COLORECTAL CANCER is among the most common malignancies in the US with 95,000 colon and 39,000 rectal cancer cases estimated to occur in 2017. In patients under the age of 20 however colon cancer is literally 1 in a million.
For one young patient, the odds were not in her favor.
On the morning of April 12, 2017, I arrived at my laboratory to find a frail young woman in a wheelchair accompanied by family. They had just arrived from Sacramento, a 6 hour drive, after a large hospital there had discharged her to home hospice.
This 19-yr-old, 2nd year college student, had presented to the ER in late January with abdominal pain. When she returned on the 31st a CT scan suggested colitis. After antibiotics proved ineffective, she was taken to surgery.
The findings could not have been worse.
Diagnosis: Stage 4 Colon Cancer
Throughout the abdomen was poorly differentiated adenocarcinoma that appeared to arise in the descending colon. The peritoneum and mesentery were invaded with “signet ring” cells. After discharge she sought an opinion from the University Medical Center.
While tumor boards reviewed her case, she deteriorated and was admitted to a second hospital where gastrointestinal obstruction led to the placement of a stomach tube to drain the abdominal contents.
Recommended to Hospice
The family contacted me to say she was being discharged to hospice, as she was deemed too ill for treatment. That was the day before we first met.
Upon our meeting the next morning, I was struck by her youthful beauty, her strength and her desire to fight.
I admitted her to the hospital on the spot.
CT scans identified abdominal fluid that was aspirated to provide cancer cells for FUNCTIONAL PROFILING in our laboratory.
Results of Her Functional Profiling Test
Platinum-based combinations were found highly active, a degree of activity that was markedly enhanced by the addition of drugs that target the epidermal factor pathway (EGFR). The combination of Erbitux (the antibody against EGFR) and FOLFOX was selected and treatment began immediately.
The patient was gravely ill. So much so that the hospice recommendation, however dire, could be understood.
Dehydrated, malnourished, pale and anemic, the patient’s tumor markers i.e., CEA of 38 (12 times normal), and CA 19-9 of 1066 (35 times normal) confirmed that we had our work cut out for us.
While her original physicians had been hesitant to treat, based on the known toxicities and the statistically low likelihood of benefit, we had the luxury of laboratory data that clearly identified sensitivity to therapy. We were not engaged in a guessing game, but instead a worthy battle to find out how long it would take us to get her better.
Her Treatment Begins
This was not for the faint of heart, as the patient needed intensive support and required re-hospitalization on 2 occasions.
In keeping with our expectations, just 1 week into therapy, the CEA fell from 38 to 12 and the CA 19-9 from 1066 to 562, but her symptoms did not abate. The enormous tumor volume had compressed her kidneys requiring stents and the persistent abdominal pain proved to be a post-operative wound abscess (infection) that required CT-guided drainage.
Inpatient treatments moved to the outpatient setting, as family and friends supported her stay in Southern California.
Despite side effects, she remained resolute.
Continued Response to Treatment
As we rounded the 2nd month, and the 2nd cycle of therapy, the patient returned to us with good news. Her gastrointestinal function was normalizing and she was now able to clamp the drainage tube. The pain had improved and she was gaining weight.
Repeat CT scans revealed that the dilated loops of bowel had resolved and the tumor encasing the small bowel had disappeared. The abscesses were gone and the kidneys were functioning normally. The previously markedly elevated tumor markers had returned to baseline.
Ten weeks after we had first met, this brave young patient boarded a flight to Sacramento to resume therapy closer to home. She had regained her smile.
I made a special visit to my clinic on the day that she was scheduled to depart. I told her how proud of her I was and that my regret was that I could not finish the job that I had started.
Her good outcome was beyond a success. It was a miracle.
The patient and her family sent kind notes. She wrote “You believed in me when others did not” and the family “You gave her a chance when no one else would. You brought other medical professionals to her side. You made them and us believe that she had a shot, and you were willing to do anything possible to give it to her.”
An Important Lesson to Be Learned
This is but one story of many, yet it reflects a theme of great importance.
When cancer patients are treated based upon the statistical probabilities, physicians have low expectations. This is the reason why her doctors were so quick to resort to hospice.
The stats in her case did not engender optimism.
With the luxury of a laboratory analysis however, a physician can determine which patients warrant aggressive intervention. Knowing that the odds of response are two-fold greater (P<0.001) and the likelihood of 1-year survival statistically superior (P=0.02), can give even the most pessimistic oncologist reason to treat.
I was honored to take care of this brave young woman and urge patients like her with difficult cancers not to give up. If we can gain the upper hand on cancer, we can confront even the most difficult diagnoses.
In this disease, there is no room for guesswork.
As always, I appreciate your thoughts and comments.