Coronovirus (Covid-19) and Palliative Chemotherapy

I have known a few people who are dealing with cancer for several years – they have been on treatment off and on for years. Amazingly, we have managed to keep disease under control. Some on cytotoxic chemotherapy, some on hormone blockade, some on immunotherapy, some on wait-and-watch and so on so forth.

The Coronovirus (Covid-19) has changed everything. We are worried about people who are immunosuppressed with steroids or chemotherapy. People who have had several lines of treatment and can still get some form of cytotoxic therapy are now being counselled about stopping chemotherapy. The benefit of 4th or 5th line of treatment is small, but the risk of immunosuppression is very high.

The risk of death higher.

Very difficult conversations. Most outpatient consultations now are either with the patient alone or with one relative/friend or via a teleconferencing platform. Really difficult conversations as hard as they are… and now with more restrictions – it is even harder. The heartache is felt by the patient, their families, friends, treating doctors and the nurses. The reception staff who have known these people for years are also struggling with the circumstances.

Terrible times. Most of us with overcome this. I feel sad for people who will not.

Toilet Paper and Cancer

The Coronovirus (Covid-19) pandemic is bringing out the best and worst in us as a society.

One of the problems is that some of us are buying huge quantities of items from supermarkets and hoarding them (or still selling them on the black markets for huge mark-up prices).

I recently had a patient who was diagnosed with breast cancer – which had spread to her brain. This was managed with steroids and radiotherapy to the brain lesions.

She was then started on tablets which block the hormones driving the breast cancer. The plan was to start her on a CDK4/6 modulating tablet along with the hormone blocker. I had planned to start her on Abemaciclib – which is the few medications which cross into the blood-brain barrier. The biggest problem being that these tablets can cause severe diarrhoea for the first few weeks.

The dilemma then being that this poor patient did not have enough supply of toilet paper – as they could not source it from any of the supermarkets.

We contacted the local supermarket and the manager was so helpful. He kept aside one box of toilet rolls for the patient. Also helped rebuild my faith in society.

She was then started on Letrozole and Abemaciclib. She is doing well as of now.

This was the first time the lack of toilet paper actually affected my decision making for patient care!!

Think about people around you. Care.

Younger patients with cancer

I have been working with people diagnosed with cancer over 2 decades now and I can safely say that the patient demographics have changed.

The patients I see in clinic or the ward have remained about the same, but they are getting younger. Even a few years ago, we would see a young woman in clinic and everyone would feel really sad for her. We now routinely see really young women in the clinic – there are a few patients now who are still in their 20s.

Something has changed. Something is making people get cancer earlier in life. Something is making people’s cell mutate and cause havoc with their lives.

Is it is the genetics? Is it the food we are eating? Is it our lifestyle? Is it the excessive radiation around us? Is our environment getting worse? Is the pollution driving the cancer?

I do not know the answer, but what I do know is that my patients are getting younger and younger. It is devastating to them, their families and their care-givers (including us as their medical care-givers).

We need to work harder to prevent cancer and if we do not succeed in preventing it, then treat it really well to cure them.

Cancer Voices – ASCO

The American Society of Clinical Oncology (ASCO) has the annual scientific conference every year in Chicago. This year too the meeting was held and I attended a session called ASCO Voices.

This featured a variety of personal narratives and perspectives to expand views of oncology, medicine, and the world — from big ideas to personal passions. These lightning talks offer a break from the science and an opportunity to reflect on personal stories and experiences.

The session was held in the Arie Crown Theater at McCormick Place in Chicago. Each ASCO Voices presentation is 5 – 7 minutes. No podium and no slides; just a story and a stage. Brilliant talks. Worth listening to the sessions.

ASCO Voices Talk

Monica Morrow, MD, FASCO
Surgery Is Never Elegant When Women Are in the Operating Room

Yehoda M. Martei, MD, MSCE
Whose Breast is it Anyway? Breast Cancer and Sexuality in Sub-Saharan Africa

Ashley Sumrall, MD, FACP
I Promised

Ishwaria Subbiah, MD MS
Doing Everything

Scott Capozza, MS, PT
The Obligation of the Cured

Cancer and Bucket Lists

What is a bucket list?

