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.

Common questions you might have about chemo but were too scared to ask

There is a nice article in the ABC site explaining in simple terms the effects of chemotherapy on the patient.

Cytotoxic chemotherapy has been the mainstay of systemic anti-cancer treatment for a few decades now. Things are slowly changing in a few cancer types. The future will be radically different, as we start to understand as to who exactly needs to treatment and with what.

Common questions you might have about chemo but were too scared to ask

Are all cancer gene mutations harmful?

We test for various genes in the setting of cancer or to assess the cancer risk for siblings or future generations.

The problem is that not all genes are the same. Also the mutation might be somatic (one off defect) or germline (familial). Harder to know the difference without checking for specific parameters.

The ABC has a nice article about this topic.

Gene Mutations

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 our Microbiome

People who are diagnosed with cancer have a relatively delicate immune balance. We are not truly sure about the factors involved in the immunological cascade.

People take lots of medicines, supplements and more to enhance their immune system. This has become a multi-billion dollar business. Unfortunately, most of these have low or no benefit.

One of the exciting and intriguing things which is emerging is the role of the gut in the immune system. What we eat and what our guts produce are becoming increasingly important from an immune perspective.

Probiotics are a bad idea for patients on immunotherapy. The logic being that immune systems are created on the normal gut flora – which is amazingly diverse. Taking probiotics spoils the equilibrium in the gut. Not a good idea.

Antibiotics have the similar problem. They kill the normal gut bugs and change the dynamics of the intestinal flora. Do not take antibiotics for things like viral infections or suspected infections.

It is so humbling to know that everytime we think we have found a new and wonderful door of understanding…. it just opens another maze to tackle.

Doctors and Nurses are good people

Doctors and Nurses are generally good people. They are usually taken for granted by the hospital administrators and executive.

This article in the New York Times is excellent. Great piece.

https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html#click=https://t.co/7Jl8rL9Kbi

Lung Cancer in non-smokers

Lung cancer is predominantly an illness seen in smokers or former smokers. There is an increasing number of patients with lung cancer, who have never smoked. Ever.

The huge stigma of lung cancer remains in this present day and age. People still say in hushed accusatory tones… “he was a smoker”, “she really should have stopped smoking”, etc.

The main issue being that we cannot change the past, but can fix the present and modify the future. Stop smoking. Believe in yourself. Focus on treatment. Get on with life.

Lung Cancer in Non-Smokers

 

Cancer Care in Australia

Cancer care in Australia is just fantastic. Truly is.

The USA has cutting edge technology and a plethora of Phase 1 clinical trials and research work, but for the average person who needs treatment, Australia is still miles ahead. It is not just the issue of the medications available, surgery options, radiotherapy…. but the social and financial issues.

The South Australian Govt helps patients who drive more than 100 km per journey with financial assistance for their fuel and accomodation.

Most chemotherapy, biological and immunotherapy medications are available in Australia – via tax-payer Medicare subsidy or access programs.

The problem is that many people do not appreciate the medical care in Australia. The care from doctors, nurses, reception staff, pharmacists, cleaners, medical records and the rest of the team in the health care sector – is mostly really good. We tend to highlight the few bad stories (hopefully the incidents will be prevented in the future), but may not emphasise the good work which people do.

I have patients who are on treatment in Adelaide and decide to go on a holiday across the country. We arrange for treatment to happen across cancer centres in various parts in Australia. It happens somehow. Pretty amazing.

God bless Australia.

Chemotherapy related diarrhoea and an App!!

One of the possible side-effects of intravenous and tablet based chemotherapy or targeted therapies is diarrhoea. We encourage patients to use Loperamide tablets (Gastro-Stop) to treat and prevent diarrhoea. It works most times, but not always.

Diarrhoea is a adverse effect, which is not managed as well as we should. We have taken huge strides in the areas of vomiting and to some extent nausea, but diarrhoea has still not been tackled well enough.

Some of my patients, who are on chemotherapy, and struggle with diarrhoea (not just the loose bowel motions, but the urgency and uncertainty of the bowel motions) – are scared to go out to public places. Like some of the them tell me – “when you go to go, you got to go now”.

I hunted for possible solutions and came across a free App called Flush – Flush app

This has a database of toilet across the city and country towns. I am really not sure how they manage the database and if there is a way to update it in real time, but it surely has helped give some confidence to several of my patients.

Seems like a silly problem?! Ask the person who is struggling with the issue.

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.

