Lian (not her real name) is a 65-year-old lady from one of the  Riau islands of Indonesia. I received an email from her son Henry (not real name):

• My mother felt something in her breast. It was getting bigger from mid-2021.
• This is about 2 months after she got vaccinated.
• I brought her to Jakarta in October 2021 for a check-up. An ultrasound in Jakarta showed the diameter of the  tumour in her right breast is 2 cm.
• Recently she felt pain and I brought her to Hospital A, a private hospital in Penang, last week to do another check-up.

1. Blood tests.

Her full blood picture, liver function test and tumour markers were all within normal range.

• USG.

Ultrasound Right Breast:

• A solid lesion with irregular margins seen at about 6 o’clock position (above) measuring about 2.9 x 2.7 x 2.7 cm. This is suspicious of a malignancy.
• There is a solid lobulated lesion measuring about 0.7 x 0.5 x 0.7 cm at about 2 o’clock position, about 1.8 cm from the nipple. this contains some calcifications.
• An enlarged right axillary node measuring 1.9 x 1.2 x 1.8 cm shows loss of normal fatty hilum (above). A few other smaller right axillary nodes also show loss of normal fatty hilum.

• Mammogram of right breast.

• There is a distinct lump in her right breast.

• PET scan.

• No focal FDG-avid lesions in the head and neck region,  lung parenchyma lesions, chest wall lesions, mediastnal nodes or hilar masses.
• An FDG-avid mass measuring 2.9 x 2.7 cm in the right breast.
• An FDG-avid right axillary node measures 1.8 x 1.3 cm. Small nodes are seen around this. No other FDG-avid axillary nodes seen. 

• Biopsy.

• Right breast lump, core biopsy (6 o’clock): Invasive carcinoma of no special type (NST), grade 3.
• The tumour cells are negative for oestrogen, progesterone and Her2 receptors.

Lian was told that due to the “big” size of the tumour, she had to undergo chemotherapy first before her surgery. The family was unhappy with the idea of undergoing chemo before surgery. So they decided to go home without any further treatment!

Costs Of Diagnostic Procedures

Henry said:

• I spent around RM 10,817 in Hospital A. This costs include the following:
• PET scan which is around RM 4,600.
• RM 3,000 for mammogram, blood test and ultrasound.

Before and after the surgery Lian needs to undergo chemotherapy and immunotherapy.

• For chemo, it is RM 5.000 each time and she must take 8 times, every 3 weeks. Total cost RM40,000.
• For Immunotherapy, it is RM 15,000 each time and she needs to receive the treatment about 17 times for a year. Total RM255,000.
• I was told that this is a triple negative cancer  – so must undergo  immunotherapy (antibody) besides chemotherapy to avoid the cancer’s return.
• The cost for chemo + immunotherapy is very expensive. We couldn’t afford to do it.

Told About CA Care

Henry wrote:

• When we were back home from Penang, my cousin told me about you. He heard from his friend named Pak Edy who suffered bowel cancer 12 years ago and he got treatment from you
• And later, my sister also talked with our neighbour. Coincidentally, her mother is also taking your herbs. Her mother took your herbs since last year.

At this point I received an email from Henry.

Good evening, Doctor,

The biopsy indicated the cancer is a triple negative and it is a Stage 2 cancer.Hopefully you can give us some advice on what we must do to cure her disease.

The reason why we are trying to find other alternative is because we can’t afford to do the chemo and immunotherapy which is very expensive. If we need to see you in Penang, I will try to arrange the time to meet your schedule.

Reply:  Any woman who has breast cancer — had biopsy but refused to remove the whole breast is just STUPID — AMAT BODOH. You must remove the breast now. You cannot just keep it there. Do a total mastectomy i.e., remove the cancerous breast totally.

This is a triple negative cancer type — dangerous! After you remove the breast, come and see me after 2 weeks. I would not see people who do not remove their cancerous breast.

Hi Doctor,

Thank you for the quick response doctor. Do you have any recommendation for the hospital to do the mastectomy? Because if we go back to Hospital A, we would be asked to do chemo and immunotherapy first, then do surgery after that.

Reply: Okay, go to Dr. B in Hospital B and see what he has got to say.

