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Q. My 70-year-old aunt has cancer and is unwilling for chemo. Kindly suggest her a good option.

Answered by
Dr. Pawar Satyajit Jalinder
and medically reviewed by Dr. K Shobana
This is a premium question & answer published on Sep 13, 2021 and last reviewed on: Aug 01, 2022

Hello doctor,

My aunt, around 70 years old with a history of asthma, underwent gallbladder surgery two years ago. After the surgery, she was diagnosed with cancer. They consulted a doctor, and he advised chemotherapy as a treatment option. But her family members refused to proceed with the treatment considering her age. In addition, a lesion near the liver was detected in an abdomen ultrasound taken one year ago. But they did not proceed with the treatment.

Three days ago, they had done a whole body USG and found a mass on the pancreatic head, and the patient had a lot of pain in the abdomen.

I would like to know:

1) If we plan for surgery, which surgery shall be done?

2) If they do not want surgery, which type of chemotherapy can be given, and how many cycles does she need?

3) Suppose they do not wish to go for even chemotherapy too. Can some oral chemotherapy be suggested?

4) How should we manage this severe pain of pancreatitis?

At present, she is taking the following medicines.

1) Tablet Lupizox twice daily.

2) Tablet Drotin Plus as and when required.

Can we replace Ultracet in place of Drotin, or do you suggest a better choice for managing pain? Kindly help.

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#

Hello,

Welcome to icliniq.com.

I have reviewed your query and the reports you provided (attachments removed to protect the patient’s identity).

Before answering your questions, I would like to point out the inconsistency in the reports, and I would like to get them re-checked. The first abdomen ultrasound shows a lesion in the liver, which is not seen in the second ultrasound. It only indicates a lesion in the pancreas. So I want to confirm it with CT (computed tomography) scan.

Now coming to your questions,

1) Before surgery, we need to see if the lesion can be removed completely. To do that, pancreatic protocol CT is needed to see if the lesion is not attached to any major blood vessels. And the decision on surgery can be made only after that.

2) Ideal treatment for this tumor remains surgery. Only if the cancer is not resectable, then can chemotherapy be considered.

3) If they do not wish to go for chemotherapy, we have options of low-dose oral chemotherapy. But before that, we need to assess blood reports. Also, before starting chemotherapy, a cancer diagnosis must be confirmed either by biopsy or FNAC (fine needle aspiration cytology) as different cancer types have other chemotherapy options.

4) Pain can be managed with escalated analgesics as per WHO (world health organization) ladder. She can take Crocin (Paracetamol) or Tramadol, which gradually escalated. If the pain is still there, she might need to be shifted to opioid analgesics.

Thank you.

Thank you for your reply doctor.

My aunty visited a doctor last day. He suggested doing specific tests and PET scans. I am also enclosing her histopathological report of gall bladder two years back. The doctor advised chemotherapy based on these reports, but my aunt did not accept the proposal and returned to her hometown. In between, she had USG in regular intervals. Now the pain has increased, and they thought to take an oncological reference. After seeing the current PET scan and other blood reports, the doctor suggested going for USG-guided FNAC for liver mass, as seen in the PET scan. It seems that the doctor has ruled out surgery and has not given much hope to chemotherapy.

However, based on the present reports, I seek your valuable advice.

It will be helpful if you can reply step by step to understand better.

1. Is surgery possible in the present case or not?

2. Can chemotherapy can give any result?

3. If yes, which type of IV chemotherapy should be used?

4. Do you feel the proposed FNAC by USG guided will give any benefits to patients? As we know from her past histopathological reports of the gall bladder, it is adenocarcinoma.

5. If we do not want all the above, can we go for oral chemotherapy? If yes, which type of chemotherapy is recommended for her? Kindly help.

#

Hello,

Welcome back to icliniq.com.

I have reviewed your reports (attachment removed to protect the patient's identity).

1. It is metastatic disease, and surgery is not feasible.

2. Chemotherapy will help reduce the extent of disease and prolong life. At her age, if she is fit (good performance status), then I would still consider chemotherapy

3. Gemcitabine or Carboplatin based treatment would be suitable considering her age

4. I would consider doing FNAC as her CA19.9 is normal, which usually remains raised in CA GB (cancer of gallbladder). Treatment can be different to confirm it is adenocarcinoma only and not some other type of GB (gallbladder) cancer.

5. Oral chemotherapy is less effective than IV (intravenous), but oral Capecitabine can be tried if she tolerates it well. At this point, I would also advise doing a solid tumor NGS (next-generation sequencing) panel to look for any targetable mutation that might be targeted with oral or IV (intravenous) drugs, which are safer than chemotherapy. Kindly revert in case of more queries.

Thank you.

Hello doctor,

Thank you for your reply.

I am attaching the latest reports of my aunty, whose condition is not good. She has been released from the local hospitals, as the doctor lost all hope. Her Bilirubin is very high. Can we plan a biliary stent to give passage to bile so that jaundice can be managed? She has not taken any chemotherapy, as a family member refused to go for any chemotherapy or radiation, as suggested by the doctor. Kindly help.

#

Hello,

Welcome back to icliniq.com.

I have reviewed the reports, and this is a advanced stage IV malignancy. Based on reports, she has obstructive jaundice, and interventions like PTBD (Percutaneous transhepatic biliary drainage) will help in management.

I would suggest biliary stenting only if her general condition is stable (PS-2), meaning if she can at least go to the washroom on her own or with support. In that case, doing PTBD will help in improving her symptoms. If she is already bed-bound -adding another intervention will only cause her pain rather than help. Other than PTBD, she can be started on supportive medications like Udilive or Thiotrace to improve liver functioning.

Thank you.


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