A selfie that can save you

Mr. Brahma Rao, a bank executive noticed a small ulceration on the border of his tongue. He was not a smoker and never chewed tobacco. He thought perhaps she has injured his tongue by teeth bite and continued with normal activities. After nearly 4 months he suddenly noticed severe pain in his right ear which alarmed him and the ulcer also had increased in size. He was worried and contacted me. As he was abroad and visiting his family and was due to return, I asked him to send me the pic of the border of the tongue like ‘a selfie of the tongue’ which he did.

tongue-pic

It clearly showed a small 1 cm. ulcer and the edges were elevated. It is a very important symptom and sign as lesions on the tongue having what is called ‘referred pain ‘ of the ear is because of nerve infiltration. I diagnosed him as early tongue cancer and he underwent treatment. Fortunately there was no spread at all and he recovered very well.

 

It is an important pointer for all. The tongue is so visible and can be easily seen and felt. Any kind of nodule or ulcer or nodule that is persistent for more than a month is not to be taken lightly. Tongue cancer is painless and has referred pain to the ear. In vitamin deficiency or an aphthous ulcer is more painful, superficial and small.

It is easy to document by a pic and sent to a doctor.

Ultimately you are responsible for your own health and sooner the diagnosis, the safer you will be.

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Beware of sudden deterioration of ‘diabetes’ and loss of weight

 

Recently a colleague of mine frantically phoned up saying that someone who is very close to him has to be seen by me. The patient was a mild diabetic and recently his sugars shot up. He was then taken to a diabetologist who started him on  insulin dose. Then he started losing weight and in the next 4 months he lost 4 kgs. The diabetologist opined “It is because of control of diabetes and it is good that he is losing weight”. However after his sugars came to near normal he continued to lose weight and he lost 4 kgs over the next 3 months by which time there was a sense of urgency.

It was then that he underwent CT Scan and was found to have pancreatic cancer which was inoperable. My colleague was devastated, that inspite of availability of medical expertise diagnosis was delayed.

This is not unusual. It is very important to remember that sudden deterioration of diabetic status suggests either ‘infection’ or ‘tumour’. It is very important at this stage to get a scan done so as to rule out the presence of tumour. Early diagnosis is most important for management of pancreatic cancer as surgery remains the only most useful treatment.

Once again I have to re-iterate that weight loss is not to be taken lightly and any significant weight loss has to be investigated thoroughly including a scan.

Can anyone ‘sense’ cancer?

Can anyone feel that they may have a serious illness and it could be cancer?

You may think ‘Its not possible’, but yes cancer can be ‘sensed’

I ask all the patients, whether they felt ‘not normal’ and that there is a serious illness lurking around. Most of them say  ‘yes’. There is a feeling that something is wrong. the body is becoming weaker and the energy is going down. Or loss of weight and stamina.Many times visit to doctor is postponed or get treated with some usual medications.

Its a combination of nonspecific symptoms, but one does feel ” definitely unwell” .

I am reading the book” when breath becomes air” by a young neurosurgeon Paul Kalanithi, who is diagnosed with advanced lung cancer. He also realises that there is some serious illness, may be ‘cancer’. Its a moving story of an aspiring surgeon who works hard and is about to realize his dreams, when cancer strikes him. He writes his own story , perhaps mirroring the stories of many patients he had seen.

I recall a professor of surgery, a well known teacher, who one day suddenly declared that he had pancreatic cancer. His family and friends were surprised as he looked healthy.

‘Why  do you think so?’

‘For years I have taught students that migratory phlebitis  (red streaks on legs ) is a sign of pancreatic cancer and I have show them in my patients’.

“Now I have the same sign”.

He was investigated in disbelief, but the diagnosis was confirmed.

The first response however is denial, even more amongst doctors. No it cannot be. Then as time goes, the inevitable symptoms like pain set in and  the diagnostic tests are done.

I see many like him. So many experience that loss of energy as though slowly the life is getting squeezed. Its is best to  get investigated at the suspicion and not wait for full blown symptoms. Time indeed is the most critical as stage of diagnosis is the only major predictor of prognosis. Earlier the better.

You may be a busy corporate executive or your children have board exams. Something is always happening, but your health is a super priority. Nothing else matters.

The same thing happens to Paul in the novel. Loss of weight is due to ‘overwork’. Acidity is ascribed to ‘too many coffees and  stress’. Not eating well as ‘no time’.

I recently saw a CEO with symptoms and its only after six months that he went for investigations. Work deadlines,travel, annual reports , social life – so many ‘important’ things- more important than our health. we have so many proverbs but hardly ever care.

Health is wealth ( proverbial sense) , but it only ‘depreciates’ and not ‘appreciate’ like real ‘wealth’ in the bank.

Well the bank balances can evaporate with a single illness.

I see this also in elderly. ‘why bother my son or daughter when they are so busy with their jobs’. That’s not correct. Most families care for their parents and would be devastated if they find an advanced cancer . Many just ask the question” Can my mother or father be cured?”. No matter how old, even 80s, but they want the parents to be with them a bit longer.

Thats normal and human, just push the line a bit. A little more time , just a little !

So when you sense ‘something is wrong’, don’t brush it away.

An early check up can save your precious life.

 

 

 

 

Is cancer incidence increasing?

