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ABSTRACT
3
MULTI-MODAL
MANAGEMENT
OF A PATIENT WITH METATASTIC DISEASE
UNDERGOING CHEMOTHERAPY
By
M. Truett Bridges, Jr. M.D.,
Medical Acupuncture/Pain Managernent/Holistic
Medicine,
Atlanta, Georgia
EDUCATIONAL
OBJECTIVE
Present an integrated
treatment plan for a systemic disease with
multiple symptoms. PROBLEM
Metastic carcinoma:
pain, constitutional symptoms, and side-effects
of chemotherapy.
CHIEF COMPLAINT
"I am about
to start chemotherapy."
HISTORY
OF PRESENT ILLNESS
This 59-year-old
white male presented to his physician with
symptoms of "prostatitis" in December, 1996.
He was placed on antibiotics with no response.
Ultrasound and biopsy revealed adenocarcinoma
of the prostate. A bone scan revealed widespread
bony metastasis.
Pelvic pain was partially
controlled with hydrocodone. Transurethral
resection of the prostate (TURP) was done
in April, 1997 for obstructive symptoms. Acute
obstruction necessitated repeat TURP two weeks
later. Biopsy revealed transitional cell careinoma
in the prostatic urethra, a diagnosis felt
to be more consistent with the aggressive
nature of his disease. It is possible that
this represents two distinct primary malignancies.
The patient was bedridden
with severe pain by summer, 1997, and uncontrolled
by hydrocodone. He consulted an orthopedist
in July, and an MRI was done, which revealed
the further spread of cancer. After several
attempts, he located an oncologist with whom
he was comfortable. Sustained-release morphine
(MS Contin) and hydromorphone (Dilaudid) were
prescribed for the pain; a course of radiation
therapy was recommended for palliation. During
the course of radiation, he became ambulatory,
but able to take only a few steps. Shortness
of breath led to a chest X-ray, which revealed
lung metastasis.
In September, 1997,
the patient presented for acupuncture evaluation,
during the last week of 25 radiation treatments.
He was scheduled to begin chemotherapy the
following week. He had been told he had about
2 to 4 months to live without chemotherapy.
At this point, he was on MS Contin 120mg BID;
was using Dilaudid 8 mg about every 3 hours
while awake, due to poor baseline control.
He had experienced a 65-pound weight loss
in 1997, was able to walk only about 100 feet
without resting, and was unable to sleep for
extended periods of time.
PAST
HISTORY
After initial
diagnosis of prostate cancer in 1996, the
patient and his wife had converted to a strict
macrobiotic diet. Their assumption was that
his was a slow-growing, non-aggressive tumor,
that treatment was not forthcoming, and that
a natural approach would be best. This unfortunate
experiment dropped his weight from 225 pounds
to about 170. When the illness rapidly progressed,
his weight dropped below 150, and he became
quickly malnourished.
FAMILY/SOCIAL
HISTORY
The patient
is a Ph.D. clinical psychologist, married,
with two adult children, and an excellent
support network.
MEDICATIONS/SUPPLEMENTS
Pain medications
as above. Casodex (bicalutamide), Zoladex
(goserelin acetate), 714-X (experimental immune
stimulant available in Canada).
CHEMOTHERAPY
Taxol (paclitaxel),
Paraplatin (carboplatin), every three weeks.
ALLERGIES
NKDA
REVIEW
OF SYSTEMS
History of eczema
as a child; hay fever as an adult.
PHYSICAL
EXAM
Emaciated, out-of-breath,
depressed-appearing man who seemed older than
his stated age. The torso listed to the left.
There was a 2 cm cherry-red lesion at the
comer of the mouth, felt to be metastatic.
He complained of being cold.
Pulses were rapid,
thin, and weak throughout, especially at Yin
positions. Tongue was moist, pale, with pronounced
spleen fissures and scalloping of the edges;
no coating except for a thin white layer over
the lower heater area.
DIAGNOSIS
Adenocarcinoma
of the prostate/transitional cell carcinoma,
with widespread metastasis to bone, lung,
and skin/subcutaneous tissue.
Combined deficiency
of Qi/Blood, Spleen/Kidney and other Yin organ
deficiency.
TREATMENT
Treatment was
eclectic, utilizing TCM, French Energetic,
Neuroanatomic styles. The patient was seen
at least weekly; every third week, he was
treated the day prior to, and the day after,
chemotherapy. His wife was also instructed
in placement of press-tack needles to be placed
at PC 6 and ST 36 the morning of his chemotherapy
sessions. He received a total of 25 acupuncture
treatments over 4 months; at that time, his
disease was felt to be stable and his response
so favorable, chemotherapy was discontinued.
Needles varied but
were usually 34g-36g, 1-2 inches. Treatments
lasted approximately I hour.
ASSOCIATED
MODALITIES
Patient was
given ChemoSupport by Three Treasures (G.
Macciocia), and other herbs to tonify Spleen
and Kidney. He was encouraged to continue
meditation and prayer; increased protein/calorie
intake, and consumption of high quality organic
produce was recommended.
OUTCOME
/ SUBJECTIVE
Patient experienced
essentially no nausea/vomiting during the
chemotherapy period. His mood and sleep patterns
improved. Increased appetite and enjoyment
of food was noted. He denoted that his pain
abatement had improved remarkably. He soon
planned to be off all opioids, so that he
could drive again. He attributed his remarkable
lack of side-effects to the ongoing acupuncture.
He reported minimal constipation, and no diarrhea.
OUTCOME
/ OBJECTIVE
There was an
8-10 pound weight gain during chemotherapy.
The facial cutaneous lesion disappeared. His
affect noticeably improved, as did his gait
and steadiness on his feet. He laughs and
is making plans for the future.
He
decreased the morphine dosage from 120mg BID
30, to 30mg QHS; he has taken no Dilaudid
in weeks. He no longer complains of being
cold.
There were no complications
during the course of acupuncture treatments.
White count, hemoglobin, and platelet count
remained stable throughout.
FOR
ADDITIONAL READING
1.Dundee, JW, et al. Acupuncture prophylaxis
of cancer chemotherapy-induced sickness. Journal
of the Royal Society of Medicine, 82(1989):268-271.
2.Dundee, JW, et al. Acupuncture to prevent
cisplatin-associated vomiting. Lancet, 1987,
May 9:1(8541):1083.
AUTHOR
INFORMATION
Dr. M. Truett Bridges, Jr. specializes in
Medical Acupuncture, Pain Management, and
Holistic Medicine in Atlanta, Georgia. His
affiliations include Diplomate, American Board
of Anesthesiology; member, American Academy
of Medical Acupuncture.
M.
Truett Bridges, Jr., M.D.
4920 Roswell Road, Suite 36
Atlanta, GA 30342
Phone: 404-843-3400 Fax: 404-843-8101
Email: TruettB@mindspring.com
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