very little,
was extremely restless and his limbs were trembling all the time. He died
in the wee hours on 18th April, nearly three months after the metastasized
cancer was detected for the first time.
All of us are convinced that it
would have been far better to go for palliative care. We were told that
such care could be given by a normal MD to relieve symptoms and pain and
steriods could be given to impart a sense of wellbeing. In this scenario
there was little sense in considering the long term adverse effects of
steroids.
My niece's husband, a doctor
himself, summarized the whole thing quite succinctly. He said that the
family could not bring itself to accepting the sane advice of putting the
patient on palliative care; and that any other family that was unfortunate
enough to consult us in this matter, would surely ignore our own advice based
on our harsh experience. In the choice between quality of life and
painful longevity, howsoever little, the latter, unfortunately, always seems to
prevail. And thus the practice of oncology goes on.
I have a feeling that all
practicing oncologists treating a patient advanced in age and suffering from
metastasis, should be mandated to compulsorily offer the second option of
palliative care only. Few do so currently.
