149 – I Learn How to Keep Margaret Alive, Part 2: 17 January 2025

Early in the afternoon ofn 3 December 2021 I demanded that the health insurers obey the law.

By 7.30 pm on that day, Margaret’s cancer had retreated and her stents were removed.

I knew then that if I wanted Margaret to live, I had to force the health insurers to obey the law.

I was determined to enable Margaret to live.

Margaret and me on 26 March 2015 at Wilpena Pound, South Australia.

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As recounted in Blog 148, Margaret rang me at about 7:30 pm when she woke after her operation.  She had spoken to the surgeon and the surgeon had told her she could go home.  In the two days between the previous operation on 1 December and the latest operation on 3 December, the cancer had shrunk to the smallest size that the surgeon had ever seen it.  The cancer was not gone, but it had shrunk – and it had done this without any further treatment in the two days between 1 and 3 December.  The surgeon could not explain what had happened.  The surgeon told Margaret that unless she experienced cancer symptoms, he would not schedule another “look see” operation until one year later - December 2022.

The written report from the surgeon said this.

EUS Findings 1 As previous EUS, there was a nodal mass on the left of the celiac axis, measured up to 20 mm.  The lesion looked malignant and as requested, the lesion was biopsied using EUS FNA technique.  One pass of 25 G needle were performed for histology. 2 There was a cyst in the pancreatic head/ neck region.  The cyst looked benign and had no malignant features.  The ampulla was thickened and was hard on FNA.  One pass of 25 G FNA was performed to check for presence of carcinoma. 3 The main PD was 2.5 com in size. 4 The liver was also screened careful[ly] for mass lesion but no definite lesion can be seen in the visualises portion. 5 BBD stents had decompressed the biliary tract EUS Interventions FNA was performed

EUS = Endoscopic Ultrasound

FNA = Fine Needle Aspiration

PD = Pancreatic Duct

BBD stents = Benign Biliary Disease stents

The report says the stents had “decompressed the biliary duct”.  In plain English, this means the stents had restored the Margaret’s biliary to normal functioning.  On 1 December 2021, the biliary tract had been so blocked by the cancer that it could not function at all without the stents to keep it free of blockage by the cancer.  On 3 December the cancer had shrunk so much that Margaret’s bile duct had returned to its normal size and was functioning normally.  Something the surgeon does not mention in this report is that the cancer had shrunk so much that the surgeon removed the two stents in the bile duct because they were no longer needed!

I was torn between overwhelming joy and overwhelming shock as I left home to go to the hospital to bring Margaret home. 

On the Wednesday, Margaret had been on the verge of death.  She was being kept alive by two stents that allowed her bile duct to continue working.

Two days later on 3 December, the cancer had retreated so much that the surgeon removed the two stents from her bile duct.  The stents were no longer needed to keep Margaret alive.  It took days for me to properly digest what had happened.  As I wrote these words more than two years later, I am still stunned by what happened.

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At 12.51 pm on 3 December 2021, I emailed the first of what became a flood of letters to HCF demanding that it obey the law. 

At 12:54 pm on 3 December, I emailed the first of a separate long series of letters to the Commonwealth Ombudsman demanding that it force HCF to obey the law.

By 7:30 pm on 3 December, Margaret was granted a reprieve from death that we had prayed for, but never dared imagine might ever happen.

Without realising it, I had begun an unremitting struggle to force HCF to obey the law. 

I was so naïve on 3 December 2021 that I did not imagine for a moment that the Australian Health Department, which is supposedly the primary regulator of health insurers, knew exactly what the health insurers were doing and had decided to ignore their refusal to obey the law.

I was so naïve on 3 December 2021 that I did not imagine for a moment that the Commonwealth Ombudsman, which is supposedly the back up regulator of health insurers, also knew exactly what the health insurers were doing and had also decided to ignore their refusal to obey the law.

I was so naïve on 3 December 2021 that I did not imagine that the health insurers had intimate knowledge of the refusal of the regulators to do their jobs and that they knew they could ignore the law without any consequences from the regulators.

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Once I realised the significance of what had happened, it was impossible for me to stop struggling to force the health insurers to obey the law.  Letting the health insurers continue to break the law could never happen. 

If I let HCF and the other health insurers continue to be contemptuous of the law, Margaret’s cancer would return and she would die.

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When I eventually won the battle with the health insurers many months later, Margaret was still alive.  This - not the surrender of the health insurers – was what filled me with joy. 

