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.

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Another love story and cancer, but genders reversed

 

This also is a true story.

Also about a young couple.

Five years ago Tanisha, a pretty young girl, around 22 , an airhostess in Indigo airlines, came to me. She had a recent diagnosis of cancer of the colon but otherwise in good health.

Her boyfriend who came with her was very anxious and said, “We want to do everything possible for her, she is so precious”.

I said, “Certainly, we will do whatever best we can for her ”.

They were engaged to get married. She underwent surgery and he was waiting outside.

“Everything okay doc?”

I said, “All went well, she has no metastasis, so she will do well. Histopathology showed lymphnode positive so she has to undergo chemotherapy”.

When I mentioned chemotherapy she was a bit low and said, “Will I have hair fall?”

“May be but these drugs may not produce hair fall and that will be temporary.”

He said, “Can she bear children?” I said, “My friend, at this point of time her life is important, not procreation. But , we can preserve her ova for child bearing in future.”

She accepted all this with a smile and started undergoing chemotherapy. He was there for 1-2 cycles. After that I did not find him and her sister used to accompany her.

Then I asked, “Where is your fiancé?”

She gave a sad smile and said, “He broke the engagement.”

“Why? I thought he was very committed to you.”

She said, “His family was not in favour.”

I said, “But he could have had the guts to stand by you.”

There was no answer.

She completed 12 cycles of chemotherapy and after a couple of years of follow up, used to come occasionally. When she came last, she was her bouncing self and said, “Doctor, you know, I am flying Emirates and am so happy that I am able to see the whole world. Whatever happens, happens for good. Now I know who are my real support and who love me dearly.”

I said, “Of course, adversity shows you, your true friends.”

“In prosperity, our friends know us; in adversity, we know our friends.” John Collins
ManjuV asked on twitter “what happens on reversal of genders”.

“This actually happened when a girl is the victim. Perhaps some men are selfish and will not hesitate to abandon a woman.”

 

 

Can ‘love’ defeat Cancer?

 

This is a true story.

A true story of a young boy and a girl.

Karan, a young man, around 25, was very happy that he got selected after passing through a highly competitive examination and  joined his MBA Course at IIM Kolkata.

Suddenly he noticed blood in stools. His happy world turned upside down !

He was shocked when he was diagnosed as Cancer of Rectum. Very unusual to happen at this young age, particularly when there was no family history. After evaluation we suggested that he undergo Chemotherapy and Radiation first, followed by surgery.

He was very brave. Accordingly he followed all instructions. He had chemotherapy and radiation and came back for evaluation 3 months later. The tumour had regressed significantly but, in his case, as it was very close to the anal verge I had suggested surgery with a ‘permanent colostomy’.     Permanent colostomy at such a young age is certainly not easily acceptable.

He used to come with his fiancée. Obviously there was also a factor of a long term relationship.

At one point of time they talked to me together saying “what about us getting married?’’. I said, “ See, at this point of time I would advise you against marriage because  you are still on treatment” and the matter was pushed to the background.

So he said he would rather take more chemotherapy and avoid surgery if possible. He went back to Kolkata but after a month came back saying that doctors in Kolkata have convinced him that chemotherapy is not a good option and he should undergo surgery. He was then prepared for having a permanent stoma. His fiancee was fine with him having a stoma. Anything to save his life!

The surgery was uneventful, he had a stoma, everything was going fine.

He was  later taking chemotherapy at Kolkata, coming and seeing me for followup.

His fiancee would always accompany him and had an anxious look at each followup. With the help of her and friends and he completed his MBA and came to me smiling saying that he has an MBA and also a job offer.

He asked me, “Can I do a job ?”.

I said, “Of course, you can do a job”. “I can certify and even put in a word for you”

I knew he wanted to plan a start up.  “What happens to your start up?”.

He said that at this point a job is better for him for stability.

However, unfortunately, this young man had a recurrence and he was put on further chemotherapy which was pretty toxic to him. I gave him a certificate that he could do a job but as bad luck would have it, his condition did not improve and he went on from 1st line of chemotherapy to 2nd line of chemotherapy with more toxicity.

All the while he and his fiancée were always together supporting each other and it was really touching to see a young lady, knowing fully well how the boy’s condition is shaping up, is willing to give him all the support and all the love that he needed.

They had researched all over and found that there was some kind of therapy  in the USA and were wanting to go there. So all the necessary formalities were done. They were all set to go  but they came and met me just a couple of days ago.

Yes, there was uncertainty and apprehension in his voice. But she as usual was very supportive.

She showed me proudly and said “ Two weeks ago we decided to get married and this is my mangalsutra”. I was completely astounded at this girl’s courage and love for someone who is probably has limited options, leave alone live normally.

Then she asked me, “Doctor, can love defeat cancer?”

I was dumbstruck as I really did not have any clear answer but I did not want to take away the last flicker of hope from them.

“Who knows? May be  love can control cancer and let’s hope for the best”.

God bless those who have such unconditional love and those willing to fight with all courage inspite of adversity.

