CANCER STORY

Liver Cancer: He Died After a RM 10,000 Open-Close Surgery

The Doctor Said: “No More Hope” After a 60-Million-Rupiah Operation for Bile Duct Cancer

The Doctor Said: “No More Hope” After a 60-Million-Rupiah Operation for Bile Duct Cancer

Hass (not real name, M847) is a 44-year-old male from Indonesia. In early 2010, he had jaundice. The doctor suspected this was due to Hepatitis. Hass was prescribed medication. After a month, the treatment was not effective. Hass went to a private hospital in Kuching.

A CT scan on 28 January 2010 indicated a 6 mm stone in the gallbladder. There was a 1 cm hypodense lesion in segment 8 of his liver. This could be just a cyst. The common bile duct was dilated. The maximum diameter was 16 mm. There was a 18 mm mass at the distal common duct. Conclusion: Mass in the lower common duct with biliary obstruction.

Immediately Hass underwent an operation to remove his gallbladder and the bile duct tumour. The histopathology report dated 3 February 2010 indicated: infiltrating moderately differentiated exophytic adenocarcinoma of bile duct, invading through entire thickness of the wall and metastatic to periductal lymph nodes. Margins of excision free of tumour.

An ultrasound of the abdomen on 8 June 2010 showed no evidence of tumour recurrence although his CA19.9 increased from 52.4 (in March 2010) to 1420.0. A CT scan on 9 June 2010 indicated a 15 x 10mm lesion in segment 7 of his liver. The 10 mm cyst in segment 8 of his liver remained the same. In addition there were a few paraaortic lymph nodes noted from the celiac axis down to the liver of the renal hilum. The largest node measured 20.0 mm – the others were subcentimeter.

The doctor told Hass that the cancer had recurred and he was unable to help him anymore. Hass was asked to undergo chemotherapy. But he refused.

Below is a table showing the rise of CA 19.9 markers from March to October 2010.

Date	CA 19.9
Before operation	2,000 plus
18 March 2010 – after operation	52.5
8 June 2010	1,420.0
3 August 2010 – last visit to surgeon	5,645.0
1 October 2010	18,746.18

Hass came to see us in Penang on 8 October 2010. Listen to our conversation.

Review of Medical Literature

Understanding the Liver-Gallbladder-Pancreas-Bile Duct Complex

Attached to the liver, is a pear-shaped structure called the gallbladder.
The liver makes bile and this is transported to the intestine by a long tube-like structure called the bile duct.
The gallbladder is attached to the bile duct by a small tube called the cystic duct.
The top half of the bile duct is associated with the liver while the bottom half of the bile duct is associated the pancreas through which it passes on its way to the intestine.
Blockage of the bile duct by a cancer prevents the bile from being transported to the intestine. When this happens the bile accumulates in the blood giving rise to jaundice. The skin and eyes becomes yellow. This condition may also cause severe itchiness.

(Diagrams are obtained from the internet)

The clinical presentation, prognosis and natural history of bile duct cancer (or cholangiocarcinoma) depend on where the cancer originates. The cancer may occur:

In the part of the bile ducts contained within the liver. This is known as intra-hepatic.
In the part of the bile ducts outside the liver. This is known as extra-hepatic.
In the duct between the left and right portal veins. This is known as hilar bifurcation.

Anderson et al. in Diagnosis and treatment of cholangiocarcinoma, The Oncologist, Vol. 9, No. 1, 43–57, February 2004, noted that approximately:

60%-70% of cholangiocarcinomas occurat the hilar bifurcation.
20%-30% inthe distal common bile duct.
5%-15% within the liver (intra-hepatic).

Patients with extrahepatic tumors usually present withpainless jaundice due to biliary obstruction, while patients withintrahepatic tumors usually present with pains, pruritus (66%), abdominal pain (30%-50%), weight loss(30%-50%), and fever (up to 20%).

In their review, Anderson et al also noted that:

The majority of patients with cholangiocarcinoma presents with unresectable,advancedstagedisease and have a survival of less than 12 months. Cure rates are low, even with aggressive therapy. The average 5-year survival rate is 5%-10%.
Surgery remainsthe only intervention offering the possibility of a cure. But the treatment goal should be complete excision with negativemargins.
All patients should be fully evaluated for resectabilitybefore any type of intervention is performed.
Neoadjuvant and adjuvant therapieshave not improved survival in patients withthis tumor.
Since the prognosis for unresectable patients is poor, palliative measures should be aimed at increasing qualityof life first and increasing survival second.

Results of Surgery

Among selected patients who undergo potentially curative resections,5-year survival rates are generally from 8%-44%.
The importance ofachieving a margin-negative resection cannot be overemphasized.The 5-year survivalrates were greater when a negative margin was obtained, 19%-47% versus 0%-12%.
Distal lesions represent approximately 20%-30% of all cholangiocarcinomasand are usually treated with pancreaticoduodenectomy (Whippleprocedure). Achieving a margin-negativeresection is also important with these tumors. The 5-year survival rates in selected patients who underwentcurative resections is21%-54%.
Intrahepatic cholangiocarcinoma is usually treated by hepaticresection. Three-year survival rate of 60% was reported in patients who underwent a margin-negative partial hepatectomy.