I was of course thrilled by the mean spirited surrender of the health insurers and the ending of the efforts of the health insurers to crush Lift Cancer Care Services, but the elation from this surrender paled beside the continued life granted to my wife.

 

148 – I Learn How to Keep Margaret Alive: 16 January 2025

I learned on 3 December 2021 how to keep Margaret alive.

To keep Margaret alive, I only needed to force the health insurers to obey the law.

No matter what happened after then, I knew I would make the health insurers obey the law.

Margaret and me on 19 November 2020 at Loveon Cafe.

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In Blog 39, I wrote this.

Throughout Friday 3 December 2021, I worked frantically on letters of complaint to our health insurer HCF and to the Commonwealth Ombudsman.  In theory, the Ombudsman was the government agency which, in conjunction with the Australian Health Department, enforced the laws governing private health insurance. At about 4.30 in the afternoon, I emailed this letter of complaint to HCF.

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I have now had the opportunity to check my records of that frantic day of work and worry.  The computer tells me that at 12.51 pm on 3 December 2021, I sent an email to HCF.  The following documents were attached to that email.

·         Letter of complaint to HCF dated 3 December 2021 about the refusal of HCF to pay claims for treatments provide to Margaret by Lift Cancer Care Services.

·         Copy of letter of complaint dated 3 December 2021 sent to the Commonwealth Ombudsman on 3 December 2021.

·         Table 1: Itemisation of 32 Separate complaints by Margaret Redden Re HCF.

·         Table 2: Itemisation of Claims Accepted by HCF.

The computer also tells me that at 12.54 pm on Friday 3 December 2021, I sent an email to the Commonwealth Ombudsman.  Attached the email to the Commonwealth Ombudsman were the same documents that I had sent to HCF:

·         Letter of complaint to Commonwealth Ombudsman dated 3 December 2021 about the refusal of HCF to pay claims for treatments provide to Margaret by Lift Cancer Care Services.

·         Copy of letter of complaint dated 3 December 2021 sent to HCF on 3 December 2021.

·         Table 1: Itemisation of 32 Separate complaints by Margaret Redden Re HCF.

·         Table 2: Itemisation of Claims Accepted by HCF.

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I had been awake since 3.00 am on the day before Margaret’s operation on 3 December. 

I had also been awake since 3.00 am on the day of the operation.

I was physically and mentally exhausted.  I was worried sick about Margaret’s upcoming death.  Like Margaret, I expected the operation scheduled for the evening of that day would simply confirm what the surgeon had already told Margaret after the operation on the 1^st of December – Margaret’s cancer was thriving, Margaret was dying and Margaret would be dead in the near future.

I typed the Tables I sent with my letters of complaint in the morning of Friday 3 December before I wrote the letters themselves.  I needed to know the detail of exactly what had happened.  Had HCF refused to pay all of the claims or only some of them?  Had HCF explained why it had refused to pay the claims?

Back then in December 2021, I was reluctant to make any assumptions of illegality.  My starting point was that surely HCF would never intentionally disobey the law.  This meant the refusal to pay the Lift Cancer Care claims must have been the result of a misunderstanding.  It was weeks before I realised that HCF had not made some innocent mistake.  It was weeks before I realised that HCF did not give a flying fart about what the law required it to do.

It was months before I realised that the government enforcement agency – the Commonwealth Ombudsman – knew exactly what HCF had been doing and had made a decision to refuse taking any action to enforce the law.

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On 3 December 2021, I was naïve.

My wife was dying.

I knew other patients of Lift Cancer Care Services were grievously ill.

I knew HCF, NIB and Teachers’ Health were refusing to pay what the law required them to pay for treatments provided by Lift Cancer Care.

I thought the refusal of the three health insurers to pay for the Lift services must have been the result of some simple mistake.

Once I pointed out that the health insurers had made a mistake, the health insurers would promptly fix the mistake – and if they did not fix the mistake, the Commonwealth Ombudsman would force them to fix the mistake.

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The surgeon was commencing his list of operations at 6.00 pm that evening.  Margaret did not know where she was on the list.  If she was first, her operation would happen shortly after 6.00 pm and she would be awakened no earlier than about 30 minutes after the operation finished.  If she was further down the operations list, it would be later in the evening before she was awakened.

Once the operation was finished, Margaret would be taken back to the ward and the surgeon would visit when he had finished his list of operations.  Margaret would ring me only after the surgeon had seen her and told her what he had found during the operation.

