Can do, if you have RMB 1 million

In July 2014, two patients came to seek our help. Patient One is 63 years old. Patient Two is 51 years old. Both are Indonesian males. They knew each other while staying in a hospital in China. Both had liver cancer and they went to China to undergo a liver transplantation procedure. Unfortunately both did not find a cure after spending RMB 1 million (per person) for their treatment. Both came to us after their cancer recurred.

Medical history

Patient One: He had hepatitis about 15 years ago. In 2010, he was diagnosed with liver cancer. He went to Singapore and had TACE (Transcatheter arterial chemoembolization). Unfortunately the treatment did not help him.

In 2012, he underwent a liver transplantation in China. He waited for a month to get a donor. In total, Patient One stayed in the hospital for 90 days. The procedure cost him RMB 1 million. As a follow-up, he was given immune suppressing drugs, not chemotherapy or radiotherapy.

Patient One was well for about 6 months. Unfortunately, on his third follow-up in October 2013, he was told the cancer had spread to his lungs. Patient One went to Singapore for help and was prescribed Sorafenat (a genetic Sorafenib or Nexavar). He was on this drug for about 6 months. In the first month on Sorafenat, he had blisters on his head.

In February 2014, Patient One came to Penang for more opinion. He was again told by the doctor to take Nexavar and at the same time do a biopsy. He refused.

Patient One came to seek our help in July 2014.

Patient Two: He was told that he had hepatitis B in 1985. He received about 100 injections of interferon every 3 weeks. Unfortunately, the treatment failed. By 2011, his hepatitis developed into liver cirrhosis and full blown cancer. He underwent TACE and RFA (radiofrequency ablation) in Singapore. Both treatments failed.

Patient Two went to China in March 2012 and underwent a liver transplantation procedure. He stayed in the Chinese hospital for 90 days.

In November 2013, on follow-up, Patient Two was told everything was fine. But in January 2014, his alpha-fetoprotein started to increase and was 49.9. Follow up CT/MRI/PET scan in Singapore showed a tumour in his liver and another tumour near his heart. In short, his cancer had recurred and even spread to his heart.

In February 2014, he underwent RFA again for his liver lesion.

In May 2014, he underwent a surgery to remove the tumour on the surface of his heart.

In July 2014, CT scan revealed 2 new lesions in his liver and the tumour near the heart had infiltrated into the heart muscle.

His alfa-fetoprotein had increased from 49.9 to 110 plus and then to 159.6. In August 2014, it was at 161.5. The doctor told Patient Two that he could not do anything more.

On his own initiative Patient Two continued to take these drugs: Prograf, Everolimus, Baraclude and the generic Nexavar from India. After taking the Indian “Nexavar” for 2 months he had diarrhoea and his skin peeled.

Patient Two started to take herbal teas and herbal tablets. He also tried the “Terapi Rompi” for 5 months. In July 2014,  he came to Penang to seek our help. 

Sweet Statistics from the Net

We made a google search using this phase, liver transplantation survival rate. Here are some of the results.

Survival rates after liver transplant

• Your chances of a successful liver transplant and long-term survival depend on your particular situation. In general, about 72 percent of people who undergo liver transplant live for at least five years. http://www.mayoclinic.org/tests-procedures/liver-transplant/basics/results/prc-20014076

• A liver transplant can extend your lifespan. Still, it’s important to understand that you may not be in the clear forever, despite a successful surgery. According to theAmerican Liver Foundation, 75 percent of transplant patients live at least five years after surgery. Sometimes the liver can fail, or the original disease may return. http://www.healthline.com/health-slideshow/liver-transplant#5

• The 1-year survival rate after liver transplantation is about 90% for patients living at home and about 60% for those who are critically ill at the time of the surgery. At 5 years, the survival rate is about 80%. http://www.emedicinehealth.com/liver_transplant/page14_em.htm

• Four thousand consecutive patients who underwent liver transplantation between February 1981 and April 1998 were included in this analysis and were followed up to March 2000. The overall patient survival for the entire cohort was 59%. Between 1967 and 1980, 170 liver transplants were performed at the University of Colorado, with a 1-year survival rate of 30%.Between 1968 and 1983, 138 liver transplants were performed in Cambridge (UK), with similarly poor outcomes.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1421181/

• We regularly exceed the national average for liver transplant survival rates: 91% 1 year adult liver transplant survival rate, 84% 3 year adult liver transplant survival rate. Average length of stay across all transplants of 6 days. 4 days less than the national average
  http://integrisok.com/nazih-zuhdi-transplant-institute-oklahoma-city-ok/liver-transplant/liver-transplant-life-expectancy-statistics

Transplant Patients with Hepatitis or Cancer

• For patients with hepatitis C, recurrence of the hepatitis causing damage to the new liver is the most common reason for the new liver to fail. This can happen over many years, but in rare cases, it can also occur within the first few months.
• Patients withliver cancer can experience recurrence of the cancer after transplant, even if the initial cancer was small. Small tumors (micrometastases) may be present outside the liver at the time of transplant that are not visible on imaging tests. These can grow and cause symptoms later. Fortunately, recurrence is uncommon after transplantation (there is about a 30 percent risk of recurrence) if patients have early-stage liver cancer (Stage I or II).
• Patients with hepatitis B can also experience recurrence, but much less commonly than with hepatitis C. http://www.montefiore.org/gastroenterology-liver-center-transplant-longterm-success

Who Are Not Candidates for a Liver Transplant?