Chemotherapy

Chemotherapy has not been shown to markedly improve survivalin patients with either resected or unresected cholangiocarcinoma.The majority of reports use 5-FU alone or in combination withmethotrexate, leucovorin, cisplatin, mitomycin C, or interferonalpha.
The 5-year survival rates were not significantlydifferent between patients who received chemotherapy and surgeryand those who received surgery alone.

A note in http://emedicine.medscape.com/article/189843-treatment stated that: “Chemotherapy has not been proven to be of definite benefit.”

Experience of doctors in Fuda Hospital, China indicated that:

Cancer arising in the extrahepatic bile duct is an uncommon disease, curable by surgery in fewer than 10% of all cases.
In most patients, the tumor cannot be completely removed by surgery and is incurable.
Palliative resections or other palliative measures e.g. stenting procedures may maintain adequate biliary drainage and allow for improved survival.

Experience of doctors in India indicated that:

Surgery may be used to remove the cancer if it has not spread beyond the bile duct. It is not always possible to carry out surgery, as the bile duct is in a difficult position and it may be impossible to remove the cancer completely.
There are different surgical procedures depending upon how big the cancer is and whether it has begun to spread into nearby tissues.

These surgical procedures are:

Removal of the bile ducts. If the cancer is small and contained within the ducts, then just the bile ducts containing the cancer are removed.
Partial liver resection. If the cancer has begun to spread into the liver, the affected part of the liver is removed, along with the bile ducts.
Whipple’s. If the cancer is larger and has spread into nearby structures, then the bile ducts, part of the stomach, part of the duodenum, the pancreas, gall bladder and the surrounding lymph nodes are all removed.
Bypass surgery. Sometimes it is not possible to remove the tumour. Other procedures may be performed to relieve the blockage and allow the bile to go into the intestine. The jaundice will then clear up.
Stent insertion. One way to relieve jaundice without a surgical operation is to perform ERCP (Endoscopic Retrograde Cholangiopancreatography). This procedure involves insertion of a tube, called a stent into the blocked bile duct. The stent clears a passage through the bile duct to allow the bile to drain away. The tube usually needs to be replaced every three to four months to prevent it becoming blocked. If the tube does block, recurrent high temperatures and/or return of the jaundice will occur.

In summary, Witzigmann et al. in an article, Guidelines for palliative surgery of cholangiocarcinoma, HPB (Oxford). 2008 June 1; 10(3): 154–160, listed the following guidelines for surgery of bile duct cancer:

Non-surgical stenting is regarded as the first choice of palliation for patients with short life expectancy.
For patients with longer projected survival, surgical bypass should be considered.
Palliative resections may be beneficial to patients with distal and hilar bifurcation.

Questions to Ponder

The fact is very clear. Surgery for bile duct cancer in this case is an absolute failure. Is this failure a rare event? Probably NOT! A surgeon told his liver patient: “For ten liver operations that I performed, nine patients died”. Good information indeed but the problem is that he made this comment some three years too late. This patient had already undergone the operation and had suffered a severe recurrence.

A few more questions come to mind:

According to the literature, not all patients with bile duct cancer are suitable condidates for surgery. “All patients should be fully evaluated for resectabilitybefore any type of intervention is performed”. To what extent is this evaluation done?
The surgeon recommended chemotherapy after the recurrence. What benefit can the patient expect from this? Medical literature clearly indicates that “Chemotherapy has not been proven to be of definite benefit.”
Is the suggestion of chemotherapy after the failure of surgery, a way of “passing the buck” to someone else? “I have done my job to cut it out. My responsibility is over. Now you go to the oncologist and see what he can do for you.”

More related stories:

Liver Cancer: He Died After a RM 10,000 Open-Close Surgery

Liver Cancer: He Died After a RM 10,000 Open-Close Surgery

Goh (not real name, H438) was a 36-year-old male. In June 2010 he had diarrhea and his blood pressure was low. He was admitted into a private hospital in his home town. An USG was done and he was told that his liver was not good. After three days he was discharged from the hospital. Health returned to normal. Two weeks later his abdomen became hard. He went back to the hospital again and a CT scan done indicated hepatoma – or liver cancer.

Goh came to a private hospital in Penang. He was asked to undergo surgery, to remove half of his liver. An operation was done but was later aborted. This open-close surgery cost him RM 10,000.

Not knowing what else to do, Goh and his family came to seek our advice on 24 October 2010. His CT scan report dated 15 October 2010 stated: “Both lobes of liver are enlarged and studded with multiple ill-defined heterogeneously enhancing lesions. The largest lesion located in segment 4b measures 15 x 20 x 15.6 cm. Impression: Multicentric hepatoma with minimal ascites and dilated left intrahepatic duct.”

Blood test results elevated liver enzymes. SGOT = 203, SGPT = 56, Alkaline phosphatase = 736 and Alpha-fetoprotein = 213.73.