I expected Margaret to ring me no earlier than 8.00 pm.  I was certain the surgeon would insist that she stay in hospital – at the very least – until the next morning.

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I was shocked when Margaret rang me at about 7.30 that evening.

I was even more shocked at what she told me.

“Come and take me home!  The surgeon says he has never seen the cancer look so small!  He says I can go home!”

I immediately drove to the hospital and brought Margaret home.

I had written letters of complaint to HCF and to the Ombudsman.

The result of me writing my two letters was immediate.  Without any additional treatment between Wednesday 1^st December and the operation on Friday 3^rd December, the cancer had shrunk dramatically and Margaret was able to come home.

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I had learned how to keep Margaret alive.

To keep Margaret alive, all I had to do was force the health insurers to obey the law.

I knew I would do what I had to do to keep Margaret alive.

I would force the health insurers to obey the law.

 

 

147 – Margaret Learns How to Paint: 15 January 2025

Because I decided to force the health insurers to obey the law, Margaret gained an additional 20 months of life and had a painting lesson on 15 May 2022.  Margaret is in the exact middle.

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The surgeon had scheduled yet another operation on Margaret for Wednesday 1 December 2021.  The cancer had vanished from the lymph nodes, but it was still there and the primary source of the cancer in her ampullar was still present.

The 1 December operation took place as scheduled.  The news from the surgeon could hardly have been more dismal.

He had not been able to administer endoscopic radiotherapy to try and blast the cancer because the inflammation in Margaret’s digestive system had not gone down but increased.  The inflammation had prevented endoscopic radiotherapy during the previous operation and the medication since then was supposed to have got rid of the inflammation so the radiotherapy could go ahead on 1 December.  The surgeon’s written said this.

Gastroscopy Findings Stomach – Normal. Duodenum – Normal         Duodenal Papilla Major Papilla – The 2 old stents were seen. The ampullar was markedly ulcerated and the duct/ biliary orifice were widely opened.  This looked like radiation therapy to the area and this has led to a patent duct. Cannulation of PD was not successful again. The CBD was cannulated and opened a marked dilation in the proximal portion (up to 20 mm).  There were lots of filling defects which was a mixture of sludges/ stone fragments and airbubble on balloon trawl. Good drainage via the biliary orifice was seen, thus, no stenting was required. Conclusion Patent CBD, no stent required. PD no accessible.  No RFA treatment

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The medical language in the report was not easy to understand, but the oral report the surgeon gave to Margaret was very clear. 

The cancer was thriving and Margaret should expect the cancer to kill her sooner rather than later.

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The surgeon decided he would perform yet another operation on Friday 3 December.  He hoped to find out more about the growth of the cancer.  This meant Margaret was trapped in the hospital.  If Margaret returned home from hospital, the government restrictions surrounding Covid meant she would not be readmitted to the hospital in two days’ time on 3 December.

My visit to Margaret on 2 December after the 1 December operation was hard for both of us.  I wheeled her in a wheelchair to the hospital coffee shop.  While we were in the coffee shop.  Margaret pointed to the part of the hospital which housed the Palliative Care Unit.  She also spoke about Mary Potter Hospice; Mary Potter is a ward in that hospital dedicated to the care of the dying.  She said she would visit Palliative Care and Mary Potter after I went home.  When I rang Margaret later that day, she told me she had been to Palliative Care and Mary Potter, that the staff were extremely helpful and that she had done all necessary paperwork to use their services.

We were so very close to the end, but Margaret was still completely composed and dealing efficiently with the administrative detail to enable her to die with as much dignity as possible.

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So that was how we were dealing with Margaret’s likely death in the evening of that Thursday 2 December 2021.

In the very near future, the cancer would kill her and she was doing everything she could to make my life after her death and just before it, as straightforward as she could. 

That night I began thinking about Margaret’s funeral.  What should I say?  What music did I want during the service? 

My sleep was terrible that night.  I woke up at 3:00 am on Friday morning, mentally repeating what had happened on the Thursday morning.  Realising that staying in bed would not get me any extra sleep, I got up, walked for an hour, breakfasted and read the newspaper.  Doing things to “keep me busy" made the hours pass, but so very slowly.

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My thoughts that morning kept returning to the behaviour of the health insurance funds.

Margaret had been receiving treatment all year at Lift Cancer Care Services and the treatment had obviously helped keep her alive.