Media and Patient hopes

Each week in clinic, patients and their family members will bring me cut-outs from newspapers or magazines or video recorded clips from a TV article – mentioning about the latest and greatest cure for cancer. They bring the article will such hope and expectation. Rightly so.

The problem is that 90% of the times, I have to break their hopes by telling them that most of these reports are experiments are done in a laboratory test-tube or an early phase clinical trial. The chances of most of these drugs reaching a clinic is low or even if they do arrive, it would be at least 4 – 5 years. Most of the patients who need that medication now, will never get to use it.

I understand that journalists have to publish interesting articles, but I really do hope that they would clearly state that this is experimental medication and might take several years to get to the clinic or something like that. Seems like a trivial issue, but it is a pretty big deal for patients and their family members who are struggling for anything new.

The hope lives on.

Quora and Cancer

I ventured onto a website called Quora. Fascinating site. People ask questions about pretty much any topic in the world. There are people who try and answer the query. Over the past year or two, I started answering cancer related questions. It has been a fascinating journey. At times, it worries me about giving answers to people I have no idea about, their circumstances, their medical background, what their doctor has said to them, etc…. but over time I have learnt to be generic but specific.

It does not seem to be a second opinion, but a generic opinion. There are several doctors on the forum trying to help people from across the world.

The site is nice and simple. Most people can navigate it without too many problems.

My Quora link

The Trainee Doctor who took all the blame!!

A great indepth article in the BBC about Dr Hadiza Bawa-Garba, who was smashed with work load, responsibility, lack of support and then hung to dry. It worries many of us working in hospitals, because this could happen to any of us. Any time. The result could be the same.

The trainee doctor who took all the blame!!

Learn to protect yourself. Learn to protect your colleagues and friends. Work together. Work safe.

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

Royal Flying Doctor Service Donation

I remember watching a TV show about “The Royal Flying Doctors” and used to wonder about the amazing service they provided to people in remote areas in Australia. I wondered why people liked living so far away from cities and crowds. As time gets by, as maturity helps… I learn to appreciate the distance from things. More importantly, people live on farms and cattle stations. They provide the food we eat daily. We need to learn to thank them.

If and when the farmers get unwell, we must support them. The Royal Flying Doctor service is an institution in itself and have grown to help thousands of people in their dire times.

Geoffrey Carrick owned a cattle station in the far-north Queensland outback. His 138-square kilometre property was sold for $9.85 million and the money was donated to the Royal Flying Doctors Service and the Children’s Hospital Foundation. Thank you Sir and your family.

The full article from the ABC – Royal Flying Doctors – Donation

Patient Guide for Cervical Cancer

This is taken from the ESMO website.

ESMO link

ESMO presents a new ESMO Patient Guide in Cervical Cancer. It is part of our Patient Guide Series, based on the ESMO Clinical Practice Guidelines.

This new ESMO Patient Guide in Cervical Cancer offers essential new information compared to the previous edition:

ESMO Patient Guide on Cervical Cancer Cover
  • Information on HPV vaccination and the HPV DNA test
  • Information on the increasing use of CT, MRI and PET in disease staging
  • A section dedicated to the involvement of patients in decision making
  • A section focusing on the treatment of cervical intraepithelial neoplasia (CIN)
  • Treatment algorithms (adapted to be accessible to patients) for each disease stage
  • A section on fertility preservation
  • A section on cervical cancer and pregnancy
  • Information on new drugs (bevacizumab, pembrolizumab)
  • A section on supplementary interventions – supportive, palliative, survivorship and end-of-life care
  • Information on clinical trials, including immune checkpoint inhibitors
  • Tables covering the important side effects of all systemic treatments
  • A new section on the importance of exercise
  • A new section dedicated to the long-term effects of treatment

The previous edition of this guide was translated into 10 languages through the kind support of national medical associations and patient advocacy organisations.

Translated versions will make it possible for even more patients to benefit from the updated and reliable information in this new guide.

We welcome support for the translation and dissemination of this new and updated version. To express interest in providing a translation, please contact us.

This guide has been developed and reviewed by:

Representatives of the European Society for Medical Oncology (ESMO):
Nicoletta Colombo; Claire Bramley; Francesca Longo; Jean-Yves Douillard; and Svetlana Jezdic.

Representatives of the European Oncology Nursing Society (EONS):
Anita Margulies; Lise Bjerrum Thisted

Patient advocate:
Maria Holtet Rüsz

Immunotherapy: Nobel Prize 2018

This text is taken from the ESMO (European Society of Medical Oncology) website.

