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. 

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Fearless Crusaders

 

Last Friday was a great day.

In fact I can name it  as the  ‘Survivors’ Day’.

Nearly 10 patients who are long time survivors of 5-20 years came for review on the same day, by random coincidence. It certainly makes one feel happy to see them leading normal lives without any fear

I was particularly happy when Suhasini, a young lady came in with a broad smile. I was very glad to know that she was operated 6 years ago for Colon cancer.

She asked me, “Doctor, can I start my family now”?

I was thrilled as I know that she was single when she got operated.

I said, “Certainly, I would like to meet   the wonderful young man who accepted and married you”. She said he is on the way. “We were courting before I was diagnosed but he never left my side and continued to be my support. After 5 years he convinced his parents and even my parents that he will be with me forever”. As she was saying this her husband walked in. I am genuinely proud of this young man. There are so many instances where engagements are broken after diagnosis not just in a young person but even in their parents. In a society with so many unfound fears and superstitions, this couple stood like a shining beacon. I assured them that everything is fine and they can have a wonderful family.

I do have many instances of such remarkable couples who not only fought the disease but went on to lead their lives with full vigour.

Hats off to such fearless crusaders.

Focus on each mile stone and you will reach the destination

 

Last week I operated on a complex Pancreatic Cancer. After completing the 6 hour surgery I was very happy that everything went well and the surgery was successful. I came out of the theatre and called the family and said that the surgery is successful, the whole tumour has been removed with all the lymphnodes etc. Instead of being happy, one of the relatives kept asking me about the recurrence. I was a bit frustated. I do understand the reason for anxiety but the patient was not even out of recovery room.

You have to realize that cancer treatment is not like a cough and cold with about 4-5 days of antibiotics. It is long drawn and involves different types of therapy. It is important to remember that this is a journey and our destination is potential cure. The journey has many milestones exactly like your own journey on a road. When we travel we only look at the milestones, perhaps we cannot even see a milestone which is more than ½ km away. But each milestone, once you cross, takes you closer to your destination and that is exactly how we need to approach the treatment of cancer.

First , during surgery there should not be any unpleasant surprises, the disease should be localized so that the surgeon can do a good surgery. So, successful surgery is the first milestone.

Second the patient goes to the intensive care unit for a day or two, so the second milestone is a shift from intensive care to the regular ward which means that all the systems are functioning normally.

Then the third milestone is discharge from the hospital. The surgeon does a lot of plumbing and joining the intestines and tubes and ducts together. Everything takes time to heal and once it heals the patient would resume on a diet and is discharged so that is an important milestone – Discharge from the hospital.

Then comes the pathological reports which are important for staging of the disease, also gives an information on how the further treatment has to be managed. This is when you can have a detailed discussion on the options of treatment, the usual fear about chemotherapy is unfounded. If necessary ‘Yes’ chemotherapy would be needed for preventing or lessening chances of recurrence. Chemotherapy might involve a little longer treatment on a periodic basis, so one should approach this positively. I had written earlier and will write again as to how you can handle chemotherapy if necessary.

Then comes the follow up of periodic examinations and tests. Generally if a period of 2 years is crossed most of the chances for recurrence come down but in some of the tumours recurrence can be as late as 5 years or even longer. But this is all part of the journey.

Yes it is tough. But anyone who embarks on this journey with a positive attitude, willing fight to reach the destination, has a lot more chance of making it to the destination i.e. complete eradication of the disease.

Remember , “Focus on each milestone and then you will reach the destination.”

We need a ‘moonshot’ for Cancer

Recently Joe Biden made an emotional appeal for ‘Moonshot’ (the famous declaration by JFK that America should put a man on the moon) for Cancer. President Obama endorsed this by asking for 1 billion dollars to fund cancer research.

JFK, in his Rice stadium speech, did not talk about small things but instead spoke about big dreams. He said “We will put man on the moon in this century”. This obviously led to the creation of the US space program; a focused endeavor laced with excitement and supported by funding.

Yes, Cancer certainly needs a ‘moonshot’ at this time. It was Nixon who provided an impetus for cancer research by declaring “War on Cancer” in 1971. With 100 million dollars in funding, the National Cancer Institute was established. It is nearly 45 years since that dramatic announcement.

Where are we now?

As I look back on the last 30 years of cancer, I reminisce my journey in the medical field of cancer. I joined as a young passionate and enthusiastic surgical resident in 1982. 34 years later, Cancer is still an unsolved and serious problem affecting humankind and we really need to find solutions. In the last 30 years, there have been series of excitements and disappointments on the management of cancer.   I, in my own capacity, fine-tuned my surgical skills, to be able to perform complex surgeries with ease and safety. However there seems to be a sense of despondency among the community and the people: “Why, after billions of dollars of research funding, are we unable to find a cure for cancer?”

I recollect that there were 3 waves of hope showing a lot of promise but soon after faded out. One was a wave of ‘simple blood tests’ called ‘tumor markers’. The promise was that a simple blood test would be sufficient to detect the cancer. But it was soon found that there were too many false positives and today it’s no longer advisable to use for detection.