Hi Doctor,

We took action very quickly after we got your advice. I tried searching for some hospitals which are reachable by sea and bus from our hometown.The first option is hospitals in JB. However, there is no breast cancer specialist in JB. Then I found in a breast cancer specialist in Hospital M in Melaka.  We did teleconsultation by video at the beginning. The doctor said that the tumour seems not so big from the report I sent to her.Therefore, she asked us to meet her in Melaka to see whether or not we can do the surgery without chemo first.

The first estimated cost for mastectomy in M Hospital RM 12,000. Since my mom also needs to remove another tumour in her left breast then the cost will come to around RM 15,000.

The estimated cost of surgery in Hospital A in Penang is RM 20,000. This is only the cost for surgery excluding room charges.

Again, thank you so much for your quick response. Really appreciate it.

Oct 19, 2022. Hi Doctor,  Good afternoon.

My mother has done the mastectomy yesterday Oct 19th without chemo in Melaka.

Oct 21, 2022. Hi Doctor,

My mom was discharged from hospital this afternoon and everything seems to be okay. Herewith I attached the hospital bill for your reference.

1. Total hospital charges                                 RM10,039.71
2. Doctors’ fees                                               RM  6,499.27
3. Surgeon               RM3,988.00
4. Anaesthesia               1,490.15
5. Lab services                  477.12
6. Radiology services      544.00

                              Total cost of mastectomy + lumpectomy RM 16,538.98

Lessons We Can Learn From This Case

1. Get your bearing right. I am really glad that Lian took an immediate step to have the cancerous lumps removed from her breasts. If these lumps were allowed to grow in there, they will eventually burst and could give rise to more problems. Over the years, I have seen patients who came to me with “rotten” breasts. They have the mistaken idea that herbs or supplements can make the cancerous tumour in their breast go way. Wrong!

• Chemo before surgery – different experts have different opinions! Lian was told to undergo chemotherapy before surgery. She refused chemo and went home rather “lost”, that is after spending RM 10,817 for the diagnostic procedures in Penang. My advice to her son was: Go and find another doctor! I am happy that she found one doctor in a Melaka Hospital to do the surgery without having to do chemo first. 

• Before agreeing to the treatments, know what you are getting into. The standard protocol to treat breast cancer is: surgery, followed by chemotherapy and/or radiotherapy. But now, the latest option being offered to patients is immunotherapy which costs a “bomb”!

You may want to ask: How effective is immunotherapy?  This is answer that I got from the internet:

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From the very beginning Lian and her son were given some idea of what the total cost of the treatment is going to be like. Surgery would come to about RM30,000, chemo RM40,000 and immunotherapy would cost her at least RM255,000 or a quarter million ringgit. The family could not afford that. This is indeed sad.

Over the years many patients who came to seek our help told me that they had to sell a house or a piece of land to pay their medical bills. I also had patients who spent RM30K and had no more money. They just packed off and went  home – giving up the idea of receiving medical treatment in Penang.

• Ask if the treatments like chemo and/or immunotherapy are going to cure your cancer. Spending money is one thing, the most important question we need to ask is – what would be the outcome of the treatment after spending a quarter million ringgit? Is the cancer cured? Unfortunately, no one can guarantee a positive outcome. Unfortunately too, some patients would NOT want to know the answer to this all important question! Over the years, I have seen many failures  — money lost and patient ended up with severe side effects of the treatment.

Dr. Norah Lynn Henry wrote an article Immunotherapy for Breast Cancer Treatment: Is It an Option? (https://www.cancer.net/blog/2020-09/immunotherapy-breast-cancer-treatment-it-option). She said:

• One challenge of immunotherapy is not knowing who is likely to benefit from the treatment.

• Second, immunotherapy can cause substantial side effects, including life-threatening ones. The most common side effects are skin reactions, such as redness and blistering, and flu-like symptoms, such as fever, nausea, weakness, and body aches. Different types of immunotherapy can cause different side effects.

• An important third challenge is the high cost of this treatment.

• Beware, the cost of treatments differ from hospital to hospital. Lian went to Hospital A in Penang.  She had to spend RM 10,817 on diagnostic procedures! That is before the actual surgery which would cost another RM20,000 plus.