I met Roopa the other day and she asked me, “Doc, every friend or relative seems to be having cancer. Why? Is cancer incidence increasing?”

I am asked this question very frequently and I keep giving same answers to explain ( not convincingly ) the increasing numbers. With increasing longevity of life there is likely to be more cancer & non-communicable diseases. Life styles have changed and may contribute.

I recently went to the Indian Cancer Society Meeting on the Cancer Registry Project.   The Mumbai Cancer Registry records only residents of Mumbai and not migrant population and has plotted the incidence over the last three decades. Great work and a tough one too!

Breast and Lung cancers are increasing. There is  increase also in rectal and colon cancer.There is a continuous and constant increase in liver and gall bladder cancer in Mumbai. It is likely due to migrant population from north settling in Mumbai. Cervical cancer is decreasing as the hygiene is improving and parity is decreasing. In short we are transforming into a western pattern of incidence.

The worrying feature, however,  is the increase in mortality due to cancer. Stage to stage, more patients succumb in India than in other countries.

We have not made a significant dent overall in treatment. Its not that we don’t have facilities or expertise. We just continue to see patients in advanced stages.

I chaired a panel of experts.. The panel felt that prevention and early detection are the key. What is required is better diagnostic facilities for early detection

  • Creating awareness among people
  • Lifestyle modifications
  • Physician awareness and referal

These are not really difficult and if we concentrate on this perhaps we can start showing decrease as it is already happening in some of the countries in the West, in gastric, lung and cervical cancer.

More thoughts on these later.

 

 

 

‘Be aware’ of anaemia or Low hemoglobin

 

Jai is a regular donor to our Foundation. He is one of those who donates every year without asking. This time he came with a cheque earlier than ;usual and I asked him, “you normally would put in a cheque in March.” He said, “No, this is from my wife. Whenever she wins a kitty party she donates the whole amount to CACF. This is a remarkable way of using kitty money rather than on clothes or fancy things.

I asked Jai who is a businessman the sequence of events that led his coming for surgery. He is already 3 years post-surgery and doing well. Obviously he could detect the disease early and this is his story….

“I am part of the walking club and every morning I go walking for 60 min on Carter road but slowly I started becoming slightly breathless. My friends used to jokingly say that I am getting old and unable to keep up with them. I really could not keep pace with them. I started becoming breathless whilst walking up a flight of stairs too. Initially I thought its because of my heart but my ECG, everything was normal. I went to my general physician who ordered usual tests and to my utter surprise haemoglobin was just 8 gms against normal of 12 gms. So obviously I was feeling breathless because not enough oxygen was being carried by low haemoglobin. This started a series of investigations and fortunately my general physician got a scan done which showed mass in the colon and subsequently endoscopy confirmed Colon cancer and I came for surgery.”

This is a very important story and also brings out a valuable point on being aware of some of the signs and symptoms and taking necessary action on them.

Anaemia or low haemoglobin is one of the classical presentations of gastro-intestinal cancer and it should not be taken as lack of iron or nutrition or due to any other cause. Many times anaemia can be manifested by just tiredness, weakness and breathlessness. Once anaemia is detected it NECESSARY to have a sonography or scan done which can pick up any lesion. It is also good to test the stool for occult blood. If occult blood is positive in any of the 3 samples, colonoscopy or endoscopy are warranted. In this way we are can pick up GI cancers very early.

The best part about GI cancers is that when detected early they just need surgery and good surgery will ensure a long time survival. Most of them, nearly 90%, survive for 5-10 years. Even chemotherpy can be avoided.

So just be aware of these symptoms. The symptoms should not alarm you but should alert you for investigations.

Take care of your health.

Door to door screening for cancer ??

Today there is an announcement on a door to door screening for Cancer, diabetes and cardiac illness in 100 districts in India costing 250 crores ( 37.5 million dollars) .  I was astonished. I don’t know about diabetes and cardiac diseases, but door to door screening for CANCER ??

Thats not logical or rational nor is it cost effective. I wrote in my earlier blog that screening for cancer is NOT the answer. Sweden is a classic example. Its a country with small population, social health care and all the people are followed up throughout their life. The infrastructure is excellent.

So when mammography screening for population was introduced, it was believed that breast cancer would be detected early. Once detected early, the treatment can be effective and lives  can be saved. It seems so logical and simple. But…

After two decades, the breast cancer mortality did not come down.The women undergoing screening had many false alarms and procedures. Lots of stress and tension and finally NO DIFFERENCE.

Why did this Happen??

There are many biases in screening. Lead time bias is just one of them. Cancer is so much like the human organism and cell. It has finite cycle and also ages. so whether you detect a 5 mm tumour now or a 1 cm tumour after six months, the outcome does not change.

It does not mean that you keep waiting once the tumour is detected. Soon there will be spread to lymph nodes etc.

But screening raises a lot of questions. When to test ? Whom to test? and how frequently should we test?

Pap smear was one such screening  technique and all women above 40 were advised to undergo PAP smear. But logistics of doing a pap smear, once in life time of a lady, are so enormous. It is just not possible.

The cost and the ability to handle doubtful lesions are so much that population based screening like the one planned as door to door testing, is just NOT cost-effective or feasible.

Instead, as I wrote earlier ( Jan 2014) , seven warning signals  can alert us to seek medical attention or undergo tests.

 

 

 

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