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Mabel Wong, 85, had been feeling tired. Her health had always been good, but her recent bouts of fatigue were growing worse. She also started to feel short of breath, and her family members noticed that she looked pale and wan. 
Initially, Wong (whose real name has been withheld for reasons of patient confidentiality) tried to brush her symptoms off as a passing phase or a natural decline of energy that came with age.  But the fatigue grew worse and lingered for two months.
 When Wong felt so weak that she could no longer leave the house, she finally sought medical help. 
Tests showed that Wong was anaemic, with a low red blood  cell count and a haemoglobin  count of six grams per decilitre of blood, which is about half the normal level. 
A low count of haemoglobin - the protein molecule in red blood cells that carries oxygen - would have caused her breathlessness.
Wong's red blood cells were also abnormally large, and she had low levels of white blood cells and platelets. Her doctor suspected that something was wrong in her bone marrow, where red and white blood cells and platelets are made. He ordered a bone marrow biopsy, which showed the presence of a high percentage of very primitive blood cells called blasts.
When blasts fail to mature properly into normal blood cells, it results in an excess of blasts and a shortage of normal blood cells. 
Healthy marrow has less than  5 per cent of blasts present.
When a patient has between five and 20 per cent of blasts in the  bone marrow, they have myelodysplastic syndrome (MDS),  a bone marrow disease in which damaged blood-forming cells continually create defective cells and cause low levels of normal blood cells. If blasts exceed 20 per cent, it would be due to  acute myeloid leukaemia (AML). 
Wong had 15 per cent blasts present in her bone marrow. She had high-risk MDS, meaning there was a high chance it could progress to AML.
With AML, the abnormal cells reproduce very fast and quickly replace the healthy ones, thereby drastically reducing the body's ability to carry oxygen, fight infections and clot blood. AML can kill within months. 
The cells in her marrow also showed complicated chromosomal abnormalities, adding to a gloomy prognosis. 
Wong had a decision to make. Although she was living abroad with family members at the time, the vast majority of her family and friends were back in Hong Kong. She considered that the toll of an illness such as MDS would be better shared by her large network of loved ones back home.
Furthermore, the comfort and familiarity of her surroundings during a difficult time of illness might also help shore up her mental and emotional resources. 
Wong decided to move back to Hong Kong and seek treatment. She turned to Dr Raymond Liang, director of the Comprehensive Oncology Centre at the Hong Kong Sanatorium and Hospital, for help. 
Liang's first priority was to help Wong feel better. A blood transfusion gave her immediate relief as the healthy blood was able to carry oxygen throughout her body and energise her.
Next, he considered her treatment options. If Wong had been younger than 60, Liang might have proposed a bone marrow transplant. But such a rigorous therapy now would take too great a toll on her body.
So instead, Liang used a chemotherapy drug that acts as a demethylating agent.  Methylation of DNA is a process that controls whether a gene is turned on or off. An increase in methylation causes some genes that regulate cell division and growth to turn off, promoting cancer or abnormal  cell growth.
With MDS, where damaged cells also divide abnormally, interfering with the methylation process would potentially turn back on the gene that suppresses cell division, and allow the body to regain control of cell growth.
The prescribed chemotherapy drug, azacitidine, also helps by killing the fast-dividing cancer cells. Unfortunately, it has only a 50 per cent response rate. 
For three months, Wong received drug injections for seven consecutive days each month. During this time, Liang continued to give her blood transfusions every two to three weeks. 
After three treatments, Wong's white blood cell and platelet count had climbed back  up, and she no longer needed the blood transfusions.
To know how well the drug was working, Liang ordered a bone marrow biopsy. It showed that the number of blasts had been reduced to 7 per cent. 
However, the drug is no cure  for MDS. Liang hopes that the treatment will delay the onset of AML, buying Wong some time and a better quality of life.
Wong will continue the treatment until it stops being effective. In the meantime, Wong has reclaimed some normality in her life. She enjoys mahjong games and eating out  with her friends and family.




Senior has a marrow escape