Toilet ki ek aur katha- Personal hygiene and Prevention of Cervical cancer

I am so glad that ‘toilets’ are receiving the importance thanks to the movie ‘toilet ki ek prem katha’. Here ‘s the reason why toilets should be demanded by every lady !

Cervical Cancer incidence and mortality is decreasing steadily.

However most of the reduction happened in the developed countries as this graph shows.(GLOBOCAN)

All this happened even before HPV vaccine was introduced . Even pap smear screening was not total in some countries.

How did this happen?

Its clear that improved personal hygiene due to access to toilets with privacy was an important factor . Personal genital hygiene in both men and women can reduce cervical cancer.

Just compare with the countries with least number of toilets per capita ( WHO/UNICEF)

20150708_Toilets_FoGLOBOCAN_BSC_87648723

All  in the areas with high cervical cancer.

Of course there are other factors like unprotected sexual activity and HPV does spread due to poor habits. There was a nice study way back in 1999 from Kerala, in a survey based in Trivandrum centre,  that highlighted the correlation of cervical dysplasia to  lack of access to hygiene with toilets, sanitary napkins etc .

Expensive vaccines and even more expensive population screening are not suitable for large rural populations like India and Africa.

The fact however is that the rural and urban poor ARE AWARE of the ill effects of poor hygiene but have no access to clean toilets

That’s a preventable tragedy!

Its time for action !! It’s time this basic need is ensured in every household

Conflict of interest:

I know Akshay Kumar but was neither influenced or approached to write. The  thought developed for sometime in discussion with Dr Anita Borges.

Why are patients dissatisfied with medical care ?

 

Papers are full of news and headlines of the dissatisfaction of patients with health care. Why does this happen? I am not being judgemental on any one issue, but want to share a fundamental truth about modern medical care.

It is really worth listening to a TED talk by Kevin Jones .

We all assume that medicine is an “exact science”. Even science itself is not “exact and always true”. Some of the biggest principles of science like Newtonian physics had to give way ;to Einstein’s theory of relativity and then later on to quantum physics. So nothing is an absolute truth even in pure sciences like physics and medicine is far from perfect.

In actual practice, we treat based on some evidence. Most robust evidence is by a clinical trial or trying a therapy or a procedure ,which would be useful in a majority of patients. The important word here is “majority”. Typically a bell shaped curve in which the middle segment of majority would benefit from the treatment. But within the same population are those who are outliers and who are not part of the majority and this number can be as high as 30% or sometimes even more. So the benefit is limited only to those who are within the median.

So every medical treatment in some way, as the author says, is an experiment. It may be tough for any patient to accept that he is part of an experiment but it is a journey undertaken both by the doctor and the patient. So actually it is a contract, a contract between a doctor and the patient. The doctor explains the limitations of the treatment he is proposing and the patient also understands and accepts the limitations.

In our field of cancer surgery, almost every patient asks me “Can you guarantee me that the disease will never come back?”

Of course I can’t guarantee. Most of the time we don’t even know why it has happened for the first time. So one has to understand that while in a particular stage, like stage 1 or stage 2 there can be survival of 80-90% but still there is a 20% who will have an adverse outcome. As on today we may not be able to predict which patient is going to remain well and which patient will have problems. This is true of every single cancer treatment.

Now coming to other surgical procedures. Yes, surgical procedures do have their risks. There is no surgical procedure which can be done with zero risk. One has to balance what is the risk of the disease versus the risk of surgery. Modern surgery has a risk of 5% or less in most of the major procedures and it is a lot more safer than before of a lot more complex surgeries which includes not only major cancer surgery, cardiac surgery and transplants and even complicated bariatric surgery but none of the surgeries can be 100% risk free.

Many times the patient expects the answer that “no, there will be no risk and yes, he will be 100% free of the disease” . That is what he wants to hear. Even when the explanation is to the contrary he will go from pillar to post. Today I had a lady who had already seen three doctors, two of them advised that she will need a procedure with a stoma and one surgeon said he will not do a stoma. So obviously the patient is a bit confused.

We have to tell what is a realistic expectation. I think most of the time the patient partly understands it or does not want to understand.

In all the situations, there is obviously a huge gap between the expectation and the result.

One may say that after bariatric surgery, losing 300 kgs. is a remarkable achievement, but one may even argue but that does not solve the problem of other issues, like inability to walk, etc.

What is the real answer? The real answer is that every single treatment is a contract between a doctor and the patient and each of the parties should take a decision based on certain facts and will accept that there are likely to be deviations from the norm. They have to be accepted as part and parcel of the treatment.

Till then, adverse news in headlines will continue.

 

Why me?

 

Almost every day I am asked this question by my patients – “Why Me?”

“I have no habits, I do not drink or smoke, I am still young and need a full life.”

“Why Me?Why should I get this disease out of the blue.”

Well, I think there is no real answer and I keep searching for the answer for myself.