Just a few months ago, one patient had a total mastectomy at Hospital B in Penang. In total she spent only RM15,000. Take note, Hospital B is said to be a non-profit (privately funded) hospital. But be reassured the surgeon who did the mastectomy is just as competent and well known as others in Penang. In fact, this surgeon is one of the two doctors I would recommend that you go to if you have breast cancer. Remember again, expensive does not necessarily mean it is better!

• Beware of the overuse of diagnostic procedures, overuse of PET scan, over treatment, etc. Take a close look at what Lian had to undergo in preparation of her surgery – she did a blood test, ultrasound, mammogram, PET scan and finally biopsy. All these procedures contributed significantly to the total cost of RM10K. Let me just pose one question – are ALL these procedures absolutely necessary? For some procedures the answer is yes, but not for all of them.  Let me not give my own opinion on this  but quote what other medical experts say …..

Shannon Brownlee et al in an article Evidence for Overuse of Medical Services Around the World (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708862/) wrote:

• We use the term overuse to refer to any services that are unnecessary in any way and for any reason.
• Overuse (of medication, diagnostic tests, therapeutic procedures) is a global problem that afflicts rich and poor countries alike.
• In the United States, estimates of spending on overuse … range from 6% to 8% of total health care spending.
• Around the world, overuse of some individual services may be as high as 80% of cases.

Kelsey Chalmers et al (https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2779118) wrote:

• Overuse is defined as the delivery of tests and procedures that provide little or no clinical benefit, are unlikely to have an impact on clinician decisions, increase health care spending without improving health outcomes, or risk patient harm in excess of potential benefits.

• Although clinicians are responsible for ordering tests and treatments, their practice patterns may be influenced by hospital policies and culture.

A report by AACC – formerly known as the American Association for Clinical Chemistry (https://www.aacc.org/cln/cln-stat/2018/march/15/close-up-on-diagnostic-test-overuse) said:

• Overuse of laboratory tests is a chronic problem.
• Study finds up to 70% of lab tests in a hospital setting are likely either clinically unimportant or unnecessary.

In an article Understanding over-imaging (https://www.mdanderson.org/publications/conquest/understanding-over-imaging.h37-1589046.html) Laura Sussman wrote:

• The American Society of Clinical Oncology (ASCO) recommended against the use of CT, positron emission tomography (PET), tumor markers and nuclear bone scans in early-stage breast cancers.

• Carlos Barcenas, M.D., points out that the recommendations of the National Comprehensive Cancer Network — the gold standard for treatment guidelines — clearly state that for women with early disease, the proper procedures for diagnosis only include mammograms, ultrasounds, clinical exams and blood work.

• “Often doctors think they’re not being good to their patients if they don’t do all they can by way of testing,” explains Giordano, chair of Health Services Research. “But there’s a shift in focus to doing what matters for the patient and what’s proven to improve outcomes, rather than testing for the sake of testing.”

Caroline Helwick in an article PET Scans Not Recommended for Most Patients with Breast Cancer: Potential New Controversy in Breast Cancer Testing (https://www.ahdbonline.com/issues/2010/march-april-2010-vol-3-no-2/93-article-93)  wrote:

• According to the updated 2010 practice guidelines of the National Comprehensive Cancer Network (NCCN), the work-up of patients with early breast cancer should not include imaging by positron-emission tomography (PET) or by PET/computed tomography (CT) scanning.  The NCCN Breast Cancer Panel gave a thumbs down for the use of this modality in a number of settings.

• PET or PET/CT can be helpful in some cases of stage III disease in which standard staging studies are equivocal or suspicious, but it should not be routine in the staging of newly diagnosed stage I, II, or operable stage III breast cancer, the Breast Cancer Panel concluded.

• “The implication of our recommendations is that PET/CT is overused in breast cancer,” said Robert Carlson, MD, of Stanford Cancer Center, Palo Alto, California.

• “What is fueling the overuse? I don’t really know. It is simple to order, but it is very expensive. So there are financial issues in terms of rewards for physicians who perform them frequently.

• Our society assumes that any technology with a high price tag has value, but the newest technology is not necessarily the best technology,” Dr Carlson said.