Goh presented with pains in the shoulder area. These pains only appeared after the surgery. Before that there was no pain. He was not able to sleep. His eyes were blood shot. His abdomen was extended with both legs swollen. His breathing was difficult.

Unfortunately, Goh died not long after seeing us.

Comments: I don’t think it is necessary for me to give any comment on this case. The fact speaks for itself. Goh died barely two months after this aborted surgery. What do you think – would he have died earlier or later if he did not undergo that surgery?

This is one book which I believe everyone should read – Confession of a Medical Heretic by Robert Mendelsohn. The author is not an ordinary man. In the US, he wrote a syndicated column called “The People’s Doctor”. He was an associate professor at the University of Illinois Medical School and a director of Chicago’s Michael Reese Hospital. He was also chairman of the Medical Licensure Committee for the state of Illinois. In Chapter 3 of his book, Dr. Medelsohn wrote:

I believe that my generation of doctors will be remembered for … the millions of mutilations which are ceremoniously carried out every year in operating rooms.
Conservative estimates … say that about 2.4 million operations performed every year are unnecessary.
My feeling is that somewhere around ninety percent of surgery is a waste of time, energy, money and life.
Modern cancer surgery someday will be regarded with the same kind of horror that we now regard the use of leeches in George Washington’s time.
Greed plays a role in causing unnecessary surgery … there’s no doubt that if you eliminated all unnecessary surgery, most surgeons would go out of business.
Ignorance plays a part in a lot of unnecessary surgery.
Greed and ignorance aren’t the most important reasons why there is so much unnecessary surgery. It’s basically a problem of belief: doctors believe in surgery. There is a certain fascination in “going under the knife” … that (surgeon) can overcome anything because he can operate you … “You don’t have to take care of yourself, we can fix you if you go wrong.”
To protect yourself … your first step is to educate yourself. Get a second opinion. If you decide that surgery isn’t the answer, do whatever you have to do to detach yourself from the situation. In any situation short of an emergency, you’ve got plenty of time not only to decide whether or not you need the surgery but also who should perform the operation.

More related stories:

The Doctor Said: “No More Hope” After a 60-Million-Rupiah Operation for Bile Duct Cancer

Surgery for Liver Cancer: Eighty Percent Success?

Wang (not real name, M872), 48-year-old male from Medan had been living with “blood-in-his-stools” for the past ten over years. This problem was attributed to piles. In November 2010 he came to a private hospital in Penang for a medical checkup. A scope of his colon did not show anything wrong. However, an ultrasound of his abdomen showed an ill defined, 7 x 9.2 cm mass in the right lobe of his liver.

Blood test was positive for Hepatitis B. Liver function test indicated elevated liver enzymes – ALT = 101, AST = 43 and GGT = 107. Alpha-fetoprotein was normal at 4.84.

CT scan done on 12 November 2010 indicated a 8.2 x 7.2 cm mass suggestive of hepatoma in segment 8 of his liver. A small solid lesion is also found in segment 7 measuring 1.8 x 1.2 cm. This may represent a satellite lesion of hepatoma. A simple cyst is noted at segment 8 below the right hemidiaphragm.

Wang went to see another doctor in another hospital. A repeat CT scan was done on 13 November 2010. The results were similar to the one done a day earlier.

The surgeon suggested that Wang undergo surgery to remove the tumour. The operation would cost RM 40,000. After the operation, Wang would have to undergo chemotherapy. The cost of each chemo is around RM 4,000 to RM 5,000.

Wang and his wife were disappointed and decided to go back to Medan without doing any surgery or chemotherapy. Someone learnt about their predicament and suggested that they come to CA Care for advice. We spent more than an hour with them. Below is a video recording of a part of our conversation that day.

Comments:

Most of the story-telling was done by Wang’s wife. She only talks Chinese! It appears to me that she is a “smart and wise” lady even though she is not educated.
She said: “When the doctor (surgeon) said that my husband had to undergo surgery and chemotherapy, I knew that this is a serious case”. This shows that she is not a dumb, naïve village girl – never mind if she does not know how to read the CT scan report or figure out what the blood test shows.
I asked her: “Did you ask the doctor if surgery can cure his cancer.” She replied yes. Most patients who come to us did not do that! How could that be? They don’t even want to find out what the prognosis is like! Not this lady.
She even asked the doctor: “What if we do not do the chemotherapy?”. The surgeon replied: “It is like cutting the lallang. You need to apply chemical after you mow it down. Only then can it be eliminated.” The answer was right on spot because this lady works in the farm – she understood it well. To kill off the lallang you need to apply chemical poison. Sometimes the land had to be dug up or overturned to get rid of the rhizome. So she said: “Then what would that do to my husband?” The implication is – what would happen to the patient if you poison him like you poison the lallang?
She also asked the surgeon: “When you cut up my husband, what are the chances that his cancer is cured?” Again this kind of question is never asked by most patients before they undergo an operation. The surgeon replied: “More than 80 percentage success rate.”
I asked the lady: “The doctor said 80 percent success – did you believe him?” She replied NO. I asked her why. She said: “There is one statement that the doctor made which got stuck in my head. Earlier I asked the doctor about the risk involved – how certain was he that everything would turn out right.” The doctor replied this lady: “The same case like you flying in from Medan to Penang. The airline does not guarantee that you are risk free.” Though the doctor did not admit outright that the treatment has risk, his reply very much implies that there is risk – the lady got the answer.
Later in our conversation, I came to know that Wang’s sister also had liver cancer. She received chemotherapy. She died after four cycles. While many patients or their loved ones appear naïve – don’t under estimate them! They have gone through some bitter experiences in life and they are not about ready to forget them. For such people, doctors need to do a lot of convincing to make them accept chemotherapy again.
I feel sorry for this couple. They came all the way to Penang and had to spend so much money. They can do the treatment – no problem about that for as long as they can pay the hospital bills – but cure appears to be elusive.

