Apple Inc rules

At the recent ESMO (European Society of Medical Oncology) conference it was fantastic to see the number of folk who have iPhones and iPads. If they needed a laptop it was nearly always a Macbook Air.

Nearly 16500 delegates under one roof, everyone with a device to get onto the Internet and they crashed the Net server a few times.

The power of group computing.

Herceptin duration

A few years ago when Herceptin (trastuzumab) was launched for the early stage of Her2+ breast cancer, the timing of treatment was fixed at one year. Why one year? No clue. Just a consensus figure decided by the oncology investigators.

At the European Oncology meeting held in the end of Sep 2012 - data from large studies were presented. The two main studies were comparing one year versus six months of Herceptin - this showed that probably one year is better than six months. The other study of one year versus two years showed that one is probably enough.

So the consensus a few years ago, was right. Twelve months is the magic figure (for now).

Hiatus in life

I started this blog with gusto and then slowly faded away. I think I would broaden my horizons and write more regularly on a variety of topics.

Adjuvant GIST - Gastro Intestinal Stromal Tumours

GIST is classically operated upon and thought to be cured by surgery. Unfortunately more and more clinicians are finding that patients have recurrence of disease. Nowadays, there are way to find possible recurrence risk rates, and treat accordingly.

If a patient has a high to moderate risk of recurrence, then they must be offered Imatinib (Glivec or Gleevec). The duration of treatment continues to be a matter of discussion - most people agree for one (1)year of treatment, but there is now data to show that three (3) years of treatment is necessary.

I suspect that treatment would be needed for long term (much longer than three years), as the survival curves at one year and three year of treatment are quite similar, when treatment is stopped.

The important thing is to ask your surgeon to consider Imatinib therapy or refer you to a Medical Oncologist for discussion.

Driving and Brain Metastasis

People who have been driving their vehicles for several years (most times decades) are really upset when we tell them that they should not be driving their cars.

In Australia the onus is on the clinicians to get affected patients to stop driving their cars. The treating clinician is meant to tell the patient to stop driving and send a letter to the Driving Authority to withhold/revoke the patient's driver's license.

The number of clinicians who even know about this is minimal!!

If a patient's cancer has spread to their brain, the chances of seizures or altered consciousness are quite high. There is no specific time or place when things can get out of control. Also these patients have had radiotherapy, surgery, are on high dose steroids, narcotics, etc... and thus the mental cognition and reaction time is dramatically altered.

The conversation is a difficult one. But a very important one. It could save the patient's life and others on the road.

Terminally Ill Mum Sues Insurance Company

Terminally ill mum suing insurer

It's a tough life. Can get tougher due to some folks.

The Gutsy Challenge

The Gutsy Challenge

Movember

MOooooooovember

I participated last year (2011) and we raised nearly $ 4000 (AUD). Pretty cool. Worth re-doing this year.

Best Oncology Textbooks

Which is the best Oncology Textbooks?

I think:
# DeVita's Cancer: Principles and Practice of Oncology
# Abeloff's Clinical Oncology
are the best ones.

There are tons of other books, but these two seem to cover the maximum amount of information in the best possible manner.

Urine protein and Avastin / Bevacizumab

Avastin (Bevacizumab) is a good medication in metastatic bowel cancer (both colon and rectum). It is used for extended periods of time with chemotherapy to control and reduce the burden of cancer.

It is very important to check the urine for proteins while on this medications, as it does have a potential to damage the functioning of the kidney. In case, the kidneys are secreting proteins, it is then important to check the quantity and then if needed to stop Avastin till the kidneys recover.

We have found that a significant number of doctors forget to check urine protein, while patients are on Avastin.

Infections from doctors

Infections can also be transmitted from doctors and nurses to patients. It is quite well known. Hospitals across the world are trying to convince medical staff to clean their hands - wash with soap and water or use rubbing alcohol.

The other common things which are sources of infections are doctors' white coats (which are not washed very often), neck ties (never washed), stethoscopes (hardly ever cleaned), telephones, and the list goes on.

Think about it.

Doctors as patients

One of the nightmares for medical units across the world is to have a doctor as a patient. Everything is has to be extra-careful in the discussion, tests, planning and implementation. Each thing is checked and double-checked.

I know that I am a terrible patient. I do not quite remember completing a full course of antibiotics or doing the things recommended to me.
The problem is that for some strange reason (?Murphy's law), when we are extra-careful; things go extra wrong. Some people term it the "VIP syndrome".

Hospice and Nursing Homes

Today's ward rounds were a bit sad. I have a bunch of patients who are quite unwell, some due to cancer and some due to unrelated issues. One thing is certain that they would not be able to manage alone at home. A couple of these patients, do not have any family or friends to support them at home either.

