BMJ  2003;327:1089 (8 November), doi:10.1136/bmj.327.7423.1089

Filler

A memorable patient

The expert

The BMJ leads the way among medical journals in emphasising the importance of patients having a voice and the concept of the expert patient.¹ I have recently had the privilege of meeting a patient who is expert in the anticancer properties of vitamins and nutrients and in anticoagulation. His knowledge, skills, and attitudes have probably prolonged his life. Doctors and patients may learn from his experience on several levels.

He presented with a colon carcinoma in 1994 (at age 65) and subsequently had a liver metastasis. He underwent resection of the primary tumour and the liver metastasis and was deemed to be in clinical and radiological remission. In 2001 his cancer recurred in the form of a second liver metastasis. A further attempt to excise the liver lesion failed, and a surgical opinion in one country suggested that nothing further could be done with regard to resection or chemotherapy.

The patient's review of the relevant literature gave him hope that further resection and remission might be possible. He travelled to another country, where a second surgical resection of his liver metastasis was successful. This was followed by a short course of chemotherapy. His carcinoembryonic antigen levels fell but remained above normal.

After additional extensive research, the patient started taking a self prescribed cocktail of vitamins and nutrients. He titrated the dose of each vitamin and nutrient to minimise toxicity and maximise efficacy, using his carcinoembryonic antigen level as an index of tumour activity. He currently takes the following vitamins and nutrients daily: vitamin C 1150 mg, vitamin E 10 mg, L-lysine 1500 mg, L-proline 1125 mg, conjugated linoleic acid-6 4000 mg, brewer's yeast 3000 mg, selenium 0.2 mg, garlic 1200 mg, probiotic 5 billion units, -lipoic acid 200 mg, acetyl-L-carnitine 250 mg, coenzyme Q10 60 mg, milk thistle 176 mg, lycopene 250 mg, glucosamine sulphate 1000 mg, chondroitin 800 mg, copper 3 mg, L-arginine 750 mg, N-acetyl cysteine 300 mg, manganese 1.5 mg, green tea extract 1800 mg. His carcinoembryonic antigen level is currently undetectable with this regimen.

In 1998 he developed an above knee deep vein thrombosis after an operation unrelated to his cancer, and was treated with heparin and warfarin. He had a further deep vein thrombosis in 2002 and was referred to me for an opinion on the optimal duration of his warfarin therapy. I explained to him the interactions between thrombosis and cancer. I also explained the risks and benefits of stopping warfarin, continuing warfarin in therapeutic dose, and continuing warfarin with a view to keeping his INR minimally prolonged. I mentioned a recent relevant paper in the New England Journal of Medicine.² He indicated that he was familiar with these research findings.

At the end of a satisfying and mutually enlightening discussion, he elected to take low dose warfarin with a view to minimal prolongation of his INR. We will review him intermittently in the anticoagulation clinic. He is aware that alteration of some of his supplements may interfere with the metabolism of warfarin.

This was the shortest new patient consultation in clinic that morning. The patient declined the offer of co-authorship of this article to preserve his anonymity.

department of haematology, Mid-Western Regional Hospital, Dooradoyle, Limerick, Republic of Ireland

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We welcome articles up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. Please submit the article on http://submit.bmj.com Permission is needed from the patient or a relative if an identifiable patient is referred to.

References

1. Donaldson L. Expert patients usher in a new era of opportunity for the NHS. BMJ 2003; 326: 1279-80.[Free Full Text]
2. Ridker PM, Goldhaber SZ, Danielson E, Rosenberg Y, Eby CS, Deitcher SR, et al. Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism. N Engl J Med 2003; 348: 1425-34.[Abstract/Free Full Text]

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Patient - Heal Thyself

Dr. Herbert H. Nehrlich
bmj.com, 14 Nov 2003 [Full text]