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Fighting Cancer during a Pandemic

The outbreak of COVID-19 infection has changed the world. To date, no less than 150 million people have been infected and more than 3 million have died.

Each country has had to balance the need of controlling the spread of the disease and maintaining its economy and livelihoods of the people. They have had to confine large populations of people to their homes, restricting inter-state travel, shutting down schools and businesses, closing borders, imposing travel restrictions and quarantining those who are infected or have had possible contact with the infected.

Health care resources in some countries have been stressed to the point of collapse or near collapse. The lack of intensive care facilities and in some countries, the lack of even basic medical resources like oxygen supply, has led to an uncountable number of deaths.

With all eyes are focused on COVID-19 infection, it may be difficult to remember that there are still patients who suffer from many other illnesses - including cancer.

For the last 15 years, Parkway Cancer Centre has been serving the needs of cancer patients from the region. These overseas patients come from Malaysia, Indonesia, Vietnam, Philippines, India, Sri Lanka, Bangladesh, Pakistan and the Middle East.

When COVID-19 first occurred, we were all hoping that the outbreak would be short-lived and quickly controlled, just like SARS in 2003. Sadly, it was not to be. A year has gone by, and the pandemic continues to rage on.

In Singapore, we continue to see small numbers of infected individuals pop up in clusters within the community. This has made the Government very cautious in only allowing small numbers on essential travel to enter the country.

Each overseas patient who wants to come to Singapore for medical treatment needs to apply to the Ministry of Health (MOH) for an entry visa. The doctor supporting the application must justify why the patient cannot be treated in the home country and needs to come to Singapore.

Pauline (not her real name) is a 36-year old Chinese lady who managed to come to Singapore in March 2021.

She first noticed a lump on the left side of her tongue in November 2020. She saw several doctors who reassured her that it was nothing serious and treated her with some topical medication.

Over time, the lesion of the tongue became larger and increasingly painful.

She was eventually referred to an ENT (ear, nose and throat) specialist in her own country who carried out a biopsy on 22 February 2021. A few days later, she was told the bad news that she suffered from Squamous Cell Carcinoma (SCC) of the tongue.

She was told that she needed to go for surgery immediately. Her surgeon tried to reassure her, saying “you go to sleep for a few hours and by the time you wake up, the cancer will be all gone!”

What troubled her was that while the surgeon kept saying that it was a minor operation, he also said that he would need to take a piece of muscle from her body to cover the operated area.

Upon hearing the news, she contacted my clinic and I met her through video-conference on 25 February 2021. It is very difficult to assess a cancer patient without the benefit of seeing and examining the patient.

I explained to her that surgery has conventionally been the primary treatment modality for patients with SCC of the tongue. However, there are advances in cancer management which deploy the use of upfront chemotherapy to down-size the cancer, before deciding on surgery or radiotherapy.

After hearing my explanation, Pauline was determined to come to Singapore for further assessment.

Following the video-consultation, we assisted Pauline in submitting her application to MOH for permission to come to Singapore for treatment.

On 4 March 2021, we received confirmation from MOH that her application for entry was not approved. Pauline was devastated. She cried on the phone and begged me to “save her”. She reminded me that she was a young mother with four children, the youngest of whom was 4 years old.

On the next day, I submitted a letter of appeal to MOH.

In the meantime, Pauline had gone for a PET-CT scan and she sent me the report together with the radiological images. After seeing the PET-CT scan, I was convinced that surgery was not the preferred option for her.

Although I am not a surgeon, I knew from the scans that surgery would involve removing her tongue, floor of mouth, lymph nodes as well as possibly the voice box. This meant that Pauline would end up being tube-fed and unable to talk for the rest of her life.

I showed her PET-CT images and report to two senior ENT surgeons, Dr Andrew Loy and Dr Goh Yau Hong, and they both kindly wrote letters of support on Pauline’s behalf to MOH for her to come to Singapore for treatment.

While waiting for the appeal to be reviewed, the patient was under tremendous stress because her ENT surgeon told her that she needed to be operated on immediately and wanted her to give consent for the surgery.

Each day, she would text and/or call me, pleading with me to help her.

The appeal to MOH was successful. Pauline arrived in Singapore on 16 March 2021 and her treatment was started on 18 March 2021.

Treatment was a combination of chemotherapy plus immunotherapy. Almost immediately after the start of treatment, Pauline noticed that the tumor was shrinking in size and no longer painful.

She has completed 6 weeks (2 cycles) of treatment and the follow-up PET-CT scan on 28 April 2021 showed that the tumor had reduced in size and activity by 70%.

While the results are encouraging and I am cautiously optimistic that she will do well, the road ahead is for her remains long and arduous.

As we count the deaths of many who have died as a direct result of COVID infection, let us not forget the cost of the pandemic on those who suffer from other life-threatening conditions such as cancer.