Women fight ‘Cancer’ with more strength

Today is the World Cancer Day

In the last four decades as a “Cancer Surgeon’,

I repeatedly saw the remarkable strength and resilience in many women in the fight against cancer.

In fact women are genetically stronger.The large X chromosome (XX) obviuosly holds more genetic punch that the puny Y ( XY)of men.

There is a purpose as they bear the burden of the maternal duties like child bearing, child rearing and with all that the modern women work harder and be competitive in jobs.

They are better prime ministers too.

Now for facing the challenge of “Cancer’.

I have seen some remarkable examples of physical and inner strength in dealing with Cancer. ( all names changed)

Sujatha had ovarian cancer stage 3. Ovarian cancer responds to chemotherapy well. But…

Chemotherapy has its distressing side effect of hair loss. For a lady, that is a social and physical trauma. But Sujatha persisted.

“I will WIN Dr J” she declared and went through the chemo with a smile and then surgery and again chemo. Total six cycles !

One would expect some depression to set in . But she was chirpy throughout.

Covid pandemic came and her physical visits became few till this year.

Suddenly, I see a smart lady, with glorious hair, bring a box ! “Is it Sujatha?? “

“Yes, How do you like my new look “.

“Fab ! I told you that hair will come back but you have done some magic !”

“I brought this present for you. These beauty products are all made my me using natural ingredients. Please ask your wife to try”

The products are amazing.

I felt so good and realised that attitude is every thing and women have the grit and mental strength to face odds.

I have seen it in Neeraja and feel humbled.

TEN surgeries and Chemo cycles — one would expect someone to lose heart

Not Neeraja

“Doc are you going to operate for the 5th time. “You are not tired of cutting me up ??”

“As long the tumour recurs and is localised, may be…….” ( e have limited options for sarcoma)

“When are you coming home and I will cook a great dinner with my own recipes?”

She cooks and blogs and tweets and is always smiling. Such is her moral strength.

We complain about small inconveniences. The traffic is bad, this is not done and so on.

But these ladies with their courage to face the adversity are the motivation for us to keep doing our work.

I pray for them !

Cancer patients are waiting ! and waiting !

Cancer patients are waiting !

Waiting for surgery ! Waiting for Radiation ! Waiting for their chemo drugs !

Today I connected with Bhagwandas, one of my patients from Jaipur whom we had sent for chemoradiation for rectal cancer. He was asked to wait as NO new patients are not being taken for treatment in hospitals. Its now over three weeks. He was worried about his disease. Will it spread? When will the treatment start?

As I do video consults with my patients from across the country, I can see a disturbing trend emerging. Cancer patients are waiting, waiting for long periods of time, for surgery, for radiation and chemotherapy is being changed to oral medication. Same is the story of another patient in Chattisgarh, another in Indore and yet another in Surat and I am sure this is the pattern across the country of patients waiting.

While initially I did reassure them that it is a matter of a couple of weeks, now it is going to be much longer.  We do not even know if it is going to go even beyond May 3^rd. They are exposed to 2 risks – one of disease progression and two of susceptibility to COVID. And third, most importantly, logistics and risk of travel which they are not able to do now.

I can imagine the problems of those have to undergo dialysis on a regular basis which may not be available close to them.  What is happening in the districts and beyond is something which we cannot even fathom.

We have to start dealing with this.  If we don’t then we are going to have more non COVID deaths than COVID itself.

Yes, with due precautions we will do surgeries.  Some of the radiation centres are already opening up.   If we lead by our own example then I am sure this effort will be multiplied across.

One   thing is certain.  If we close down centres just because a couple of patients or the doctors get detected, we will be doing huge disservice to these patients. We should be able to manage and run the centres with adequate sanitary measures and even rotating the staff and those who are positive can be quarantined for 14 days whilst others step in after testing.  There is no other way.  We cannot continue the lockdown for seriously ill patients.  Period.

Our patients and our hospitals come first !!

 

 

 

 

Cancer, Chemotherapy and COVID -19

Cancer patients, Chemotherapy and COVID -19

.  Mr. Yogesh underwent surgery for colon cancer about 6 weeks ago.  He had recovered fairly smoothly and was sent home well before the lockdown.  Now, after a week I had a video-call with him and the first question he asked me is “when do I have to start chemotherapy”?

