From Rare Inflammatory Disorder To Cancer: Early Screening Is Vital – S. Mathana Amaris Fiona

A patient started showing symptoms last year, was diagnosed with RF in February, but died from advanced cancer, a disease he never knew of at the start.

I refer to news reports that Malaysia only allocates 2.59 per cent of GDP for public health expenditure, causing a long wait for MRI and CT scans in government hospitals. 

Needless to say, sufficient allocation for public health expenditure enables early screening for a multitude of medical conditions, from rare inflammatory disorder to cancer. 

Rare Inflammatory Disorder

Budiman (not his real name), started having swelling of legs sometime in September and October last year. He lost weight and his walking pace slowed down. He consulted doctors in government hospital (during his regular check-up) and also doctors in private clinics, who gave him painkillers and ointment. He’s a non-alcoholic and non-smoker.

By January this year, the pain at the lower abdomen worsened.  

A urine test in a private clinic indicated presence of blood in the urine (hematuria), which may be due to kidney stones (renal calculi).  An ultrasound indicated mild swelling of kidneys and he was asked to consult a urologist.  

In the first week of February, he consulted Dr K, urologist in a private hospital. A CTU (CT urography) was performed. The diagnosis: Retroperitoneal Fibrosis (RF), causing mild hydronephrosis (swelling of kidney). This is medical jargon to Budiman.  

RF is a “rare inflammatory disorder in which scarring of tissue (fibrosis) occurs behind (retro) the membrane that lines the cavity of the abdomen (peritoneum)”.

Symptoms of RF include pain in the lower back, weight loss, fever, nausea, anemia, loss of appetite, swelling of legs and obstruction of ureter (tubes that carry urine from kidney to the bladder). The exact cause of RF is not known (idiopathic) and affects more males than females.  

Dr K mentioned that RF is tricky to be managed and requires a team of specialists and the treatment cost would just go up in private health care centres.  t was during the time when some government hospitals had to suspend non-Covid health care services. 

Budiman submitted a referral letter by Dr K to the urology clinic in a government hospital and he was told that a doctor’s appointment would be given in three to six months’ time. Two weeks later, Budiman started having pain again, and Dr K gave him another referral letter to the general surgery department in a government hospital.  

Multiple Diagnostic Tests To Find The Unknown

In March, while waiting for an appointment at the specialist clinic in a government hospital, Budiman consulted Dr C, who specialises in general surgery in another private hospital. Dr C recommended him to do a CT scan of the abdomen and pelvis, with contrast (a special dye to highlight the areas of the body examined). The radiology report indicated RF as well. 

A senior consultant, Dr L, suggested a biopsy to rule out other primary/ secondary causes. Since there is a long wait for CT scans and biopsy in government hospitals due to restrained budget, as per the doctor’s advice, Budiman carried out all the tests in the private hospital to speed up the medical investigation.   

Dr B, who specialises in interventional radiology, conducted a rather tricky biopsy guided by CT scan. The tissue block collected was then sent for histopathology examination, HPE (study of biological tissues under microscopic examination). Further, tumour marker tests were performed. 

Finally, the histopathology lab report by Dr F stated: “Metastasis Carcinoma with unknown primary”. It turned out to be cancer.  

The term metastasis refers to spread of cancer cells from the primary site to surrounding tissue or distant organs (Stage 4 cancer). To correlate clinically, further CT scans of the head, neck and thorax were performed on Budiman to look for the primary site of cancer (where it started).  

This is because a single test cannot accurately diagnose cancer, and it usually involves a number of diagnostic tests such as blood tests, tumour markers, physical examination, laboratory tests, biopsy, scanning, endoscopy, etc.  

Next Available Treatment

Suggestions were given to Budiman on the next available treatments: “Some hospitals have the latest radiotherapy techniques and positron emission tomography (PET) scanning facilities. At least one private hospital in Petaling Jaya has a CSR programme for those who cannot afford cancer treatment.  Or try getting into Institut Kanser Negara (IKN), but appointment is only through internal communication between the oncologist from a private/government hospital and the oncologist from IKN.”

Factors that determine a cancer treatment are: cost and duration of treatment, distance to treatment centre, and treatment plan (combination of chemotherapy, radiotherapy and surgery). Whether a cancer treatment is curative or palliative, it depends on the disease progression (Stage 1 to 4).  