There is one important lesson we can learn from this story. How reliable or true are statements made by a doctor? Is it backed by good statistics and good research? At this point I am reminded of what some doctors wrote. Let me quote.

Dr. Block, herself a doctor, wrote in the foreword of Fight for Your Health: “Don’t just blindly follow what your doctors say. Find out the truth for yourself.”

Dr. Mendelsohn, in his book Confessions of a Medical Heretic wrote: “Doctors in general should be treated with about the same degree of trust as used car salesmen. Whatever your doctor says or recommends, you have to first consider how it will benefit him … because surgeon gets paid when he performs surgery on you, not when you’re treated some other way.”

Dr. Chestnut in his book, Lying With Authority wrote: “Somebody has got be lying – lying with an air of authority. The vast majority of surgery and drugs, including chemotherapy, does not treat or cure disease; it treats symptoms – often with devastating side effects.”

Dr. Hamilton in his book, The Scalpel and the Soul wrote: “As doctors, we generally don’t tell outright lies. We just don’t speak the truth fully.”

It is not nice to say that doctors tell lies – but the above quotations seem to say that some do, though they represent a minority. But I must say I like what Dr. Hamilton said: “We generally don’t tell outright lies. We just don’t speak the truth fully.” In this story, the surgeon told Wang and his wife that the treatment has more than 80 percent success.” His answer can be dead right or dead wrong! Let me explain.

From the perspective of this surgeon he is absolutely right to claim that the treatment has more than 80 percent success rate. A surgeon’s job is to cut up patients. After that he passes the patient to the oncologist or someone else. As far as he is concern his part of the cancer war is done. With the present state of the art technology, surgery carries minimal risk – like us flying in an air plane. The possibility of a crash is there but it is not likely (yes, it can happen!). Dying from surgery does occur although it is not likely.

But is that what the patient is looking for – just not dying from surgery? From the perspective of Wang and his wife, they are looking for a cure of his cancer! To them, the answer of 80 percent success takes an entirely different meaning. Cure means completely elimination of the cancer and it will not come back. That is what all patients ask for. Therefore, if patients are made to believe that they can attain an 80 percent chance of cure if they undergo surgery or chemotherapy is definitely false.

Let me repeat what Dr. Hamilton said: “we just don’t speak the truth fully.” Does this mean that doctors intentionally withhold some vital information which patients should know? If so, is that fair? I think the most vital information not told to patients is that though surgery is safe it will NOT cure the cancer. The chances of recurrence after an apparent successful surgery are very high. If you follow the case studies presented in this website, you will know that some patients die not long after their liver surgery.

Perhaps is this the reason why Dr. Mendelsohn said we should regard doctors in general “with about the same degree of trust as used car salesmen”?

In this article I have refrained from commenting if indeed the advice to operate is appropriate or otherwise. I would like to believe that the doctor has recommended this path with the best of intention. Even that, we need to be reminded that according to liver experts only 10 % to 30% of those who present with HCC are candidates for surgery. Meaning surgery is not the answer for all cases of liver cancer. Also surgery is good for only small tumours. Again, Dr. Mendelsohn’s words come to mind, they do this “because surgeon gets paid when he performs surgery on you”.

Let me conclude this article by trying to answer my earlier question: to what extent is the statement “after surgery there is a more than 80 percent success” true. I spent time reading my oncology books again. Below are the scientific facts written by liver experts. Read them carefully and come to your own conclusions.

Review of Medical Literature on Liver Cancer (Hepatocellular Carcinoma – HCC)

Research Reports

Ikeda et al., Cancer, 71:19-251993, reported: Eighty-three patients with HCC were treated with curative surgical resection during the past 8 years. No operative deaths occurred. Recurrence rates after resection at the ends of years 1, 2, and 3 were 37.0%, 57.1%, and 71.6%, respectively.

Iwatsuki et al., Ann Surg. 1991 September; 214(3): 221–229, reported: From 1980 to 1989, 76 patients with HCC underwent subtotal hepatic resection. Only 12 patients lived more than 5 years.

Vauthey, et al., American J of Surgery; Vol: 169, pg. 28-35, 1995, reported: Between 1970 and 1992, 106 patients underwent hepatic resection for HCC at Memorial Sloan-Kettering Cancer Center. Overall survival was 41% and 32% at 5 and 10 years, respectively.

