Why do good people have a bad outcome in Cancer?

I do not know Atul Chitnis.  I have not even heard of him earlier, till Sharat told me about his accomplishments in helping start-ups by open source software.

http://atulchitnis.net/

I read about a remarkable highly motivated and energetic person wanting to help others.   What really struck me on reading about him is that unfortunately he succumbed to colorectal cancer.  I read an update on his health in January 2013 and I started wondering on 2 issues:

  1. How can someone who is educated, well informed, well connected be

diagnosed  with Stage IV Cancer.

  1. The same issues which plague many of our patients like Chemotherapy toxicity and  expense, have affected Mr. Chitnis.

It is indeed a tragedy that good people like Atul Chitnis had a late diagnosis, a bad outcome and succumbed to the disease.

Let me put it in a proper perspective ‘How do you diagnose or how do you suspect colon cancer’?  I always ask  my patients are there any symptoms and how long did they have symptoms?  They invariably have at least 6-8 months of symptoms – like feeling lethargic and weight loss,which are really warning signals.  Then there can be dark stools, sometimes blood in stools and the bowel does not behave as it should.  The alteration of bowel habits would alert one to do a simple test for occult blood in stools.  If occult blood is present in the stools for 3 consecutive days, then colonoscopy is necessary and perhaps CT Scan too. Colonoscopy is quite simple and takes half a day. Its not painful at all. Here’s how its done.

Should all normal people undergo a colonoscopy, like in the West after the age of 50. (American cancer society guidelines attached). As a health policy on population based screening it would be an enormous load and not cost effective. Those who are conscious and want a clean chit every year can do so. But certainly those who have symptoms like the GI upsets that do not respond in a couple of weeks and have anaemia(low hemoglobin) for unexplained reasons should be on alert. Its difficult to lose weight. I know it to well.  Unexplained weight loss is an important pointer as the tumor starts drawing energy from whatever nutrition is consumed.  So let me say that the message is: ‘Please be on the look out for these early warning signals and seek medical advice early’.  Then perhaps we will be able to save more good people in our society.

Here is simple message for  your treating  doctor. Don’t’ assume that bleeding is due to ‘Piles”, a rectal examination and sigmoidocopy are a must for those who have symptoms. A visit in time will save many years of life.

My sympathies to Mr. Chitnis’ close and extended family and I do hope that the good work he started continues.

American Cancer Society guidelines for early detection of Colorectal cancer:

Beginning at age 50, both men and women should follow one of these testing schedules:

Tests that find polyps and cancer

  • Flexible sigmoidoscopy every 5 years  or
  • Colonoscopy every 10 years, or CT scan with contrast

Tests that primarily find cancer

  • Yearly fecal occult blood test (gFOBT)

Thank God I do not have to pay for my genes !

 

I was clearly worried last week as the issue of patenting of genes was to be debated the ‘supreme court of USA’.. Clearly it would be a nightmare that as soon as your child is born, you need to pay multiple companies who patented different genes.  Fortunately in their infinite wisdom, the US court has not allowed the patenting of BRCA1 and BRCA2 genes as they naturally occur in human genome discovered by scientists.

This of course raises a large query as to why  the petition to patent human genome, which is a result of millennia of evolution, can be even be considered for legal patenting.  There is also a caveat on some of the synthesized DNA genes that can be patented but one has to see the implication of the same. Let’s not discuss the jurisdiction of US Supreme Court on the gene pool of human race on planet earth.

Clearly science is now moving into more commercialization.  Earlier scientists primarily worked for the sheer joy of finding something exciting and new which was of potential benefit to the society.  Many times it involved sacrifice and only a few were recognized, sometimes after their life, by awards and prizes. Marie Curie who along with her husband has given us an insight into radioactivity, finally succumbed to the harmful activities of radiation which were unknown at that time.

Many of the brilliant scientists  do not have adequate financial returns. But then, somewhere it happened that patenting becomes more important  than publication of scientific results.  In fact, a new findings in science is patented first and published later. It is always not necessary for patenting to lead to commercial exploitation, but it does guarantee intellectual property which is much more important than commercialization. In medical science, financial reward is still not the primary motivation.

Sometimes commercial interest speeds up science.  Craig Venter, the geneticist, started a private funded institution  for unraveling the human genome.  It was a jolt and  many international academic institutions to come together to match  the speed of private enterprise and work on the human genome project and it is interesting that both completed around the same time. 

So coming back to genes in cancer,   one of the associations among the common cancers is colon cancer.  In fact, it was Henry Lynch who identified that some colon cancers are passed through generations, so called ‘Lynch Syndrome’.

There are certain characteristics in those families when it occurs in younger age and it occurs in 2 or more  individuals across 2 generations and if such a history is there we now have a reliable test called microsatellite instability by which the offspring can be detected to have the genetic abnormality in DNA  or not.  HNPCC ( Lynch syndrome) is basically due to a deficient mechanism of DNA repair  in these families.  Surprisingly because of the awareness of the inheritance these patients tend to get checked up more frequently and detected early and they need removal of nearly 80% of the colon to prevent multiple colon cancers from occurring. 

So for  a clinicians treating colon cancer :

If I see a young patient, I have to enquire about the family history and also check the MSI and if it is positive, would offer a subtotal cholectomy or removing 80% of the colon than removing just the affected colon.