He was anxious that his therapy should not be delayed.  However, he was looking a bit weak and had not gained weight.  So I had to advised him that he had to wait for a little more time to pick up weight and eat well and defer chemotherapy

Cancer patients are at a higher risk for contracting COVID 19 as cancer itself produces lower immunity.  In addition, many of the patients may  also be on chemotherapy.

So what would be the best option for these patients, particularly in solid tumours (colon, stomach etc)

The precautions of ‘social distancing’ are important and we have to make sure that these patients are given extra precautions particularly when the space itself becomes a constraint in families.  It goes without saying that they should never be exposed to   anything from outside or anyone who has even the mildest of symptoms.

What about chemotherapy?

Many of the patients are on cyclical chemotherapy, may be once in 3 weeks, in solid tumours.

Chemotherapy itself reduces blood counts and normally also they are susceptible to infections. The rational approach would be to shift them on to an oral chemotherapy so that the number of visits to the hospital are less and tide over this period. Many times we find that chemotherapy can be deferred. It is not an absolute time bound period though it is recommended that 6-8 weeks is the time to start chemotherapy after surgery.   This can be pushed to a couple of weeks to give more time for recovery

On the whole we need to balance the benefit of the chemotherapy with a possible risk of a patient making multiple trips and also getting immune-suppressed and also getting more susceptible to the current epidemic.  So it is better to error on the side caution the benefits of the adjuvant chemotherapy are not of that magnitude to risk infection.

So stay home and stay safe and comfortably wait for a couple of weeks or even more before you start your treatment.  Even if there is a gap in between cycles also, it is absolutely fine.

Cancer doesn’t spread in days, Corona does

 

A couple of weeks before the  lockdown, Parul, a 45 year old homemaker consulted me.  She and her husband went for a medical check-up.  She had no symptoms. She was shocked when Ultrasonologist found that she had a mass in her stomach.  Immediately she rushed to me.  It was a peculiar tumour arising from the stomach.  The most common such tumour is  GIST. I assured her that this normally responds to an oral tablet.

Then, as we were investigating, getting biopsies done, we crossed the Sunday Janata curfew followed by the lockdown.

Her histopathology report came while we were in lockdown .   She did not have GIST as I predicted but a different type of tumour. She needed surgery!

Obviously her big question was what would happen in these 3 weeks  under lockdown.

I had a video consultation with her. The conversation went like this:

“Doctor, You told me that I just have to take a tablet, but now recommending surgery ! “

“From day one I wanted surgery immediately as the tumour can keep growing right !”

( I have be honest and agree )

“ Parul, you are right, I did tell you. I was hoping that you would have a lesser option.”

“The pathology shows that it is a very slow growing tumour and has been detected without any symptoms.  Perhaps even if you had waited for the next 1-2 months also it would have not grown big and certainly will not spread”

It is very stressful for a patient diagnosed with cancer to be told to wait.  We all have this feeling that cancer cells multiply quickly and will spread.  This is certainly NOT true.  In fact, cancer cells multiply in weeks and sometimes in months.  This is a common cause for panic..

Can you guess how long a colon cancer will take to spread locally, leave alone spread to the other organs?   It is expected to take at least 4 months to involve ½ a circumference of the colon.  Most of the patients have symptoms for more than 6 months before they come to the doctor. In fact, most of the patients in busy centres wait a couple of months without any adverse impact.

Parul was not particularly convinced, so I offered that I can give her a declaration on a stamp paper that her tumour will not progress in these 3 weeks!

Finally she smiled and accepted.

I do have patients like Parul, who are scheduled for surgery immediately after the lockdown is lifted. Like them, I am waiting to operate and treat cancers.

Till then, I want to tell all not to worry that cancer will be spreading in three weeks.  Cancer cells certainly do not spread as fast as the corona virus which seems to be spreading exponentially at this point of time and poses huge threat to all of us.

Stay home and Stay healthy

 

Saga of a seventeen year old

 

What does a 17 year old normally do?

Hang out with friends, party and look forward to an enjoyable future.

Vishala, a 17 year old bright girl was doing just that, when she suddenly noticed that she had lost her appetite, not relishing her namkeens and snacks as she used to earlier. Slowly she found that her eyes have started turning yellow. Obviously this is a sign for worry and her parents got her investigated with the usual blood tests for jaundice thinking it is ‘hepatitis’. This was not hepatitis as ultrasound showed that the bile ducts were getting dilated (if there is jaundice, get sonography because it differentiates between hepatitis and obstructive jaundice). She was found to have obstructive jaundice and a series of investigations and imaging followed – CT Scan,MRI etc.

