Life saving chemotherapy treatment in the remote jungle of Myanmar
Naw Pai Lai a 25-year-old presented to our jungle clinic in September 2022 with a history of PV bleeding for 10 months. She had been so excited to learn she was pregnant, however she thought she was miscarrying and attended a local clinic where she was admitted for 5 days. Despite their treatment she did not improve, and her family took her across the Thai border to a hospital. It was here she was diagnosed with a molar pregnancy. They did a D&C and told her she would now be fine. She returned to her village but within a few weeks the bleeding had started again. Not wanting to travel due to the ongoing security issues she stayed at home and tried traditional medicine. After 10 months of discomfort and uncertainty she made the trip to our clinic. She was assessed by both our PA students and our Maternal & Child Health coordinator Lay Lay Poe.
Lay Lay Poe notified me of Naw Pai Lai and shared with me the understanding she had that this was a molar pregnancy- likely still related to the one she had been diagnosed with in Thailand. All things pointed to it, she had obvious signs on ultrasound, her hCG levels were significantly elevated and she was feeling unwell. A chest Xray indicated that she had lung metastases. She not only had a molar pregnancy, but it had progressed into cancer of her uterus with expansion into her lungs. The current situation in Myanmar has made it impossible to gain care in any government facility, and the expense and difficulties of getting her to Thailand at this time made that an impossible scenario also. Consulting with our team, and a Gynaecology Oncologist in the US we were able to come up with a tentative treatment plan. This would be the same plan pretty much as what she would receive should she be in the US or Australia. The next hurdle was getting Naw Pai Lai to agree to treatment and to get the medicines to our clinic.
Naw Pai Lai was like any young woman married and wanting to start her family. She didn’t want to have to wait, and she could not comprehend what this all meant. Surely a pregnancy was a pregnancy? When did a pregnancy become cancer? The questions were endless. A lot of time was spent by our team counselling her on what was needed and why. A second D&C was done and there was a mad scramble to get the medications ready. One of the surgeons contacted a friend in a nearby town and asked if she was able to send a round of chemotherapy through to the clinic. Unsure of whether this would be successful, I had contacted a pharmacist I knew and asked if he could order those specific medicines. He soon got back to me saying, yes this was possible but it would be a challenge to get them transported safely to the clinic. While I worked with the pharmacist to get the right medications ordered, we guessed at the number of rounds we would need and worked out a way to get the medicine delivered. The plan was made! Naw Pai Lai decided to return home and come back when we notified her that we had the right medicines.
A week passed and the pharmacist notified us that the medicines had arrived, so that part of the plan was put into action. It was a two day journey through difficult and dangerous terrain. Ironically, the day this medicine arrived was the same day that the medicines ordered by our doctor had arrived – all minus one drug. We were set for 7 cycles should that be needed. This felt like a mighty victory in the circumstances.
It took a further 5 days once we had the medicines for Naw Pai Lai to return to the clinic for her chemotherapy. A repeat ultrasound showed that her uterus had filled again with cancerous tissue, and we decided to repeat the d&c and start treatment. Naw Pai Lai had been counselled on the side effects of the medicines; however, they were able to encourage her with the news that this cancer was very treatable. That with the treatment we had ordered she stood a 98% chance of cure. This was the same treatment regime she would have received had she been accessing health care in Australia or anywhere else. A cycle is 2 weeks. At the end of each cycle, it was necessary to test the hormone level. Thankfully while we were yet to purchase our hormone testing machine, another clinic already had one. It is accessible and near to where she lives. Naw Pai Lai received medications on day 1, day 2, and day 8. Following day 8 treatment she would return home and on day 14 she would present to the other clinic where they would test her blood for her hCG level notify us and she would then travel the 4-5 hours by motorbike back to our clinic where she would start the next cycle of her treatment.
It was slow, it felt like it was very slow for her blood levels to trend down. The plan is once you reach negative you continue for a further 2 cycles. It was worrisome, truly the team had managed to arrange the medicines in a window of possibility. That window was closing if we needed to order more medicine. Following treatment number 5 it showed we had finally made it to negative. We needed a further 2 rounds of chemotherapy. Our DR was able to order through his network the one remaining drug and we were able to give 7 complete treatments. It was new year, and we were able to confirm that we had reached remission. Naw Pai Lai had endured well. Her main issue had been hair loss and part way through when she started to lose her hair, she chose to shave her head. She was beautiful. We will now follow her monthly for 12 months to ensure she stays hCG negative. She has a hope for her future. She will then be free to try to start to fall pregnant again. Around the time we announced Naw Pai Lai to be in remission, our clinic’s hormone testing machine arrived. Naw Pai Lai will have monthly testing at the closer clinic, and they will contact us with results and each 3 months she will come to our clinic to check in with our team. Our capacity grew so much in this time, and it was such an encouragement to our team to be able to manage this complex case and to have such a positive outcome.
Naw Pai Lai and her husband
By Monica - SPM Maternal Health Project Coordinator
Monica Parker is from New South Wales, Australia and is a registered nurse and midwife. She has been living and working in Thailand and Myanmar since 2009 and is the Co-ordinator of SPM’s Maternal Health Program. She is seconded to work with Earth Mission Asia’s Physician Assistant program based in Karen State Myanmar. It is Monica’s dream to train a strong core of professional midwives to serve the Karen people in the remote areas of Karen State. She also wants to help set professional standards in maternal health care. This includes identification and appropriate management of high-risk pregnancy and birth.
Monica and her family are currently back in Australia waiting to return to Myanmar.