I regularly read Om Swami’s blogpost which are practical and pragmatic. Lot of people obviously ask the same question to spritual teachers also. Why me ? Why should I have misery in life or unhappiness or broken relationship.  He addressed this very well in his blogpost.

I think the most powerful quote of the blog is by Arthur Ashe. Arthur Ashe, the tennis legend and a gentleman, during coronary bypass surgery, had blood transfusion and unfortunately developed HIV because in those times the testing was not done. Finally when he was succumbing to the illness, he had  great strength and wisdom to take that calamity also in his stride.

Arthur Ashe :

“The world over – 50 million children start playing tennis, 5 million learn to play tennis, 500,000 learn professional tennis, 50,000 come to the circuit, 5000 reach the grand slam, 50 reach Wimbledon, 4 to semi final, 2 to the finals.

When I was holding the cup I never asked GOD ‘Why me?’.

And today in pain I should not be asking GOD ‘Why me?’ ”

It is so important for all of us to remember that when we are successful when we get awards, medals, good jobs and all the luck, we never questioned ‘Why me?’

We assume that yes, this is what we have earned, what we deserve as we worked hard and and some luck which also favours those who are brave.

But as soon as there is some calamity or something bad happens, you question ‘Why me?’

So there are no real answers to this, as ups and downs are perhaps part of life. Yes, you will have many many good days, good years in the run and suddenly something bad happens and that is how life is. Indian philosophy has a profound explanation- Karma. If it helps , then believe.

So stop questioning ‘Why me?’ Life is not always a bed of roses. There are thorns too.

Yes, it is a most difficult test of your life test and we HAVE to pass the tough examination.

 

 

 

 

 

 

 

Challenging the Conventions in Cancer

On World Cancer Day but I thought I will share a few ‘contrarian’ thoughts :

Facts :

  1. Cancer incidence is rising
  2. We are not making great headway in management of cancer so overall cancer mortality remains nearly static inspite of trillion dollar spend
  3. We have to discard the current conventions and adopt a different approach

On the basis of this, l challenge some conventional concepts to start thinking for alternate strategies.

1) Bigger surgery is NOT better. 

This is a concept which has been challenged, thanks to surgeons who were keen observers who collaborated with their pathology colleagues and came to the conclusion that removing large chunks of tissue around the tumour would not be necessary. This led to less mutilating surgery.  Classic example being breast surgery in which William Halsted, the pioneer, proposed the Radical Mastectomy with removal of muscles.  Even without the modern chemotherapy or radiation therapy came the modifications involving less

aggressive surgeries.  Yes, there was a time  ultra radical surgeries were done but soon surgeons realised that it is unnecessary mutilation and resorted to more organ preservation techniques.  The same thing also happened in rectal  cancer surgery, where without having a permanent bag or colostomy, normal on using basic common sense and good pathology normal passage could be restored.

2) Population screening is NOT necessary – mass screenings is not an answer for early diagnosis because there is no way a population based screening can be done in a country of 1.2 billion people and this will lead to a lot more false positive results and lead to a panic amongst people.  Then, is there any answer for this?  I would again urge a selective screening.  It doesn’t matter if a mammography detects a breast lump or a woman detects a breast lump after a little while at a 1 cm. or 1.5 cm. site.  It is not a late detection. Likewise many of the tumours can be detected early if only we are aware of our body.  That is the fundamental approach.  We should be aware of our body and any change to be noticed and medical attention sought.

Selective screening is the mantra

3) Randomized trials in drug treatment  are NOT way forward

     This is the biggest hurdle for progress and also it is the most expensive part.  Do you know that 90% of the randomized trials are neither   conclusive  nor have been completed particularly if you comparing Drug A with Drug B. It is a total waste of resources and giving a false hope to patient recruited.  Drug companies spend millions of dollars on trials and obviously the cost of drugs, get passed on to the hapless patients.

4) Targeted therapy is NOT a miracle 

      Targeted therapy in  limited instances has been helpful, rest of the time it has proven to be of marginal benefit and extremely expensive and also many times, toxic.  So, chasing these targeted agents is the biggest myth. the intelligence of a cancer cell is far superior that that of a drug company and it immediately changes into different pathways which no longer are inhibited by the expensive chemotherapy drugs.  So let us stop  this chasing these targeted agents and stop doing these trials which have marginal benefits.

5) Genetic testing for every cancer is NOT necessary

The full page ads on gene testing is marketing gimmick without a scientific basis. I have not come across a single patient benefited by so called personalised treatment as the number of active drugs same few whatever the profile may say. The long reports have no value in practice.

Now that brings us to the big question – Do we spend the money on advanced cancers with diminishing returns or early cancers.  Answer to this is obviously early cancers. 

So stop investing funds on chemotherapy and targeted therapy.  It is much better if we can only develop diagnostic techniques which are less invasive or non invasive which will detect cancers which are not symptomatic and that will be the biggest shift to bring us closer to reducing mortality in cancer. 

As long as there is civilization, cancer will exist.  The only thing we can do is reduce the deaths from cancer.