She was sent to Mumbai because she was found to have a tumour in the liver hilum a very delicate, complex area. As I tweeted earlier, we really had to plan carefully for this young girl. The team was determined to do our best for the girl and we spent nearly 7 weeks planning out the procedure and consulted a colleague from Japan. The procedure meant that we had to remove three-fourths of the liver from Vishala and the balance 25% would not be sufficient for carrying on the liver functions.

You may be surprised to know that 60% of normal liver can be removed and the liver regrows in just TWO weeks . Amazing !!

I had the privilege of knowing a Japanese surgeon,Prof Makuuchi, who first described a method of enhancing the volume of the liver which we applied in her case. We then proceeded to do the complex procedure which took almost 8 hours.

Things can go right or   horribly wrong especially in such complex surgeries. The family and the patient  had complete faith in us. We also said that we will do everything possible for getting her all right. Fortunately for us the recovery was relatively smooth and now you see that she is ready to go home.

I asked her what she wanted to do now and she said, “I want to learn dancing”, which is natural for a girl of her age. She with her doctor didis post a happy picture.

It is great to have a wonderful team and a faithful patient. Certainly in this case it makes us feel happy that we could save the life of this teenager. Wish and hope she has many years of bright life!

World Hepatitis day – Test.Treat.Hepatitis

Today is world Hepatitis Day . The theme is Test.Treat.Hepatitis.

325 million people are affected with Hepatitis B and C which is root cause for liver cancer leading to 1.3 million deaths every year. Hepatitis B can be prevented and C is treatable.

As with my blogs, I want to share a true story and this time the story is about myself.

I have been operating patients with Liver cancer and Hepatitis B for the past 3 decades. Like many others, I was under the false notion that I was immunized for Hepatitis B. Hepatitis B immunization is done on Day 1, Day 30 and after 6 months. I vaguely remembered that I was immunized on Day 1 and Day 30 but was not sure on the 6 months booster which unfortunately is the case with many of us.

One of my doctor colleagues was looking for a job in another Institution and fortunately that Institution insisted on Hepatitis B and C testing. To his utter shock and disbelief he was tested positive for Hepatitis C, which must have been contracted from a patient. Fortunately there are drugs for treating Hepatitis C and also new drugs that reduces the treatment to just 3 months. He was cured completely from Hepatitis C and could join the job.

Then I thought, why not get tested for Hepatitis B & C and to my utter disbelief found that I had NO antibodies for Hepatitis B. In other words, I was at high risk for contracting the disease. This was because of inadequate immunization. So I was operating patient with Hepatitis B taking due precautions but I could have contracted Hepatitis B and C. There is effective immunization for Hepatitis B. I immediately took immunization again and now have adequate antibody titre.

This certainly is relevant and I urge my medical colleagues and friends to get tested for B and C. We do not know when get exposed. Hepatitis is a silent disease which goes on for a long time and can lead to cirrhosis or fibrosis of liver and then later  liver cancer.. This can be easily prevented.

In the US, the CDC has given directive that those born in the 50s and 60s are not immunized for Hepatitis B, as the vaccines were not part of the universal immunization programme as per today’s guidelines.  This is also  true for us.

Yes, we have risk of getting exposed. Hepatitis B spreads with body fluids, could be in hospitals, dentists, tattooing or unsafe use of injections. All this can be prevented. India has only constituted committees ( WHO infographic). This is the time for action and not just forming committees. Apart from the guidelines, WHO makes it amply clear that we can eliminate Hepatitis by 2030 . My own example is more than enough for anyone to be tested immediately.

If you do not remember that you are immunized, you can get immunized for Hepatitis B. This is partly true of those families who have patients diagnosed with Hepatitis B. Hepatitis C has no vaccine at this point of time but has good treatment.

Elimination of hepatitis reduces risk of liver cancer and cirrhosis. Saves lives.

Here’s an appeal by Dr. Tredos Adhanom Chebreyesus, Director General of WHO that calls for immediate action.

“World Hepatitis Day is an opportunity to highlight one of the world’s most pressing public health issues. Globally, viral Hepatits B and C affect 325 million but only 1in 10 of those people have been tested and only one in 5 have received appropriate treatment. Viral Hepatitis slowly and silently degrades a person’s health leading to liver cancer and cirrhosis which results in 1.3 million deaths every year. The good news is that we have new medicines that can cure Hepatitis C in 3 months or less. WHO’s new recommendations call for treating everybody with Hepatitis C aged 12 years or older with these new drugs. That’s about 70 million people. While testing and treatment are key to eliminating Hepatitis, we also need strong focus on prevention. We have a clear vision for elimination and we have the tools to do but we must accelerate our goal of eliminating Hepatitis by 2030.”

