Difficulty Of Aggressive Chemotherapy Protocols

March 1, 2012

Body

This is not a new topic. Lots of pediatric oncologists devote time to developing pediatric cancer guidelines that can be practiced safely in the resource-limited setting. This is just a sad case study of sorts of one of my kiddos in Botswana.

When he first came to see us, his leg was in pretty bad shape. So what took so long for him to come to our care? Transport money. Sadly, that's not a good reason in Botswana. As I've noted before, mom could have gone to the primary hospital in her town and been transported for care to Princess Marina for free. She just didn't know that was a option at the time.

Anyway, after an above-the-knee amputation, he received 11 of 12 cycles of chemotherapy. He got so sick after the last 2 cycles, I was frankly afraid of giving another cycle. He was doing great for about 9 months and then it started to grow... on the other leg.

He had osteosarcoma, a bone cancer, and he's the first kid I've seen having it on both legs. I wonder if there's a genetic predisposition. I'm sure there is, but we just can't test for it.

I put him on low-dose oral chemotherapy so he could be at home. It remained in control for about 6 months, then it really started to grow. I told his mom that I could, in theory, give him heavy-duty chemotherapy to make it shrink; we could even amputate. I explained that the chemotherapy it wouldn't cure him. She thought about it for 2 days and asked me to proceed with the chemotherapy treatment.

And so we did 5 days of chemotherapy. Sadly, he passed away a week later. He was the first kid I've had here to have blood in the urine, something called hemorrhagic cystitis, as a result of the chemotherapy. That was managed, but then he started bleeding from everywhere. That managed for about 72 hours and he started bleeding all over again... then he stopped breathing... and that was it. I think mom took it better than I did.

The point, of course, is that just because we can, doesn't mean we should. While I tried to counsel his mom about that, frankly to my surprise, she asked me to give the chemotherapy. Usually, I find most parents in Botswana say, "it's OK, it's God's will." This mom said the same thing, but more like back home in the States, she wanted to try anything, even if that anything might kill her child. I'm still trying to figure that out.

One last note on my little friend. During the 2 years that I knew him, he never would talk to me. He would speak to me through his mother. This time around, he spoke to me directly, in English no less. Maybe it sounds superstitious, but I think many people will understand when I say it was like he knew and was saying goodbye.

Goodbye buddy.

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