Nagao et al., Ann Surg. 205(1): 33–40; 1987 reported: Ninety-four patients underwent hepatic resections from 1963 to 1985.One-, 3 and 5-year survival rates were 73%, 42% and 25% respectively. The recurrence of carcinoma was the main cause of death in 56% (42 patients) who died after discharge from the hospital. Prognostic factors that influenced the long-term prognosis were: preoperative alpha-fetoprotein level (less than or equal to 200 vs. greater than 200 ng/mL), tumor size (less than or equal to 5 vs. greater than 5 cm), and tumor capsule.

Shyh-Chuan Jwo, et al. Hepatology , Vol. 1367–1371; 1992 reported: A total of 238 patients who received curative hepatic resections during the last 10 years were observed. The results revealed that tumor size, tumor appearance and DNA ploidy were the factors in predicting tumor recurrence after resection for HCC. Patients with a tumor size less than or equal to 5 cm or a tumor appearance of the solitary type had better disease-free survival than did those with a tumor size greater than 5 cm or a tumor appearance of multiple/daughter nodule types.

Poon et al. of the Centre for the Study of Liver Disease, University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong,, Ann Surg. 234(1): 63–70 2001, wrote:

HCC is notorious for poor prognosis because of its invasiveness and frequent association with cirrhosis.
Hepatic resection remains the treatment of choice for HCC.
During the past decade, hepatic surgeons have focused much effort on improving the surgical techniques and perioperative management for resection of HCC, resulting in greatly improved perioperative outcomes. By the end of the 1990s, studies from our institution and others have demonstrated that a zero hospital or surgical death rate could be achieved in large series of patients.
Long-term prognosis after resection of HCC remains unsatisfactory. Disease-free survival has been poor because of a high incidence of recurrence. A 5-year cumulative recurrence rate of 80% to 100% has been reported.
Reports in the 1990s from Eastern and Western centers have documented a 5-year overall survival rate of 26% to 44% after resection of HCC.

Oncology Textbooks

Harrison’s Principles of Internal Medicine 15th Ed., pg.589.

Staging of HCC is based on tumour size, ascites (present or absent), bilirubin and albumin.
If untreated, most patients die within 3 to 6 months of diagnosis.
If detected very early, survival is 1 to 2 years after resection.
Surgical resection offers the only chance for cure, however, few patients have a resectable tumour at the time of presentation because of underlying cirrhosis or distant metastases.
Radomised trials have not shown a survival advantage after chemoembolization.
Liver cannot tolerate high doses of radiation.
The disease is not responsive to chemotherapy.

The American Cancer Society’s Clinical Oncology, 3rd Ed., pg. 399-401.

Only 15% to 30% of patients with HCC are candidates for surgery.
Conditions that render HCC unresectable are extensive disease within the organ itself and metastases.
Large tumour size, bilobar involvement and presence of cirrhosis do not necessary preclude resection but adversely affect mortality and prognosis.
Resection generally is limited to patients with small peripheral lesions and preserved hepatic function.
Five-year cure rate for all HCC who have undergone hepatic resection is approximately 30%.
The value of radiotherapy is limited in treating HCC.
Chemotherapy is palliative. Patients who respond to chemotherapy will survive 9 to 12 months longer.
Mean survival for patients receiving chemotherapy is approximately 5 months (1- year survival is 27%, 2-year is 8%).
Cure and long-term survival are possible only when tumours can be resected completely.

Martin Abeloff, et al. Clinical Oncology, Vol: 2, pg. 1697, 1703-1721.

Median survival of Hong Kong patients with inoperable HCC – tumour larger than 6 cm in diameter and receiving no treatment – was 3.5 weeks.
Tumour size at diagnosis is an important prognostic variable.
Tumour doubling time ranged from 1 to 19.5 months, with an average of 6.5 months.
Study in Japan showed that for patients with cirrhosis and HCC less than 3 cm in diameter and without treatment, 1-year survival rate was 90.7%; 2-year was 55.0%; and 3-year was 12.8%.
Unfortunately only 10 to 15% of newly diagnosed HCC patients are candidate for resection.
Presence of cirrhosis is a negative prognostic indicator.
Operative mortality rate of liver resections for HCC is les than 10%, but post-operative morbidity rate remains high – between 40 to 60%.
85% of hepatic recurrences develop within 2 years of resection.
There is little evidence of significant therapeutic activity for any single chemo-agent. There is also no evidence to support the routine use of combination chemotherapy.

Liver resection is the operation of choice for patients with tumors less than 5 cm in the absence of cirrhosis. In these patients, an operative mortality rate of less than 2% can be expected in experienced centers.Following liver resection, up to 75% of patients will develop intrahepatic recurrence within 5 years. Source: http://emedicine.medscape.com/article/197319-treatment

More related stories:

Liver Cancer: He Died After a RM 10,000 Open-Close Surgery

The Doctor Said: “No More Hope” After a 60-Million-Rupiah Operation for Bile Duct Cancer

Kelantan is situated in the east coast of northern Peninsular Malaysia. I know this place as a poor and backward state. But this is where I was born and brought up. Though the people there speak Malay, the Kelantanese lingo is often not understood by people of other states in Malaysia. And the Kelantanese are proud of their lingo. This lingo is like a thread that binds the Kelantanese together – irrespective of whether you are Malays or Chinese. In this video, you will hear how we talk.