ESMO Link

On 1 October 2018, the Nobel Assembly at Karolinska Institutet has decided to award the 2018 Nobel Prize in Physiology or Medicine jointly to James P. Allison and Tasuku Honjo

“for their discovery of cancer therapy by inhibition of negative immune regulation”. By stimulating the inherent ability of immune system to attack tumour cells this year’s Nobel Laureates have established an entirely new principle for cancer therapy. For more than 100 years scientists attempted to engage the immune system in the fight against cancer. Until the seminal discoveries by the two laureates, progress into clinical development was modest. Immune checkpoint therapy has now revolutionized cancer treatment and has fundamentally changed the way we view how cancer can be managed.

A number of therapeutic approaches are available for cancer treatment, including surgery, radiation, and other strategies, some of which have been awarded previous Nobel Prizes. These include methods for hormone treatment for prostate cancer (Huggins, 1966), chemotherapy (Elion and Hitchins, 1988), and bone marrow transplantation for leukaemia (Thomas 1990). However, advanced cancer remains immensely difficult to treat, and novel therapeutic strategies are desperately needed.

In the late 19th century and beginning of the 20th century the concept emerged that activation of the immune system might be a strategy for attacking tumour cells. Attempts were made to infect patients with bacteria to activate the defense. These efforts only had modest effects, but a variant of this strategy is used today in the treatment of bladder cancer. Many scientists engaged in intense basic research and uncovered fundamental mechanisms regulating immunity and also showed how the immune system can recognise cancer cells. Despite remarkable scientific progress, attempts to develop generalizable new strategies against cancer proved difficult.

The fundamental property of our immune system is the ability to discriminate “self” from “non-self” so that invading bacteria, viruses and other dangers can be attacked and eliminated. T cells are key players in this defense. T cells were shown to have receptors that bind to structures recognised as non-self and such interactions trigger the immune system to engage in defense. But additional proteins acting as T-cell accelerators are also required to trigger a full-blown immune response. Many scientists contributed to this important basic research and identified other proteins that function as brakes on the T cells, inhibiting immune activation. This intricate balance between accelerators and brakes is essential for tight control. It ensures that the immune system is sufficiently engaged in attack against foreign microorganisms while avoiding the excessive activation that can lead to autoimmune destruction of healthy cells and tissues.

During the 1990s, in his laboratory at the University of California, Berkeley, James P. Allison studied the T-cell protein CTLA-4. He was one of several scientists who had made the observation that CTLA-4 functions as a brake on T cells. Other research teams exploited the mechanism as a target in the treatment of autoimmune disease. Allison, however, had an entirely different idea. He had already developed an antibody that could bind to CTLA-4 and block its function. He now set out to investigate if CTLA-4 blockade could disengage the T-cell brake and unleash the immune system to attack cancer cells. Allison and co-workers performed a first experiment at the end of 1994, and in their excitement it was immediately repeated over the Christmas break. The results were spectacular. Mice with cancer had been cured by treatment with the antibodies that inhibit the brake and unlock antitumor T-cell activity. Despite little interest from the pharmaceutical industry, Allison continued his intense efforts to develop the strategy into a therapy for humans. Promising results soon emerged from several groups, and in 2010 an important clinical study showed striking effects in patients with advanced melanoma. In several patients signs of remaining cancer disappeared. Such remarkable results had never been seen before in this patient group.

In 1992, a few years before Allison’s discovery, Tasuku Honjo discovered PD-1, another protein expressed on the surface of T-cells. Determined to unravel its role, he meticulously explored its function in a series of elegant experiments performed over many years in his laboratory at Kyoto University. The results showed that PD-1, similar to CTLA-4, functions as a T-cell brake, but operates by a different mechanism. In animal experiments, PD-1 blockade was also shown to be a promising strategy in the fight against cancer, as demonstrated by Honjo and other groups. This paved the way for utilizing PD-1 as a target in the treatment of patients. Clinical development ensued, and in 2012 a key study demonstrated clear efficacy in the treatment of patients with different types of cancer. Results were dramatic, leading to long-term remission and possible cure in several patients with metastatic cancer.

After the initial studies showing the effects of CTLA-4 and PD-1 blockade, the clinical development has been dramatic. We now know that the immune checkpoint therapy has fundamentally changed the outcome for certain groups of patients with advanced cancer.