 

Does Age matter?

I had written earlier on surgery for a 79 year old gentleman. Now a true story about an 85 year remarkable old  lady.

When I was coming to my clinic I saw an elderly lady in a wheel chair.

I thought to myself, whatever it is, I just have to counsel her that she would not be suitable for any major surgery and send her back home for some supportive care.

Her son is a Paediatrician in the US. He came in and I started saying, “How old is your mother? She is 85 and too old to undergo any surgery”.

Then he stopped me and said, “I also know that, but I just want you to talk to her once before making up your mind”.

I said, “Oh! Certainly, let me just talk to her”. So she came in and I said, “You see Maaji, you are 85 and surgery at your age would be problematic because of complications”. She had a colon cancer with obstruction.

She said, “I am Mrs. Dikshit,( she insisted that I use her real name). There are 15 doctors in our family. So I know what I am talking. Do you know that I never went to a hospital so far? I do not have any heart problem or any other issue and this is the first time I am getting surgery done. YOU ARE GOING TO OPERATE ON ME. I know that I will survive”.

I was amazed that this lady who is so certain about her outcome. I said, “ but…” and she cut me short and said, “ NO ‘BUT’, YOU ARE GOING TO OPERATE ON ME, IT IS FINAL, IT IS MY DECISION”.

I said, “Okay, things may go wrong”.

She said, “So what if things go wrong. I am 85 as you know and lived my life well. Even otherwise I am not going to have much of a chance, so I’d rather take a chance with your surgery”.

Reluctantly I said, “Okay, let me try”.

My team was looking at me as if to say ‘Don’t do this, you will operate and we are going to have a problem’. We carefully evaluated her and every single test was normal. There was no way we could refuse surgery and taking high risk consent we went ahead with surgery. Believe it or not, on the 8^th post-op day she literally walked home. When she came for suture removal she was walking and insisted that she will not come on a wheel chair.

I was so happy that I hugged her and said, “You are really remarkable, bless us that we would be like you at your age, so positive and so full of life”.

More and more senior citizens are getting operated. As we know, longevity is increasing and we see more and more elderly patients. We are extending our boundaries of surgery with better assessment and anesthesia. Earlier I used to feel 65 is the limit, then 70, then 75 and now it is nearly becoming 85 which is really pushing the boundaries.

But more than anything else, I think it is not just the chronological age but physiological age as to the other co-morbid conditions, how active was their life and whether they had multiple other problems. I think all these factors have to be taken into consideration while planning surgery for elderly. The mental attitude is important There are many articles on surgery in elderly. Elderly patients have same outcomes for cancer if they don’t have postoperative complications says Dr Preston “ Geriatric surgery is about the disease and not the age”.

The most fascinating story is of Dr. Michael deBakey, the pioneer heart surgeon of Baylor college, Houston who was the father figure of cardiac surgery. In December 2006, at the age of 97, he had chest pain and was diagnosed with Dissecting aneurysm of Aorta. He had treated 10000 such patients. But as with many patients of his age, he was in denial and then refused surgery. After a month the chest pain was unbearable and he nearly collapsed. His partner for 40 years Dr. Noon said, ”Either surgery or death, what will you choose”. His wife then intervened and consented for surgery. Anaesthetists were not willing to put such an elderly and important person to sleep for a complex cardiac surgery and were literally forced. The surgery went on for 7 hours and with exceptional care of HIS OWN team, Dr Debakey was discharged from the hospital. He himself could not believe that he survived the surgery. The whole story is interesting NY Times article

It will be great if all of us can age without co-morbid conditions. Yes, at some point of time there will be some illness but at least if you are fit by that time you are more likely to come out fine.

The engine has to be kept running in good condition and then you can cover long distances.

Life is beautiful but the ‘second chance’ should be a remarkable journey

 

Here is a true inspirational story.

Last week I operated on Nimi for the 3rd time. She insisted that I use her name as she is not worried or scared.   She had undergone 8 surgeries since 2009 in different places including MD Anderson centre earlier. Yes, her morale should have been down and she should have been depressed and dejected. On the contrary she is full of life and keeps joking about her “unwelcome friend’. She has recovered well and rearing to get on with her life in full speed. God bless.