Defined as “a list of things a person wants to achieve or experience, as before reaching a certain age or dying”

I see a fair number of patients in the clinic – public and private. Most people, rightly so, want to start treatment and get on with things as soon as possible. One of my jobs is to help people understand the various treatment options available and the rationale of each option. This includes talking about the risk versus benefit, the toxicity of treatment and the improvement in survival.

All this sounds great on paper or when lecturing to students or junior doctors. In the real world, things can get very difficult.

Some people want absolutely everything done to prolong life, even if it means that they are miserable for the entire time. Other people want nothing done with regard to our treatment, as they pursue alternative therapies. Yet others, can’t decide what they want.

As the years go past, many of us learn the value of talking to people and understanding what they want. What are their wishes, their fears, their aims, their goals? What does the family want? What are the plans for vacations? Holidays? Time spent with loved one? Major events planned – weddings, waiting for a grandchild to be born, graduation ceremonies. The list goes on.

I am slowly learning the importance of listening to people. It means a lot to them. And (now) me.

Oncologist with Breast Cancer – The Guardian

Great article by Dr Victoria Lavin in The Guardian describing her struggle with breast cancer, while training in Oncology in the UK. She describes the people who truly made a difference during her treatment and the lessons she learnt. Amazing.

Guardian – Oncology doctor and cancer

Christmas time

Christmas time is amazing. People try to be nicer. Families get together. Time for a short break and reflection on life.

It gets harder for people who have been diagnosed with cancer and are on treatment. I try my best to give people a break over this time, time to get away from the hospital setting, time to be with family and friends, time to recover from side effects of treatment, time to relook at life.

There are several people who are admitted to hospital and unfortunately cannot be discharged home for a variety of reasons. The idea is to give them a break for a few hours to have Christmas lunch at home.

The saddest thing is when people are just diagnosed with cancer and need more investigations and reviews; and so many services or people are on leave. These patients and families are upset and frustrated. It does not really help them, when I explain that waiting for a few days will not make a huge difference in the bigger scheme of things. They want something done now. I can understand them.

What about people who know that this is their last Christmas on earth? It is important to tell people to enjoy their time with families and loved ones, not just for the patient, but also for the loved ones who will cherish the memories.

I continue to be amazed at the generosity of my patients – who will gift me and the team with cards, chocolates, gifts and so on. There are people who take the time to thank other members of the team (who are forgotten otherwise) – cleaners, support staff, pharmacy, reception staff, etc.

I love this time of the year. It brings a joy to most people. It also helps us understand that Jesus is the reason for the season.

Angry Patients

One of the most intimidating experiences is to be confronted by an angry patient and their family/friends. They might be upset about the long waiting time or the services or whatever. Many times it is the sheer frustration of the convoluted medical system, which really upsets the patient and the family. In the process of getting angry, the primary intention of sorting out the medical problem gets buried (to some extent).

I have found it quite effective to let the angry patient rant about everything. When they run out of steam, try and work through the problem.

There have been a couple of patients, who refuse to listen and only yell. It is not worth breaking your head with them. Ask them to leave, or leave the room yourself.

I have the right to work in a safe environment.

Death or Dying

I wonder what is worse – death or dying. I suspect most people are worried about the process of dying, with regard to pain or breathlessness; but there would be a fair number of people who are also worried about what would happen after they die. What would happen to them, their families, their friends, their assets, etc.

Difficult question. Personal. As always.

Oncology and Sympathy

Most people who realize that I work with people who have cancer patients, are quite sympathetic towards me. Their logic is that most patients would die with cancer. The problem is that most people never hear about the brighter side of oncology care. They rarely hear about patients who are cured and live long and fulfilling lives. They never hear about women and men, who go through chemotherapy and go on to have children and families.

Oncology is a good field. I can cure some. Give hope to others. Care for all of them.

What does the doctor feel?

I realize that most patients and their relatives are petrified by the first appointment with their cancer doctor. A fair number of times, they have not been clearly told about the diagnosis. Getting an appointment to meet a doctor at a Cancer Centre is so daunting. Most people stop hearing anything, once they hear the Cancer word.

Ever wonder what the doctor must be feeling at the start of this terrible conversation?