 Strong genetic associations are also seen in some families with Eye tumors in children called retinoblastoma but these are rare.  So though the genetic abnormalities leading to cancer are rare, genetic testing would have a far larger implication and should not be patented as in current situation where larger interest of the society is more important than commercial benefit.

Exercise and cancer

Who needs Lance Armstrong when we have so many heroes ?

Exercise helps during cancer treatment

 

Last week I wrote about Suresh.  He was thrilled when he came to see me and said, “I always wanted to do the half-marathon before the disease hit me and now after the treatment I will run the half-marathon”.  He completed the half-marathon without a hitch and to me he is one of the real heroes! 

During his treatment, I found him reading Lance Armstrong’s book ‘Its not about the bike: my journey back to life”’.  Incidentally Lance Armstrong also had the similar disease.  I felt so terrible that Lance  let down so many people who looked up to him as a motivation during their fight against cancer.  I think that was definitely criminal.  Unfortunately  sports heroes letting down their fans is happening now. But patients feel so let down when their role model is a fraud.

Yuvraj had a similar problem and wrote about his success story. He is currently hero-worshipped by all.  Rightly so and he too read  the Armstrong’s book. There are many Heroes amongst us – just ordinary people with extraordinary courage.   Many  like Suresh who believe that they can kick the disease and continue to exercise and be physically fit. 

Let me tell you that physical fitness is one of the most important needs for effective treatment.  It is clear that a strong body can resist and fight the disease and also tolerate drugs that are necessary.  For all those who are on treatment or off treatment, do not forget to exercise.  That is your biggest single weapon against the big C. 

When do you start exercising?

If you are a fitness enthusiast like Suresh- DON’T stop. Keep exercise to at least 20-30 min of walk even during chemotherapy. Even aerobics with less intensity are fine. It relieves your stress and take your mind away from thinking about side effects.

What if you have not exercised regularly?

Its advisable to start walking at least 10 min three times a day. Yoga and meditation would help and I definitely encourage you to “keep fit”.

What about yoga?

It has been shown in many studies that yoga reduces the anxiety. Let me tell you that it is the anxiety about therapy that is worse than therapy. I have seen less literate patients take therapy without blinking.

I am attaching the NCCN guidelines for exercise during treatment, which are useful

Exercise, Exercise and Exercise and reduce your weight. This is particularly true for breast cancer where excessive fat can predispose. 

Exercise reduces the cancer risk.  More about it next time.

References:

exercise-during-cancer-treatment

http://www.nccn.com/component/content/article/61-symptoms/90-exercise-during-cancer-treatment.html

Family Support is essential for Cancer Treatment and that’s here, at home !!

Suresh, a fit, young Chartered Accountant, , was working out in a gym, when he suddenly had headache and noticed weakness of his hand.  He was then rushed to the hospital.   MRI Scan was done and he was shocked found to have a large mass in the brain.  Further Scan of chest and abdomen showed nodules in the lung and a mass in the abdomen.  In staging terms, it is Stage IV Cancer and as  anyone would assume, the family thought it is the end of the world, but there is always a silver lining in the cloud.  Suresh’s uncle and his wife rushed to me in the night completely shattered at this news.  On further tests he was found to have a ‘germ cell tumor’- the same diagnosis as Yuvaraj Singh.

It is indeed fortunate as this tumor melts away with modern chemotherapy.  They can also be detected by simple blood tests like Beta HCG and ALPHA Feto Protein. Suresh was positive and just said ”Doctor, just give me a chance to run Mumbai Marathon’.

His uncle said “We have no financial limitations and can we go abroad for Chemotherapy if you feel, if it is going to make any difference”.  I thought about it and said that Chemotherapy drugs are standard – they are same and the schedules are the same.  Our Medical Oncologists are very efficient, equal to anyone in the world but one big positive point for staying closer home is’ family support’ and the assistance you can get from so many members of the family and friends.

Manju, his wife, is phenomenal.  She took charge of the whole support system – her sister was asked to take charge of the young children. His uncle looked after the company interests and Manju devoted herself completely to taking care of Suresh, his diet, chemo cycles and of course providing the emotional support he needs.

Emotional support to me is the most important element of cancer care.  Suresh’s friends dropped in to cheer him up and he busily immersed himself in his work, reading and regular exercise.  His company was supportive and rallied behind him.

All were in smiles when Beta HCG started dropping, tumor melted away and at the end of the cycles, he had a lemon sized residual mass in the abdomen which I operated and took out with some difficulty, of course.  After that they wanted to go on a holiday to USA and also take an opinion.

I always recommend that one has to organise the work, the family, because treatment can be long, upto 6 months, with multiple admissions.  Certainly going abroad works out difficult and many times you are in an impersonal environment.  I can assure you that no doctor, other than Indian doctors, would respond 24×7 to their patients.

Suresh and his wife went to Dr Einhorn of Indiana university, a world authority on germ cell tumors who introduced the  Chemotherapy for germ cell tumors.  He was very happy with the care in India and planning of the overall treatment and in fact said  ‘perhaps many surgeons would not have removed the residual mass as it was technically challenging’.  They came back happy and satisfied they got the world’s best care and today Suresh is back to work, full of energy and activity and recently did Stanchart half marathon , a proud achievement for all.

Next week I will write about his passion for exercise and motivation and how exercise helps in treatment