About two months earlier (I think it was in October 2021) Lift told Margaret that some insurers were refusing to pay for the treatments provided by Lift Cancer Care Services.  As from 1 December, Lift needed all patients insured by HCF, NIB and teachers’ Health to pay in full for the treatments they received on the day they got the treatments. 

On 2 December, I knew Margaret was going to die in the very near future, so the refusal of the health insurers to obey the law would not be of concern to me for very long.  If Margaret lived long enough to ever need any more treatments at Lift, I could somehow find the money to pay for the treatments. 

No matter what I did, Margaret was going to die very soon and the actions of the health insurers would not really matter to me into the future.  But I kept thinking of the other cancer patients who received treatments at Lift.  How were they going to receive their treatments if the health insurers kept refusing to pay and if they did not have money in the bank to pay out of their own pockets?  

They would die much more quickly than they should if they could not get the treatments their doctors wanted them to get.

I wondered, should I take action to help these other cancer patients get the treatment they needed?  In the great fog of sorrow about Margaret’s impending death, my determination crystalised.  I had to do something; I could not let the actions of greedy health insurers cause needless deaths. 

I decided to write to HCF and the Commonwealth Ombudsman.  I imagined – wrongly – that the refusal to pay would be fixed as soon as I complained.  If HCF refused to obey the law, the Commonwealth Ombudsman was certain to force it to obey the law.

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I was wrong.  The Commonwealth Ombudsman knew what was going on and had refused to enforce the law.

HCF and the other health insurers knew the Commonwealth Ombudsman had no intention of enforcing the law.  This knowledge reinforced their refusal to obey the law.  What bank robber will ever stop robbing banks when the robber knows the police will never do anything to stop the robber from robbing the banks?

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I had no way of knowing early in that morning of 3 December 2021 that my determination to force the health insurers to obey the law would have a direct impact on Margaret’s continued life.

I wrote my first letters in what became a very long struggle to enforce the law – and Margaret got an immediate reprieve from imminent death.  By deciding to help other patients, I ensured Margaret received an additional 20 months of life.

 

146 – Margaret’s Lymph Node Cancer Disappears: 13 January 2025

This was how Margaret looked in Ireland on 17 September 2019.  By October 2021, she was dying and no longer looked like this.

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Ireland on 17 September 2019.

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The findings of the 29 September operation were a little inconclusive, but they were not good. 

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As I have already said, I simply do not have the words to describe how I felt after getting the news of what the surgeon found when he operated on 29 September 2021. 

Although the surgeon had been unable to administer radiotherapy during his operation on Margaret on 29 September 2021, he was able to implant two stents into her bile duct.  His medical words summed up what he had done:

The biliary duct was stented with 2 plastic stent[s] and this resulted in good contrast and bile drainage

The surgeon had wanted to also insert a stent into Margaret’s pancreatic duct, but the swelling in the pancreatic duct was so great that he was unable to do this.  He said “the PD could not be entered”. 

This is how the health website Healthline describes a stent.

[A] stent is a tiny tube that your doctor can insert into a blocked passageway to keep it open. The stent restores the flow of blood or other fluids, depending on where it’s placed.

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By 29 September, the cancer had not only returned, it had grown and was starting to block Margaret’s bile duct.  Without the two stents to keep the bile duct open, her digestive system would have been unable to function.  Her swift death would have been certain.

Unfortunately, a stent could not be placed in her pancreatic duct because the surgeon was worried this would cause pancreatitis.  Pancreatitis is an extremely serious disease.  The Mayo Clinic says this about pancreatitis.

Pancreatitis is inflammation of the pancreas. The pancreas is a long, flat gland that sits tucked behind the stomach in the upper abdomen. The pancreas produces enzymes that help digestion and hormones that help regulate the way your body processes sugar (glucose). Pancreatitis can occur as acute pancreatitis — meaning it appears suddenly and lasts for days. Some people develop chronic pancreatitis, which is pancreatitis that occurs over many years. Mild cases of pancreatitis improve with treatment, but severe cases can cause life-threatening complications.

The surgeon had a difficult dilemma when he operated on 29 September.  If he ensured the pancreatic duct could continue to function he might cause life threatening pancreatitis.  If he avoided possible pancreatitis this would leave Margaret at risk of the blockage of her pancreatic duct.

The surgeon decided to avoid pancreatitis and Margaret told me later that she completely agreed with the surgeon’s decision.

Because of inflammation in the pancreatic duct, the operation was able to gather only meagre information about the spread of the cancer. 