On 27 August 2010, Mat (not real name, H382), 62-year-old man from Kota Bharu, Kelantan; came to see me. He and his son walked into our centre without any medical report. I told them this is not the way we do things. I am not a village medicine man who dishes out herbs without knowing what is actually wrong with the patient. I need to read the medical reports, blood test results and see the X-rays or CT scan. So, I told him: I am blind.

It was not possible for me to send him home empty-handed. He had travelled a whole day by bus to come here. So, I had to do what I could to help him – blind or not.

Mat said he had a cancerous lump in his right neck many years ago. This had since been removed by surgery. He was okay. But for the past seven years he had liver problems (?). I did not know what that meant. Anyway he had consulted a specialist of a private medical centre in Kota Bharu before he came to CA Care. He was told there was something in his liver. His son said, he saw the CT scan with a “big hole” in the liver. Mat pointed out to me that his abdomen was hard. The doctor wanted to give him chemo. He refused. His son learned about CA Care from the internet and decided to bring his father to Penang and seek another way of treating his father’s liver. He also told the doctor that he wanted to come and see us. The doctor agreed and said there is nothing else he could offer him except chemo. Since Mat did not want the chemo, then he should go to Penang instead.

At his first visit, Mat presented with poor health. He was unable to sleep, had no appetite, bowel movements were difficult, was breathless after walking a short distance, and his abdomen was hard. He lacked energy and was always tired – sleeping most time of the day. Based on these presentations, I suspected that he might have liver cancer – a hepatoma? Mat was prescribed Capsule A + B, LL-tea, Liver 1 and Liver 2 teas.

Honestly, I did not expect to see him again! That is the way it is with many people. They come with their problems. Unload their stories unto us. Take the herbs for about a week or two and never ever return. They think we are magicians dishing out instant cures! I have made a study. Only 30% of those who come are serious enough wanting to find healing for themselves. The remaining 70% are just shopping for instant cures.
To our surprise Mat came back to see us again on 5 November 2010 – some three months later. He appeared happy and satisfied. And more important, he had regained his health.

Watch this video. The subtitles will help you follow our conversation.

Mat said he had regained his energy – not tired as before. He could go fishing with his son riding the motorbike, something he could not do before. His appetite was great – he could not stop eating. And he ate a lot. Three meals a day and wanted more but his son stopped him from eating too much. He was able to sleep well. His urine flow was good – strong stream unlike before. His bowel movements were also good. His hardened abdomen had gone softer.

This is an amazing healing story, beyond our expectation. My conversation with Mat that night was hard hitting. But I said it all with the “gentleness” of the Kelantanese lingo. So we all took it in good spirit. Mat got my points very clearly and he appreciated them, with no offence.

Mat said: “I am sorry. It is my mistake. I was complacent. I felt so healthy that I forgot to come and see you after I finished the herbs. Boss, it was my mistake. I know that Boss is going to get angry with me. But all the same, I decided to come back again for more herbs. ”

“ I know why Boss is angry with me. This is because Boss wants his patients to get well. He wants to save their lives. So it is right if he is angry when we don’t follow what he says.”

My response to Mat that night were hard.

“That is normal. When they are dying, patients will follow what I said. But when they become well, they will immediately forget my advice.”

“What is this – you took herbs for a month but you stretched them until three months before you come back again. What are you trying to do? You know, cases like yours could be serious. You can die anytime soon. By right if you get well you should continue taking the herbs without stopping.”

“Anyway, it is your life. You are responsible for it. It is up to you, you want to die or you want to live. It is your choice and your responsibility.”

“Your healing is most unexpected. I don’t expect you to get well so soon. But you did. Consider this as a blessing from God. It is a real gift from God. Appreciate it or you throw it down the drain. It will be a waste if you throw it away. Know that this is indeed a blessing. ”

“Remember, to remain healthy or to get sick is your choice and your responsibility. I have shown you the way. You have already experienced the healing. Now, it is up to you take the road and proceed further. Nobody can walk this road for you.”

To those patients reading this case study, I would say the same thing to you. Just one reminder, please bring all your medical records when you come!

Let me conclude by saying this: “All said, I like Mat – this man from Kelantan. I am glad that I was able to help him!”

5 December 2010: Mat came back to see us again – exactly a month after his second visit. My earlier message (“scolding”) got across to him. Wonderful! On top of it he brought along his medical reports.

Medical History: He had painless, neck swelling since 2000. CT scan of head and neck on 28 August 2003 indicated an enlarged “right submandibular gland. It measures 2.3 x 2.7 x 4.2 cm. Right maxillary sinus mucocele and concurrent chronic siniusitis.”

Surgery was performed to remove the lump. Histopathology report confirmed “adenoid cystic carcinoma. Tumour extends to the outer capsule of salivary gland.”

