Reflections on My First Week

It’s hard to believe that I’ve already been here for a week. The days seem to go by really fast! I believe every day I’ve seen something that I had never seen before. But now that is starting to seem routine. I’m no longer surprised by the size of tumors that kids have.  Nor am I shocked by the malnourishment I sometimes see.

One challenge I’ve found is that the Master’s students, while very good doctors, are just learning how to treat some of these cancers. Therefore, they (probably appropriately) tend to follow protocols strictly. But since resources are so limited, sometimes one has to think outside of the box. For example, I finally convinced the doctors to give IT cytarabine in place of IT methotrexate for some of their ALL patients until they are able to get more methotrexate (which apparently may not be till late May). They had not previously realized that it was OK to substitute cytarabine (which is better than nothing).

In another example, we have a new 7yo girl with a pelvic mass. On the scan, it looks like the mass is arising from the bladder or uterus. Both ureters are obstructed and there’s bilateral hydronephrosis with renal insufficiency. I convinced them to begin treatment for rhabdomyosarcoma and not wait for biopsy results. If we wait for pathology, we’ll delay treatment for a week and who knows what will happen to her kidneys by then. Rhabdomyosarcoma is by far the most likely diagnosis for a tumor in this location for a patient this age. And if it’s something else, we probably can’t cure it anyway, so why not treat for the most likely thing. Also, because of her renal impairment, we can’t give Ifosfamide, which is standard per the European protocols they use. We looked at some dose modifications in COG protocols and decided to start with vincristine and actinomycin-D alone, and then add in cyclophosphamide at reduced doses when (and if) her renal function improves.   While the Master’s students are good doctors and are learning rapidly, they simply don’t have the experience to be break from protocol and to feel comfortable making up treatment plans. But in this place and with these resources, it’s often going to be necessary to think outside the box. However, it takes knowledge and experience to be able to do that.

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