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After receiving the PET scan report, the surgeon scheduled a further operation for 1 October 2021.  He wanted to discover what the cancer was doing.

This is the surgeon’s report on the 1 October 2021 operation.

Gastroscopy Findings Stomach – Normal.  Duodenum – Normal.  The ampulla has 2 plastic stents[s] which drained bile. EUS Findings Upper GIT: 1 The nodal lesion on the left of the celiac axis was seen.  It measured up to 20 mm.  The lesion looked malignant and as requested, the lesion was biopsied using EUS FNA technique.  Two passes of 22G Core needles were performed for histology. 2 The liver was also screened careful[ly] for mass lesion but no definite lesion can be seen in the visualised portion. 3 There was a cyst in the pancreatic head/ neck region.  The cyst looked benign and had no malignant features. 4 The PD was 2-3 mm in calibre. 5 CBD stents had decompressed the biliary tract. Conclusion Metastatic nodal disease EUS FNA = Endoscopic Ultrasound Fine Needle Aspiration

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The PET scan report ensured the “nodal lesion” which had so concerned the surgeon on 14 and 29 September was a major focus of attention on 1 October.  The surgeon found the “lesion looked malignant”.  His written conclusion was “Metastatic nodal disease”.

Margaret seemed certain to die soon.

On 1 October the surgeon took tissue samples so the suspicious cells could be tested.

Although concerned about the lymph nodes, the surgeon thought Margaret’s liver was still cancer free.

He also found that a growth in the head of the pancreas was not cancerous.  

The only good news was that the bile duct stents had worked and the cancerous squeezing of the bile duct (“compression”) had been reversed.

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The stents had gained Margaret some extra time, but her situation was grim.  The surgeon gave her medication to reduce inflammation in her pancreas and scheduled another operation fir Wednesday 1 December 2021.  He hoped the inflammation would have decreased by then and that he would be able to administer endoscopic radiotherapy.

We prepared ourselves as best we could.  The cancer was certain to kill Margaret – sooner rather than later.

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Then something astonishing happened.

When the tissue samples taken from the lymph nodes on 1 October were examined in the laboratory, they were cancer free. 

Despite the result of the PET scan and despite what the surgeon saw on 29 September and 1 October, Margaret’s lymph node tissue was cancer free.

The oncologist had no explanation for this. 

I have an “unscientific” explanation of my own for what happened.  I believe the stress of my health collapse had a direct impact on Margaret.

I think the stress of having to deal with my near death on top of her own cancer, was the major reason why Margaret’s cancer returned in September 2021.

I believe I can thank the Cancellation Crew for my own health collapse and for the return of Margaret’s cancer.

As for the disappearance of the cancer from Margaret’s lymph nodes – this was quite simply a miracle just like the many other miracles recorded throughout history.

We were immensely grateful.

 

 

145 – Margaret’s Cancer Spreads to Her Lymph Nodes: 12 January 2025

This was how Margaret looked on 27 April 2019.  By September 2021, she was dying and she no longer looked like this.

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Margaret had another endoscopic ultrasound on Tuesday 14 September 2021.  The report of the operation was optimistic.  The report said this.

 

Findings On endoscopy, the ampulla was small but has some polypoid/ villiform tissue at the orifice.  Biliary discharge was noted.  The ampulla was biopsied using a forcep. On EUS, the ampullary mass is barely noticeable and has reduced in size to 8 mm the max.  There was no obvious extension of tumour into the distal CBD or PD.  Neither duct was dilated (CBD 7 mm and PD 1-2 mm).  Overall, the appearance suggestive of ongoing remission!. The previous 2 cystic lesions[s] within the pancreas: neck (23 mm) and tail (8 mm) were both seen.  Both has no high risk or worrisome features. The previously enlarged node in the celiac axis, measuring up to 15 mm was again see and was hypoechoic.  This it was biopsied using EUS FNA technique.  Material was collected for histology. EUS = Endoscopic Ultrasound; CBD = Common Bile Duct; PD = Pancreatic Duct

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This operation confirmed that the cancer remained in remission, but it raised a question about its possible presence in the lymph nodes.  This would be resolved by the tissue sample the surgeon sent for testing. 

On 23 September, the oncologist told us that the tissue sample taken from the lymph nodes was indeed cancerous.  The terrible news was that the cancer was now present in Margaret’s lymph nodes.

The Cancer Council of Australia says this about lymph nodes.