I had a chat with her after a major surgery nearly 4 years ago when we removed a huge mass.

She recovered well from the surgery and said “Doc, you have given me a second chance”.

I said, “It is not me but God who has given you a second chance but this ‘second chance’ should be used to lead a wonderful life”.  That statement seems to have stuck with her because she not only got back with vigour to her career but also enjoyed many trips abroad living life to the fullest.

There are many such remarkable men and women who not only beat cancer but also enjoy their lives without brooding continuously.

Thre is no doubt that positive attitude helps tremendously to cope with cancer and as a matter of fact any adversity. Be it chemotherapy or radiotherapy, its all about the will power. Fortunately we have a great family support system.

But more than any thing “ when you defeat fear, you defeat cancer’.

When I see such people I really feel that none of us have any cause to complain about the bad roads, monsoons and all the so called problems we face in our daily life. The biggest lesson from these patients is ‘Big C can not only be conquered but can be defeated with resounding success’.

The ‘second chance’ should be looked upon as a blessing to lead a remarkable life.

Private bathing can beat cervical cancer

The other day some of us the senior cancer specialists were discussing about ‘prevention of cervical cancer’.

Cervical cancer incidence has decreased in most countries, including those who have not implemented pap smear screening.

What are the likely reasons?

Dr. Anita Borges came with the interesting thought.

“Do you know that most women in India don’t bathe in privacy”, she exclaimed. “Cervical cancer has a lot to do with personal hygiene. Fix that and the incidence will come down.”

A very valid thought coming from a leading pathologist with decades of experience.

It is very unfortunate that women and men in India do not have the privacy of taking a completely bath without clothes as most places are public bathing spaces.

This certainly leads to poor genital hygiene and HPV viral infections which ultimately lead to cervical cancer.

So one of the easy ways to decrease this is by creating private bathing spaces. Swachh Bharat Abhiyan is a great campaign towards constructing toilets. It will be even beneficial to add a private bathing facility which can be a small room with a tap. This can reduce the incidence not only of cervical cancer but many other infections.

This cost effective solution is a lot easier to implement than mass screening/mass vaccination. So it is an appeal to the Swachh Bharat Abhiyan to add bathing spaces in addition to just toilets for the population which can be done with hardly any additional cost.

It is also interesting that Akshay Kumar is following up his film ‘Toilet ki ek premkatha ’ with another social awareness film ‘Padman’ based on Arunachalam Muruganantham’s story.

Influence by Tina must by the inspiration  for taking up these movies.

Hats off Akshay and Tina for creating awareness of a problem, we try to hide ‘ literally under the clothes’.

 

Age does NOT matter

The other day while I was scrubbed in OR, my team said, “Do you know Sir, we are operating on a 79 year old gentleman tomorrow for Whipple’s”. The tone in their voice alerted me saying that I need to be cautious.

As we all know that with age the reparative process can be slowed down and there can be other problems like heart, lung, etc.

So I said, “Ok, before we proceed let me go and see him and talk to him”.

I went and saw him and said, “Look here, this procedure carries a risk of 10% of mortality. You have to be in the hospital for longer time, you can also have an infection, etc. etc.”

He just smiled and said, “At this age I am prepared for anything. I leave it to God and you can proceed. I am not worried about the risk.”

I said, “ OK, now how about your fitness? Why don’t you just walk with me.” He came out of the bed. I started walking briskly in the corridor. I was surprised that he practically matched me in pace and steps.

I then asked him, “how do you spend your morning or how does your day start.”

He said,” Oh, I go for a swim for 1 hour.”

I said, “Swim for 1 hour at the age of 79?”

He said “ Yes I have been swimming from my childhood, so I do about 100 ft. In the pool.” I said, “this is wonderful and then ?”.

He said, “then in the evening I take a walk around Shivaji park, a 2 km. walk minimum, atleast a couple of rounds.” Then I said to myself “wow”. At the age of 79 he is definitely fitter than me and many others who have lived the life of a couch potato. I had no hesitation therefore, in taking him up and hopefully God willing he will have a good outcome and sail through.

This has also been proven in many studies world over that chronological age by itself is not the only criteria. What is important therefore, is physical fitness. I feel sad that I have already missed the boat of being fit right from the age of 30 or 40.

If you are young do start a fitness regime because that is something that is going to help you if and when you feel sick, God forbid.