More importantly, it is all about getting the patient personalised comfort care and peace of mind as much as possible.  

Budiman saw Dr L for advice. Dr L referred Budiman to his peers at an oncology clinic in a government hospital. By the end of March, Budiman got himself registered with the oncology clinic, and submitted his medical reports to the attending oncologist, Dr O, who recommended Budiman to get himself admitted for further investigation as the primary site of the cancer was unknown.

Battling Cancer 

At the time of admission, Budiman could still walk (slow-paced), eat and speak, though overall, he was weak. 

Oncology wards in government hospitals are not as comfortable and personalised as in the private hospitals – shared bathroom with poorly maintained taps and showering facility, inadequate cleanliness and privacy, and a long queue for surgeries and other medical procedures are among the concerns. Also, food packets left by Grab riders at the lobby shelves sometimes go missing and don’t reach the intended patients.

Later that week, Budiman was transferred to the emergency ward. He was put on fasting mode and drips. His lungs got weaker and he was on an oxygen mask. 

Though his physical movement was limited, Budiman had the clarity of mind to connect with his friends over the phone (as no hospital visits were allowed then). Then, he was transferred back to the Oncology Ward. The doctors were planning to start him on a low dose of chemotherapy (1/3 dose) if his condition stabilised.  

Unfortunately, his haemoglobin level dropped further. He developed fatigue, slept more, and slipped into unconsciousness (unresponsive state). Five days later, he passed away in the oncology ward.  

Budiman courageously fought till the end against a disease, which he never knew of in the beginning.  

Raising Public Awareness

There are thousands of people like Budiman who never get to detect cancer in time. Cancer is a silent killer.  

EARLY detection, screening, and also EARLY treatment increases chances of recovery and saves lives. 

Awareness programmes on early symptoms of cancer are vital to educate the masses.  Try asking the laymen on early warning signs of cancer and most of them would only relate to the movies they have seen before.   

Depending on an individual’s condition, general symptoms may vary, such as fatigue, pain, anemic, unexplained weight loss, lack of appetite, swelling and lumps, swollen lymph nodes, unusual bleeding, bladder, and bowel habit changes, etc. One should not ignore these symptoms, because the condition may worsen if left untreated.  

A total of 115, 238 new cancer cases were registered for 2012-2016 alone. Also, 82,601 individuals died due to cancer from 2012 to 2016, and 70 per cent of cancer cases were diagnosed late.  

Cancer incidence is expected to double by 2040 in Malaysia. More than 66,000 Malaysians are to be diagnosed with cancer annually by 2030. Tremendous works are done by organisations and institutions (Majlis Kanser Nasional MAKNA; National Cancer Society Malaysia; Breast Cancer Welfare Association; Cancer Research Malaysia) in educating the public.   

A Whole-Of-Society Approach

The Covid-19 pandemic delayed cancer screening and diagnosis. More outreach programmes needed to reach all segments of the society, especially the B40 (bottom 40 per cent) and M40 (middle 40 per cent) groups. 

The medical field is rapidly evolving, but many medical conditions can still go undetected or only detected at a late stage due to delayed screening.

The free national health screening should include vital cancer screening on a yearly basis for the male and female population. The mainstream treatment centres should work hand in hand with NGOs to provide the necessary screening.  

Cancer patients need financial assistance, emotional support, physical support, educational support and spiritual support to reduce the suffering that they undergo. We need policies to make health screening tests and treatment drugs more affordable to common people.  

Money spent on unproductive projects can be channeled to upgrade hospital ward facilities and to cover the medical tests expenditures. The fight against cancer requires unwavering support, commitment and synergistic efforts from everyone.  

In short, reform is needed in the public health care system.  Every life is important. 

“While there is life, there is hope.” Push the boundaries to create a cancer-free society and to celebrate life.

S. Mathana Amaris Fiona’s PhD research interests include science communication and medical ethics. The author connected Budiman to the relevant medical specialists and wishes to thank all the doctors who attended to Budiman. This article is not a substitute for professional advice, but mainly intended to inform the masses on the importance of early screening and treatment, and the necessity for health communication in public health.  

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.

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