Lymph nodes or lymph glands, are part of the lymphatic system which is part of both the immune and circulatory systems. The lymphatic system consists of lymph vessels, lymph fluid and lymph nodes and other lymph tissue.    Lymph nodes are small, bean-shaped structures that are found along the lymph vessels. They filter lymph fluid as it passes through your body before emptying into the bloodstream. Lymph fluid, which is normally clear, travels to and from the tissues in your body. It carries nutrients but also takes away harmful substances such as bacteria, viruses, cell debris and abnormal cells such as cancer cells. The filtered fluid is returned to your blood circulation.

 

The lymph nodes are, in effect, a separate “blood stream” containing lymph fluid instead of blood.  A cancer which is present in the lymph nodes, has access to virtually every part of the body.  It can grow and prosper throughout the body. 

The surgeon scheduled another operation for a further endoscopic ultrasound for Wednesday 29 September.

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Margaret had a PET (Positron Emission Tomography) scan on Monday 27 September.  The $950.00 cost of this procedure was not covered by either Medicare or our private health insurer.  The imagery produced by a PET scan is extremely detailed.  Margaret’s PET scan was so detailed, it highlighted a “hot spot” on her arm where she had received a Covid vaccination one week earlier.  Here are some extracts from the PET scan report.

Lymph Nodes: A focus of intensive uptake FDG uptake, SUV max 5.6 is noted at the left para-aortic lymph node (level of L 2/3), suspicious of modal metastasis. Another focus of moderate grade FDG uptake SUV max 4.9 is noted at right pelvis, (see key image), raising suspicion of nodal metastasis. CONCLUSION: The intense focal activity anterior to the vena cava, at level of L 4, is suspicious of ampullary malignancy, given adjacent dilated common bile duct on low dose CT … Correlation with gastroscopy and/ or endoscopic ultrasound is suggested if clinically indicated.  Differential diagnosis includes a precaval lymph node at the level of L 4. 1          FDG avid nodal metastases in the left para-aortic region and possibly in right pelvis as outlined above. 2          The low grade focal activity in the liver, may be due to physiological variable liver uptake, although early liver metastasis not completely excluded.  No obvious liver lesion is seen on separate CT today … Follow up +/ - MRI is suggested if clinically indicated. 3          Foci of bowel uptake as outlined above.  Correlation with colonoscopy to exclude benign or malignant polyps before attributing them to physiological bowl uptake is suggested if clinically indicated.

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The website Radiology in Plain English says “FDG is a radioactive sugar that is used in PET imaging.  The idea is that FDG is taken up more in abnormal tissues then normal ones.  That is, abnormal tissues use glucose or sugar more than normal ones.  This is reflected in PET scans as more uptake and a hotter or brighter tissue on the scan.”

Margaret’s PET scan report confirmed a high uptake of FDG in her lymph nodes.  This was a clear indication that the cancer had spread to the lymph nodes. 

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We both tried to digest this terrible news.  The cancer had spread to Margaret’s lymph nodes.

This surely meant she was doomed and her death would probably happen before the end of 2021.

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Another operation took place on 29 September, just two days after the PET scan.  The aim of this operation was to enable the surgeon to “zap” the cancer with radiotherapy administered inside Margaret’s body through an endoscope. 

The surgeon was unable to administer any radiotherapy.

The findings of the 29 September operation were a little inconclusive, but they were not good. The written report from the surgeon said this.

 

Duodenal Papilla Major Papilla – due to previous radiation therapy, the ampulla was markedly deformed with ulceration.  The biliary and pancreatic duct orifices could not be identified. Whilst the CBD was successfully cannulated, the PD could not be entered despite the use of different cannuli and wires.  Given the risk of pancreatitis is high without PD stenting, RFA was not performed.  A sphincterotomy (5 mm) followed by balloon dilation of the distal CBD stricture was performed.  The CBD was markedly dilated (up to 30 mm).  The biliary duct was stented with 2 plastic stent[s] and this resulted in good contrast and bile drainage. CONCLUSION Ampullar cancer causing a tight stricture at the distal CBD.  PD not accessible and thus, cannot be stented.  No RFA due to high risk of pancreatitis. CBD = Common Bile Duct PD = Pancreatic Duct RFA = Radiofrequency Ablation; Cannulation = insertion of a stent

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The cancer had stayed in remission only until I had ceased being in danger of imminent death.  Once my life was safe, the cancer roared back into vigorous life.  It was determined to end Margaret’s life as quickly as possible

I do not have the words to describe how truly horrible this news was.