Please Save My Daughter

"Please save my daughter!" The words, faint yet poignant across the long table, weighed heavily on my heart. The social workers and case managers present undoubtedly shared the weight of the situation. "She comes home crying every day," the father of the unmarried thirty-something-year-old woman lamented. His daughter, his baby girl, no matter her age, was still his little sweetheart. "I have always loved this daughter the most." He had his daughter in his forties, and with his deceased wife's parting wish, it was evident that he was struggling to let go. "We will do our best, but you need to understand that relapsed diseases are challenging to cure completely," I replied. The business tycoon, known for his firm resolve, clenched his hands together, brow furrowed, seemingly helpless in the face of this ruthless disease. "What's the consensus from your team's meeting?" he inquired, bringing back memories of the discussion from the previous week.Last Friday, just before 7:30 a.m., a group of us, clad in white coats, gathered on the ground floor meeting room, continuing a tradition almost 30 years in the making. After settling in, I reported on the patient's condition. She was diagnosed with left-sided breast cancer four years ago, and she initially ignored it. She didn't seek treatment until the lump grew to the point that it caused her entire breast to swell and ache. When the gauze was removed, the skin on her left breast was red and ulcerated, and there was a faint rotting smell. Given the situation, the surgeon determined it impossible to cleanly remove the tumor during surgery, so she was referred to the oncology department.

Decades ago, this would have been considered incurable, but in the past twenty years, preoperative chemotherapy has allowed many patients' tumors to shrink enough for surgery. Furthermore, the emergence of targeted therapies over the past decade has been a boon, enabling us to find no trace of cancer cells in many patients after surgery. As such, the patient underwent our planned regimen of four months of chemotherapy and targeted therapy. As anticipated, the tumor shrank until it was nearly undetectable, the foul odor disappeared, and the ulcerated wounds healed. A mastectomy was then performed by the surgical team, and the postoperative pathology report only identified a residual tumor measuring 0.6 cm. Of the twenty-odd lymph nodes examined, none showed signs of cancer cells, indicating an excellent response. Post-surgery, to consolidate the treatment outcome, the patient underwent six chemotherapy sessions, 25 radiation therapy sessions, and a full year of targeted therapy.

After a comprehensive battle, we initially thought that the cancer treatment had been successful, yet the cancer cells proved more resilient than we imagined. A month following the last targeted treatment, the skin of the right breast started to show redness. We first mistook it for a common rash, thinking it could be alleviated with a cream. However, as the affected area kept enlarging, the surgeon performed a biopsy of the skin. Unfortunately, the cancer had indeed returned.

After I finished the patient history report, the room lights dimmed. Like a movie screening, the radiologist proceeded to review all of the patient's imaging studies on a large screen. "Although the cancer cells on the skin are terrifying, take a look at these few breast ultrasound images." Pupils, previously dilated in the dimness, now widened further, seemingly in anticipation of good news. "There's no edema on the skin, and no tumors can be seen in the right breast or the right axilla, which differs from the initial situation." "There are also no signs of metastasis in the liver or the lungs." The nuclear medicine physician also reported, "Positron emission tomography (PET scan) shows no signs of metastasis either."

The room lights were turned back on, and everyone discreetly exhaled in relief. "What's the opinion of the pathologist?" The team leader hoped that all physicians would contribute their insights. The lights dimmed again, and a screen now displayed individual cells, somewhat glaring as eyes struggled to adjust. "These poorly differentiated cells are cancer cells. Like the previous ones, they are also HER2-positive." These facts were not surprising, but the main point was, "Under the microscope, we can see these cancer cells spreading along the subcutaneous capillaries and lymph vessels. This kind of situation is very prone to metastasis." This was the reason why the skin appeared reddened.

The situation was far from ideal, certainly not as simple as adhering to clinical guidelines, akin to following a recipe. But the purpose of the team discussion was to combine collective wisdom, to seek out a way forward for the patient. At this point, the surgeon calmly took out his phone, which held photos he had taken of the patient. The phone passed from hand to hand. "I examined the patient thoroughly. The area of redness on the skin measures about five centimeters. I am confident that I can excise it completely. The problem is that this area is close to the sternum in the center of the body, which would require a skin graft. But after assessment, the plastic surgeon deemed it feasible and agreed to co-operate during surgery." Though the plastic surgeon was not present at the time, he often played a crucial role in breast cancer surgeries.