• Not all patients are appropriate candidates for liver transplantation … patients with cirrhosis and decompensated liver disease and those with cancer that has spread outside of the liver. http://transplant.surgery.ucsf.edu/conditions–procedures/liver-transplantation.aspx
• Liver transplantation definitively cures a patient of HCC, provided that the tumor has not spread beyond the liver. http://transplant.surgery.ucsf.edu/about-us.aspx
• Not all liver cancers can be treated by liver transplantation. Only small, early tumours have an acceptable chance at success. Liver transplantation is not suitable for everyone, so all potential transplant patients must be carefully assessed.
• Can there be a recurrence of the original disease in the transplanted liver? Often, the original disease can return and cause similar liver damage. For example, a liver transplant for hepatitis C does not eradicate the illness. In many cases, the virus will re-affect the liver within one year. http://www.liver.ca/liver-disease/liver-transplants/how-do-transplants-work/

We started to refine our search to: liver cancer and  liver transplantation success rate. The rosy statistics started to become more bleak and blur!

• The numbers below come from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database, and are based on patients who were diagnosed with liver cancer (hepatocellular type) between 2003 and 2009.

Stage	5-year Relative Survival Rate
Localized	28%
Regional	7%
Distant	2%

•  For all stages combined, the relative 5-year survival rate from liver cancer is about 15%. Part of the reason for this low survival rate is that most patients with liver cancer also have other liver problems such as cirrhosis, which itself can be fatal. http://www.cancer.org/cancer/livercancer/detailedguide/liver-cancer-survival-rates

• So, is a liver transplantation the answer? If you meet the criteria (small tumor size without spread outside the liver) it depends on the availability of a cadaveric liver (liver donated after death). http://www.everydayhealth.com/liver-cancer/liver-cancer-transplant.aspx

Dr Vinay Kumaran, Head of the Liver Transplantation and Hepatobiliary and Pancreatic Surgery at the Kokilaben Dhirubhai Ambani Hospital, Mumbai tells us all about liver transplants. 

Are there many cases where a transplant cannot be done even if a patient needs one? 

A transplant cannot be done unless there is a donor. In most cases there is a living donor from the family who volunteers to undergo an operation to remove part of the liver which is transplanted into the patient. Occasionally, the family of a brain dead patient agrees to donate the organs but this is quite rare.

Can liver be taken from cadavers too like the eyes?

Yes, in a very specific situation. The cadaver should be a person who has died of brain damage (head injury, stroke, etc) and is on a ventilator at the time of death. The heart continues to beat for some time after brain death and we can continue to ventilate the lungs and give medicines to maintain blood pressure and nutrition. As long as adequate blood flow and oxygen delivery can be maintained to the other organs of the cadaver, they can be removed and transplanted with the permission of the next of kin.

What is the rate of success of a liver transplant?

A liver transplant can be said to be successful when the patient returns to a normal productive life. The success rate is about 85-90% at one year after transplant and about 75% 5 years after transplant. Some patients will have a recurrence of their disease, side effects of the medicines, complications of the transplant etc. hence the difference.

What are the side/after effects of getting a liver transplant? What is the rate of rejection? 

The patient has to be on medicines to prevent rejection for the rest of their life. This increases somewhat their risk of getting infections and such infections have to be recognized and treated. There is also a higher than usual risk of cancer over their lifetimes, predominantly skin cancers. The medicines have side effects including a risk of kidney problems, diabetes and blood pressure over the years at a higher rate than the normal populations. In general, the life of a liver transplant patient is similar to that of a patient with a chronic but controllable medical condition like high blood pressure in that periodic (once in 3 months long term) checkups and adjustment of medication is required. Episodes of rejection occur in 10 to 30% of patients who have undergone a liver transplant.

http://www.thehealthsite.com/diseases-conditions/liver-transplants-frequently-asked-questions-answered-by-a-renowned-liver-transplant-surgeon/

Lessons to Learn

Patient One told us, “I had to sell one house to pay for my medical bills.” We asked him, “Did you ever ask the doctor if the liver transplantation would cure your cancer?” No, he did not ask that most important question!

By sharing this story with you, it is our hope that patients can learn some lessons from the experiences of others. You need not have to travel the same road that they did!

So, Lesson One: Patients, know what you are doing – ask where you are going? What are your chances? You don’t want to do things just to end up being a looser later.

Lesson Two, don’t be misled by deceptive sweet statistics. Read a bit more and learn. When we started reading, it was great to know that survival of liver transplant patients could be up to 80 to 90 percent! Fantastic! But hang on, is that for patients with liver cancer? According to the SEER database, survival for those with distant metastasis is only 2 percent! So ask, is liver transplantation suitable for you?

Lesson Three: Your chance of success is only good if you have early stage liver cancer – which has not spread anywhere. In the above two cases, what do you think are their chances? If you were one of them, would you go for a liver transplant?

Beware and reflect on these quotations.