Personalized Medicine

The following true story, although pertaining to a rare condition, is typical of medicine practised in hospitals and doctors' surgeries every day all over the world. Mrs M's district nurse phones me-she is with Mr and Mrs M at their house dressing a leaking exophytic chest wall lesion. She can see a 'liver like substance' extruding from a small inferior wound, there is some fresh blood, and she is concerned that Mrs M may bleed suddenly and profusely. I ask her to send Mrs M to Casualty. Mrs M agrees, but on the condition that she is not admitted to hospital. Mrs M has mesothelioma and for several years, has only had a 'few months left to live'. She presented thirteen years ago with a pleural effusion, for which no cause was found for seven years. A pleural biopsy finally showed mesothelioma, and she underwent chemo and radiotherapy. Unusually for this type of cancer, Mrs M's months turned into years and she is now experiencing late manifestations of her disease, not often seen. Some months ago she noticed growth of hard lumps under her right arm, over her shoulder blade, behind her right breast and above her right clavicle. Stoical to the utmost, she bought new clothes and got used to bumping her chin on the lump above her clavicle every time she turned her head to the right. She adapted to using her left hand more-for holding the telephone and stirring soups. Mrs M's oncologist started her on Thalidomide, an experimental drug in an oncology setting, with the hope that these uncomfortable lesions might die away as they are starved of their blood supply. Within weeks, what were hard lumps turned to boggy masses. Ultrasound confirmed a number of large fluid filled spaces, some of which were amenable to drainage. So, we drained off two litres of highly viscous blood stained fluid from the lesion on her back, and two weeks later another litre from the lesion anteriorly. The lump on which she hit her chin had also become cystic, so we drained off as much as we could from there too. I prescribed antibiotics (whatever the viscous material was, it was likely to get infected), asked her to check her temperature at meal times and let us know if she became febrile, and sent her home for her District Nurse to review regularly. Six days later I received …