Ultrasonography of the liver on 4 December 2010 (a day before his present visit) indicated “liver is enlarged (21 x 11 cm) and irregular. Heterogeneous parenchymal echo texture with many nodular masses with varying sizes and texture with irregular outlines. A big nodule 10 x 8 cm in size in the inferior part of the right lobe crossing segmental boundaries showing necrotic centre. Ascitic fluid is present. Impresion: multiple metastatic lesions of the liver.

My first question to Mat was: “How are you doing?” Without hesitation he replied that he was good and well. During this visit he was accompanied by his son and daughter. Four points were highlighted.

The son pointed out that before taking the herbs, Mat’s abdomen was enlarged. Now, the swelling had subsided significantly although the abdomen is still hard.
Mat has more strength. He said he is strong for a man of his age – 62 years old.
Mat is able to go fishing, unlike before.
His pale palms are now pink. His face is flushed. He looks and feels healthy.
One problem Mat is facing now is his ferocious appetite. Mat said: “ I just liked to eat.” His daughter said: “Every time he wakes up he wants to eat.” I told Mat: “Most cancer patients have poor appetite. In your case you always want to eat. I don’t have herbs to stop your appetite!”

Mat promised to come back again. In the meantime he will stick on with the good diet and herbs.

Comments: According to the oncology books; Harrison’s Principles of Internal Medicine 15th Ed., pg.589: “If untreated, most patients die within 3 to 6 months of diagnosis.” Martin Abeloff, et al. in Clinical Oncology, Vol: 2, pg. 1697 said: “Median survival of Hong Kong patients with inoperable HCC – tumour larger than 6 cm in diameter and receiving no treatment – was 3.5 weeks. Tumour doubling time ranged from 1 to 19.5 months, with an average of 6.5 months.”

More related stories:

Liver Cancer: He Died After a RM 10,000 Open-Close Surgery

The Doctor Said: “No More Hope” After a 60-Million-Rupiah Operation for Bile Duct Cancer

A Great Failure and Let Down

Sam is a 51-year old male from Indonesia. Sometime in May 2008, he had pains in his abdomen. A check up in a hospital in Sarawak indicated gall bladder stone. Sam underwent an operation to remove the stone. At the time of the surgery, the doctor discovered that Sam’s liver was not good. A CT scan revealed possibility of a hepatoma or liver tumour.

Sam was asked to undergo a liver operation in Singapore which would cost him about S$50,000.00. Sam came to Penang instead and underwent an operation for his liver in a private hospital. This cost him RM 35,000.00. This operation was done in October 2008.

CT Scan Report: 3 October 2008: There is ill-defined hypodense lesion at Segment VI. It measures 3.5 x 3.5 cm. Feature is suggestive of right lobe hepatoma.

Histology Report: 7 October 2008: Liver tissue weighing 350 gm, measuring 140 x 120 x 60 mm. Diagnosis: hepatocellular carcinoma.

After the surgery, Sam underwent two times of chemoembolization, in December 2008 and January 2009. Each treatment costs about RM 5,000.00.

In February 2009, Sam suffered severe jaundice. The blood test results on 10 February 2009 is a below.

Total bilirubin	523.77 H
Direct bilirubin	394.69 H
Alkaline phosphatase	143.34 H
GGT	758.75 H
ALT	121.38 H
AST	109.07 H
Alpha-fetoprotein	5,845.0 H

Sam underwent another surgery to install a metallic stent in the upper common bile duct. This procedure costs RM 20,000.00.

A CT scan done of 10 February 2009 indicated:

Worsening of the liver with increase in the number and size of the liver nodules.
There was thrombosis of the adjacent portal vein extending partially to the main portal vein.

In spite of such deterioration, nothing was done. And Sam was sent home without much explanation.

Sam and his wife came back to Penang again in March 2009. Unfortunately this time, the surgeon who operated on Sam’s liver was rather “hostile” in his attitude. It was a complete change of the surgeon’s attitude from the previous time before Sam had the operation. Sam and his wife felt let down and cheated. Sam’s wife said that before the operation the surgeon even hugged her and assured her that Sam would be alright. Now, after the relapse he did not even want to talk to them. They also told us that surgeon insisted that Sam undergo the surgery immediately because it was a very serious case. Sam and his wife requested go home and think it over first. The surgeon told them that if they returned to Indonesia, there would be a delay and by that time Sam’s condition would have deteriorated and he (the surgeon) would not be able to perform the surgery any more. Sam and his wife were virtually coerced into making their decision.

Listen to this video conversation.

Some excerpts:

Chris: You came to Penang – what did they say?

Sam: I had to be operated.

C: Before you did the operation, did you ask the doctor if surgery would cure you?

S: It must be removed.

Wife: Otherwise the cancer will increase more and more.

C: That is not true! Oh, you came here and they say cut and you agreed to get cut?

W: If we don’t operate, it is going to be dangerous. So, okay we agreed to the operation.

C: Let me ask you one more thing. Before you came here, before the operation – what was your condition? Were you healthy?

S: I was alright – healthy.

C: And after the operation, and having spent RM 35,000.00 – were you better?

S: No.

W: Before the operation, the surgeon was very friendly to us. He talked to us very nicely.