"The extent to which cancer cells can insidiously spread often exceeds what we can visually detect, even with advanced imaging techniques such as breast ultrasound, mammography, CT scans, MRI, and PET scans. Can we really ensure a clean resection in such cases?" In the interest of the patient, blunt words and sharp contrasts, unconcerned with offending others, are commonplace in our team discussions. Despite the tension, silence filled the room, freezing the atmosphere.

"So, do we just do nothing?" A rebuttal shattered the silence. The exchanges weren't about flaunting vast knowledge, but to find the most suitable treatment from the differing perspectives of various specialties. "But will the patient truly benefit from our actions?" The Hippocratic Oath reminds us: first, do no harm. Could surgery merely inflict injury, offering no real benefit? This question received nods of agreement. "Perhaps we can supplement surgery with radiation therapy to compensate for its limitations," chimed the radiation oncologist, our key relief pitcher, "I believe we can still do our best." As more specialist opinions flowed in, it seemed a consensus was slowly forming.

"Should we opt for a mastectomy or a lumpectomy?" "Back in our time, we mostly performed full mastectomies for breast cancer, out of fear of incomplete resection and recurrence. But now with advancements in radiation therapy, chemotherapy, and targeted therapy, it's proven that the recurrence of breast cancer is not decided by the extent of surgery, but the success of other treatments. If the surgeon can thoroughly remove the patient's lesion, I would support a lumpectomy to minimize harm," shared the team leader, passing on his wisdom and experience. "What about preoperative chemotherapy and targeted therapy which have been successful in recent years, should this patient consider it?" "Since she relapsed immediately after targeted therapy, I fear these drugs won't be effective, only delaying treatment." This question was relatively easy to address. "What kind of drug treatment should be given after surgery?" Avoiding difficult questions is impossible.

HER2 positive breast cancer has always been a challenge to treat, but the advent of the monoclonal antibody Trastuzumab (Herceptin) in 2000 significantly improved disease control and long-term survival rates. However, this patient's disease seems resistant even to this medication. How can we tackle such stubbornly drug-resistant cancer cells? "Perhaps Ado-Trastuzumab Emtansine (Kadcyla) could help." I swallowed, my weak voice conveying uncertainty. It has been found that some HER2 positive cancer cells are completely unaffected by Herceptin, necessitating new drugs to join the fight. Kadcyla, combining monoclonal target antibody and chemotherapy drug, possesses both the precision of targeted drug missiles and the potent power of chemotherapy. It has been proven in phase III clinical trials to be the first choice after Herceptin failure. "But how many rounds are needed?" In previous clinical trials, long-term treatment was required to control the disease in patients with advanced metastatic cancer. However, it remains uncertain whether it is effective for postoperative patients, let alone deciding on the number of treatment cycles. Additionally, long-term treatment can result in significant economic burden and severe side effects. Not having a clear answer, and sensing my hesitation, the team leader concluded: "In complex cases, there are no standard guidelines to follow. Uncertainty and doubt are endless. Let's do our best! Please arrange a family meeting with the patient and their relatives before treatment, and ask our social workers and case managers to thoroughly explain the situation.”

In the face of a challenging medical condition, it takes more than the determination and perseverance of a medical team. Mutual trust between the patient and the physician is also vital for them to journey together towards recovery. After reporting our conclusion to the patient and her father, the father nodded. "But the cost of the medication is over two hundred thousand dollars per session, which is not a small sum." "No problem," the father said, "As long as it can save my daughter, no amount of money is an issue." The love of parents is always boundless, especially for their precious child. Though we knew the chances of curing her were extremely low, faced with the faith entrusted in us by the patient and her family, we had no choice but to shoulder the responsibility and bravely move forward.

The patient subsequently underwent surgery. The procedure went smoothly, and the margins of the resected specimen were clean. However, to our surprise, the sentinel lymph node removed from under the patient's right axilla during surgery also tested positive for cancer cells. The pathologist was right; these cancer cells were not something we could easily control. After the surgery, we administered six cycles of Kadcyla (also known as T-DM1), followed by completion of radiotherapy. This marked the end of the initial treatment course for the patient - a graduation ceremony of sorts. Yet, for the medical team, it signified the beginning of another unknown phase; we had no assurance whether the unseen enemy was still present. All we could do was pray.

Six years have passed, and the specter of cancer has not returned. We continue to pray, hoping for her to stay cancer-free forever.