Second came the wave of chemotherapy. While chemotherapy did have dramatic success in Blood Cancers, the same was not seen in solid Tumors. The responses were limited and partial. There were also significant amounts of side effects and toxicities. Many patients would say that they would rather undergo surgery than chemotherapy.

The third and current wave is targeted therapy using certain monoclonal antibodies, which is supposed to attack cancer specific targets. While there is a lot of excitement, the clinical effectiveness remains a matter of investigation and the treatment is far from affordable.

So where do we see cancer solutions?

As Joe Biden has said, all the research work is going on in silos with very little sharing of information. Scientists are basically suspicious and I feel that the following would be possible solutions for cancer treatment:

  • We need a completely radical, out-of-the box mindset. The current therapies of chemotherapy and targeted therapies at best give a few weeks to a month’s response. Not only do we need doctors and scientists, we need the whole army of physicists, chemists, mathematical modelers and computer scientists on board.

 

  • An open source Cancer research consortium: Imagine that by a universal health mandate that there is an open source research consortium funded internationally wherein all the information from all the different labs in the world is pooled. This is the kind of effort that eventually led to unraveling the genome through the human genome project. Why can’t a multinational effort of such magnitude and scale evolve to put together the information for the best minds to act upon?

 

  • Today, the best current solution in my opinion lies in early detection and appropriate treatment. For me, solid tumors particularly in the gastrointestinal tract, if detected early can be treated with good surgery and lead to long time survival; unparalleled in comparison to other forms of treatment.

How do we  detect the cancer early, is the big question?

Yes, there are challenges with this but the following story very aptly gives us not only the problems but also the solutions for cancer treatment.

In this story I will be putting some notes as to what is really important and how a particular action changed the course of life for Jayaben.

 

Jayaben, a counsellor by profession, is a middle-aged lady from Gujarat. For about 4 months she had been having bleeding and discomfort while passing stools. She had been to a couple of doctors who assured her that it is nothing but piles or fissures and she was then treated accordingly. Jayaben was not satisfied, as her symptoms were not relieved. After nearly 4 months she said ‘enough is enough’ and got a colonoscopy done.

Note : Symptoms are always there. Many times there is negligence on the part of the patients and also on the part of the physician to suspect something more serious. You know your body best and if there is something that is not going right insist on further investigations to make sure that you are completely clear.

On the colonoscopy she was detected to have cancer of the large intestine. At the time her immediate reaction was “how much time do I have? I have small children” and obviously she was worried. It is very natural for any mother to be worried about her children rather than her own life and obviously for anyone, ‘how much of time is left?’ is an important question. She was also worried about the fact that if she had undergone surgery, should would have to carry a permanent bag because some patients with rectal cancer do have a bag. These were her fundamental fears. But in the matter of 2-3 days, she pushed aside her fears and decided that there is absolutely no meaning in getting worried. “I need to get the best medical advice in this situation” she affirmed.

Note : Do not be in denial and make sure that you do seek good medical care once the diagnosis is made. Access to information will lead you to good medical care. Make sure that your first treatment is properly done. This is the best chance for you.

She underwent a combination of radiotherapy and chemotherapy and subsequently surgery. Throughout she only had one feeling, ‘Yes, I am fighting it out for myself and my family and everything will be all right at the end’.

 

Note: There certainly are huge emotional burdens not only for you but also for your family. But once you get past the initial shock, you should forget it like a bad dream and get on with life.

Today Jayaben is not only helping out many patients through funds but also through counselling and urging them to lead meaningful lives.

While we wait for the moonshot for cancer, I think we must start off with simple things like early diagnosis and good treatment. I am completely convinced that early diagnosis is the corner stone in cancer treatment all over the world but especially in a resource poor country like India. When diagnosed early you have excellent options of treatment.

Today, on World Cancer day my one true wish is that no one should be afflicted with any illness (not just cancer).

Best wishes

Dr J

 

We have lost him!

 

So far in all my blogs I tried to write on the positive attitude and positive news about Cancer. But as most of you realize, this is not always so.

Yes, Cancer is still a disease with few solutions.

Vinnu was one of the most creative architects and was the most positive person I met. In spite of knowing about his Stage IV disease he lived life to the fullest – gym everyday, going to his work, completing the tasks with gusto.

Perhaps this is what has given him the crucial extension after being diagnosed as Stage IV colon ca.

One often wonders how do good people have bad outcomes?

We are philosophical and blame karma and deeds in previous birth, etc. but fundamentally that would not make any difference for grieving friends and family. At the age of 40, you have so many plans, so many dreams and suddenly everything has condensed to a couple of years.

Personally I find it very tough. Initially we start treating such young people, then becoming closer to them, appreciating their talents and also getting to know their personal life. Everything seems to be going well and without a warning there is a huge wave and suddenly the balance is tilted against the person.

Why, How and When are difficult to answer!