C: Oh, before the operation, Ibu (mama) asked anything and the doctor would answer you? He was nice to you?

W: Yes, he answered our questions and was very nice. But after the operation, he did not want to say anything anymore. We wanted to consult him but he did not want to talk to us. When we asked him questions, he just walked away. In a rush he just said – No problem, no problem and left us.

S: No, we were not able to talk to them like this (with you).

C: Before the operation, he talked to you nicely?

W: Yes, correct, correct. He even hugged me and assured me – Don’t worry, don’t’ worry, he (my husband) would be well and alright.

S: Oh, he was so sweet.

W: We felt so good and comforted. He told us the operation has to be done immediately.

S: It told him I was not prepared for it yet. The surgeon leaned back and sighed: Arr … if you don’t do it now, your condition will deteriorate.

W: He said: I would not be able to operate you anymore.

C: Wah, that is what he told you? If you go back to Pontianak first, your condition would get worse and you would probably be half dead?

W: By that time, it would be difficult to help.

C: That could not be true at all.

S: We did not have other alternative.

C: Yes, I fully understand. Patients are often rushed into making decisions. I don’t believe this is correct. Sometime, doing nothing is better than doing something.

The blood test results on 6 March 2009 are as below:

Total bilirubin	138.00 H
Direct	114.66 H
Alkaline phosphatase	143.34
GGT	203.05 H
ALT	57.98 H
AST	98.45 H
Alpha-fetoprotein	239,595.00 H

Sam then moved on to see another doctor who prescribed him two oral drugs. 1) Baraclude (entecevir) which is commonly prescribed for Hepatitis patients. 2) Nexavar – a drug that cost RM 20,000 per month. (Note: Pang in another story was also asked to take similar drug, which his doctor said was only 20 to 30% effective).

Sam took the drug, Nexavar for a day and a half (i.e., a total of 3 tablets). He suffered the following side effects:

He felt tired when walking or even talking.
His chest felt tight.
His ear started to produce a humming sound throughout the day.
His sleep was disturbed.

Sam and his wife came to seek our help on 8 March 2009 and decided to give up further medical treatment.

Comments:

This is a very tragic story indeed. Professor Jane Plant wrote: Conventional cancer treatment can process patients to the extent that they no longer understand what is really being done to them. It started with a threat or instill of fear in patients. Your liver is rotten – if you don’t get it out it is going to kill you. And you must do it fast! And look what has become of Sam now? Dr. Richard Fleming (in Stop inflammation now) wrote: … all forms of surgery cannot provide a long-term cure because they do not deal with the underlying cause of the disease, which is inflammation … Surgery often triggers an even greater inflammatory process, which encourages the illness.

Sam handed us the reading of his alpha-fetoprotein (AFP) below.

Study the above numbers carefully. Sam’s AFP value was only 3.0 before the gall bladder operation. After the operation, his AFP started to increase, from 50.5 to 3,201. Then he came to Penang and underwent a liver surgery. The situation got worse. As of March 2009, Sam’s AFP has exceeded a quarter million.

AFP (alpha-fetoprotein) Reading

19 December 2007	3.0	Done in Sarawak
7 May 2008		Gall bladder Operation in Sarawak
11 July 2008	50.5	Done in Sarawak
25 September 2008	2,433	Done in Sarawak
4 October 2008	3,201.97
6 October 2008		Liver operation in Penang
5 December 2008	18,550	Done in Penang
30 December 2008	17,857.8	Done in Penang
10 February 2009	5,845.0	Done in Penang
6 March 2009	239,595.0	Done in Penang

When Sam tried to seek clarification with the surgeon, he was snubbed. The surgeon did not even want to talk to Sam and his wife. Sadly, patients like Sam were left in a limbo. Sam was then passed on to another doctor.

Sam was prescribed an extremely expensive drug – at RM 20,000.00 per month. Of course, Sam had no choice. Accept it or die. But the point is: Was Sam told that the drug would not cure him? No, and he did not have the slightest clue about the truth. The data provided by the drug company’s website clearly indicated the following: For liver cancer,

Patients who took Nexavar – median survival = 10.7 months
Patients on placebo (sugar pill) – median survival = 7.9 months.
Nexavar only increased survival by 2.8 months. No where in the website does it ever say Nexavar cures liver cancer.

If ever there is anything we can learn from this story, it is this: Ignorance can kill. For years, we at CA Care, have been trying to empower patients by providing them with knowledge. However, patients are not interested to read or find things out for themselves. Far too often, patients prefer to find an easy way out and remain ignorant. And then when they reach this desperate end stage they would say to us: Oh, but we do not know all these. We trust the doctors.

Note: In mid-April 2009, we were informed that Sam died. Sam was operated on in October 2008 and by April 2009 he was dead. That was just six months after surgery.

What do you think has hastened his death?

Was it the surgery or his cancer?

What could have happened if Sam did not do anything?

Could he have lived much longer (minus the hefty hospital bills)?

More related stories:

Liver Cancer: He Died After a RM 10,000 Open-Close Surgery

The Doctor Said: “No More Hope” After a 60-Million-Rupiah Operation for Bile Duct Cancer