Similar to other cancer therapies, adverse side effects are seen, which can be serious and even life threatening. They are caused by an overactive immune response leading to autoimmune reactions, but are usually manageable. Intense continuing research is focused on elucidating mechanisms of action, with the aim of improving therapies and reducing side effects.

Of the two treatment strategies, checkpoint therapy against PD-1 has proven more effective and positive results are being observed in several types of cancer, including lung cancer, renal cancer, lymphoma and melanoma. New clinical studies indicate that combination therapy, targeting both CTLA-4 and PD-1, can be even more effective, as demonstrated in patients with melanoma. Thus, Allison and Honjo have inspired efforts to combine different strategies to release the brakes on the immune system with the aim of eliminating tumour cells even more efficiently.

A large number of checkpoint therapy trials are currently underway against most types of cancer, and new checkpoint proteins are being tested as targets.

The Nobel Assembly, consisting of 50 professors at Karolinska Institutet, awards the Nobel Prize in Physiology or Medicine. Its Nobel Committee evaluates the nominations. Since 1901 the Nobel Prize has been awarded to scientists who have made the most important discoveries for the benefit of humankind.

Reference

The Nobel Prize in Physiology or Medicine 2018. NobelPrize.org. Nobel Media AB 2018. Tue. 2 Oct 2018.

Channel 10 Australia News and Immunotherapy

The Channel 10 news program telecast information from the primary kidney cancer study that we had participated in. The results had shown that in the intermediate or poor risk kidney cancer patients, combination therapy with Ipilimumab and Nivolumab was much better that the standard of care tablets. Immunotherapy was better than just simple targeted therapies.

It focused on a story of a gentleman who was diagnosed with kidney cancer a few years ago and was then started on the combination immunotherapy (as part of a clinical trial). He did exceedingly well on the study and has no measurable cancer (on CT scans). He is doing well and is back to his normal routine of life.

Brilliant stuff.

Channel 10 Adelaide News

Handwriting and Alphabets for Doctors

Several doctors write very poorly with regard to their handwriting. Some doctors who have a good handwriting seem to have missed their illegible handwriting course!!

I received this picture from a friend and am not sure about the origin of the picture (thus cannot acknowledge the author). Says it all.

 

ps: I create a bit of a stir in clinic with patients and their families, as they watch me write quite legibly with a real fountain ink pen!

Working, Overtime and Medicine

How do most doctors deal with working overtime? I am really not sure. Most of us… just work. I am learning that I need to protect myself and stick to time schedules.

Many of us, from the time of internship or residency are only taught to work and work harder. Not just work smarter, but harder. Many of us don’t really know any other way.

Work never gets over. Ever.

We need to do as much as possible and get out of the workplace to come back the next day to do the remaining.

I am slowly learning that it is vital to take time for yourself and your family/friends. Absolutely vital.

At the end of the day, the only thing that really matter is you and your family. The time spent with your wife/husband or children or people who really matter.

Hard lesson. Unfortunately, most of us learn it too late in our careers.

Protect yourself. Enjoy life.

Nobel Prize and Immunotherapy

This is taken from Ars Technica:

The Nobel Prize Committee has honored two researchers for their role in pioneering a new avenue for cancer treatment, one where the therapy targets the immune system, which then goes on to attack the cancer. The researchers, James Allison of the MD Anderson Cancer Center and Tasuku Honjo of Kyoto University, worked separately to identify and target proteins that help keep the immune system from attacking other cells in the body. When these proteins are inhibited, the immune system can target cancers, although at the risk of autoimmune disorders.

Immunotherapy discoverers get Nobel Prize in Medicine

Pulmonary Embolism and Cancer: PE

One of the big problems with cancer is clots in the blood vessels of the lungs. It is a significant cause of death in cancer patients. Most people do not really know or understand the condition.

Cancer is a condition which makes blood stickier. If you combine this with the fact that the patient is not very mobile, not drinking enough of fluid, is on chemotherapy via intravenous access device, is on medications which could affect blood clotting… it is a fairly strong combination for clot formation.

People can develop clots in their legs, which then break off and shower small clots in the blood vessels of the lungs. A large blood clot in the lung vessels can potentially kill the patient.

The treatment is making the blood thinner with medications – heparin, heparin like drugs (Clexane, Fragmin), Apixaban or warfarin.

The important issue being awareness of the condition. Sudden shortness of breath, cough, sharp chest pain, etc are some of the main symptoms.