More and more I realize -the earlier the diagnosis, better is the outcome.

People like Vinnu are a reason for us to keep fighting for all those young men and women who are unfortunate to be diagnosed with cancer in their prime, but still go ahead, getting maximum out of their life.

I cannot stop the fight nor can give up, nor can take cover under destiny .

Our job is to continue to do our best, hope and pray for the best.

Every single minute of such ‘a life well spent’ will always be remembered.

 

This is what keeps us going….

My Secretary said there is a little girl waiting to see me.

The ‘little girl ‘walked into my room. I said “Hello” . I have never seen this girl before. Then the parents walked in. I immediately recognized the parents. The mother was nursing the baby who had a liver tumour.   It was about a month after the surgery, when we had a fund raising event and Sachin Tendulkar was so moved by the story that he came and gave a personally signed bat to the family.sachin and child

The girl is now 5 years old and they had come to see Mumbai. I asked her what she liked about Mumbai. She said ‘shopping malls’. Yes of course, for a girl from a small town the shopping malls of Mumbai are the big attraction.I asked her if she had gone to the new aquarium and she said “yes, there are a lot of fish and  I liked the gold fish”. She was bubbly, full of life. She does not remember me and perhaps she does not even remember that she has been treated with chemotherapy and later undergone surgery for 12 hours and then recovery for another 12 days.child 2

It is a moment of immense satisfaction to see the little girl and the grateful family.

I was lucky that day. Shravan, a young software engineer who was diagnosed with Stage IV gastric cancer, was practically given 6 months and asked wind up his affairs. He was treated with chemotherapy and then, rather unconventionally, we went in for surgery followed by radiotherapy. I was pleasantly surprised and happy that it is now about 3 years and he is having a productive career . In spite of being a middle class professional he had been generous to donate a substantial sum towards ‘Crusade Against Cancer Foundation’ always saying that he is grateful for this gift of life.

All of them say they are grateful for their ‘second’ life. I am truly modest to reply that it is their courage and God’s will that brought about this happy outcome. I am just doing whatever I can do to the best of my capabilities.

In cancer you have two choices, either to give up or to fight. Giving up is very easy.  Fighting for the patient needs time, effort and multidisciplinary planning by many individuals. First and foremost, the patient has to muster courage and literally lift the weapons. We can only render our shoulders to fire.

Meanwhile I can only say that if you, by God’s grace succeeded in your fight, do help others. The only thing they need is a message that there are many victors in this world who have also battled and won.

God be with you!

Surgery in the morning and counseling in the evening.

Most of my days start at 9am with surgery, which goes upto 4-6 pm, and there is the evening clinic till 8 pm. While I find surgery most relaxing, not at all stressful as you may be imagining. I am in control and focused. There is no noise or distraction. No random thoughts. I do what I enjoy doing. Each surgery is a piece of art, except that the art is hidden under the abdominal scar. The reward is patients’ recovery.

I actually find the evening clinic to be much more stressful. In the evening, more than medical issues, I have to deal with emotional issues. On each day there are husbands who are worried about their wife’s illness and vice versa.

The most difficult question is “How much time do I have ?”. There is no clear answer and even a guess can be very hazardous. I do not think anyone of us has an answer to “How much time is there for anyone of us”. But it is certainly difficult to tell a mother who invariable asks “My children are small and need me to take care of them so at least give me that much of time”. As all mothers, they would rather sacrifice anything just to giet additional time for their children. Men on the other hand, are worried about their work, their finances, how to provide for their families and why should it happen to them and what are the consequences. Invariably the question“Can I go back to work?”

Questions to which I do not have answers.

But still, patients need to be comforted.

“ Yes, things are bad but can get better.”

It is ‘Hope’ that drives the whole human existence and effort.

For a student the hope that he will score well in the exams, for a mother, hope that the children grow up well, for a young man that he will find true love and live happily. May be for someone hoping to become wealthy, someone hoping to become happy.

A cancer patient hopes for ‘cure’ or ‘control’. There is no need for luxuries of life; just LIFE.

In fact TIME is most precious gift….

A few days more to settle the home, work, finances, children and many other issues

Only thing I can give is a bit of hope, to be optimistic, to allow them to gather courage in the face of adversity.

I just say “ I am there for you, the whole medical science is for you”. “Whatever best that can be offered anywhere in the world, we would  offer to you and then hope for the best”. Mostly they are comforted and go back with a feeling that ‘Yes, they can fight the disease’.

The drop-box for worries:

I started keeping a small box near the door and I generally tell them, ” Leave your worries in that box and let me take care of it”.

The least a doctor can do for a patient is to give comfort and hope. Yes, cure of disease may or may not be in our hands but certainly comforting someone in distress is an absolute must in this profession.

I feel privileged that I am able to help at least a few if not all on each day. Though it does make my heart heavy and I need to deal with this heaviness every single day and to be as normal as possible. Recharge for the next day and the days after. …

What keeps me going, week after week and year after year ??…