The alternatives are a nursing home or a hospice. Telling a person that they cannot go back home and need to move to a nursing home for the rest of their life, is NOT an easy task. People who have been fiercely independent all their lives are not happy to be dependent on others.

The other major issue for some patients is the decision to move to a Nursing Home versus a Hospice. They are too well to be transferred to a Hospice and thus are planned for a Nursing Home... but by the time they find a Nursing Home place, they are too sick to move there.

Difficult decisions. Tough on just on the patients, but also their families, friends and the health personnel taking care of them.

Life moves on.

Merkel Cell Cancer: Rare Cancers

Recently someone asked me about Merkel cell cancer. Relatively rare.

The website I suggested helped him - http://www.merkelcell.org/

Thought it might be worth sharing, in case more people need help with this condition.

Hindu customs and hair loss

I have spent time doing oncology work in India and working with patients was very rewarding.

One day in the out-patient clinic, I met with three women consecutively who were to start chemotherapy. All three women would lose their hair and it was very distressing for each of them and their families.

Two days later, I suggested to one of these women to shave their hair and make a wig out of her own hair. It seemed like a good idea to me. It was NOT a good idea for her and her family. In traditional Hindu culture, a woman would shave her hair at the time of being widowed.

No more such suggestions. Ever!!

Hair loss and Chemotherapy

One of the biggest worries about chemotherapy is hair loss. It seems to be a bigger issue than even fatigue and reduced appetite. This is what I seem to find in clinical practice. The worry seems to be more in women than men, but both genders are worried.

A lot of people are really surprised when I tell them that they would not be losing their hair. All chemotherapy drugs are not the same. Some drugs cause hair loss, some do not.

GIST: Gastro Intestinal Stromal Tumours

GIST is a truly game changing cancer. It has been around for centuries, misdiagnosed as other types of cancers. In the past few years, GIST has found to have special markers and thus the diagnosis is definitive.

Treatment is to completely remove the tumour by surgery. This is possible when it is early stage. Once the cancer has spread, surgery is not possible (most times). Chemotherapy was as good as useless. Nothing seemed to work.

A few years ago, a pharmaceutical company launched a molecule called Imatinib (Glivec). This has changed everything for GIST. Now people with metastatic GIST, pop a pill a day and continue with life. Quite amazing.

Recent data has shown that even after surgery, Glivec should be given for at least 3 years.

Game changer. Looking for more such miracles.

Waiting Time for Appointments

The huge problem is that once someone has been diagnosed to have cancer, or even if there is a suspicion of cancer; most families want an appointment with their doctor straightaway. This seems to be a valid request most times, as anxiety levels are HUGE.

As a specialist, we are usually keen to have a definitive diagnosis of cancer prior to an OPD review. The idea being that the patient's GP or doctor makes a diagnosis of cancer by a biopsy or needle aspiration and then makes the referral.

Depression

What is depression? Is it just something which needs to be shrugged off, 'cos someone is having a bad day or days? Or is it something which is a lot more deeper and needs a through evaluation? Which treatment helps - counselling or medicines?

In Crocodile Dundee (a great Aussie movie), the actor asks - why do you need a psychiatrist, don't you have mates to talk to?

Have we lost touch with each other and not willing to say the right things to friends, since it might offend the other person?

Ohh, too much to read up and find out.

Malaria

Wow. The number of people dying of malaria is rising by the decade. Apparently in 2010, over 1.2 million people died of malaria. Shocking. To think that just about a decade or so ago, we thought malaria was well controlled. It is back with a vengeance. A significantly amount of malaria is now thought to be multi-drug resistant.

Short URL

Interesting.

http://medicaloncology.blogspot.com.au is the same as http://goo.gl/mlncD

Angry patients

One of the most intimidating experiences is to be confronted by an angry patient and their family/friends. They might be upset about the long waiting time or the services or whatever. In the process of getting angry, the primary intention of sorting out the medical problem gets buried (to some extent).

I have found it quite effective to let the angry patient rant about everything. When the run out of steam, try and work through the problem.

There have been a couple of patients, who refuse to listen and only yell. It is not worth breaking your head with them. Ask them to leave, or leave the room yourself. I have the right to work in a safe environment.

Diabetes and Insulin

Patients on chemotherapy seem to have a real problem controlling their blood sugar levels. Most times it is due to the fact that we give steroids pre-chemo and post-chemotherapy to prevent allergic reactions and nausea. Diet control and even Tablet based therapies may not work optimally.

Insulin for a short time might be the way to go. It is worth exploring the option with your GP or specialist. If people are getting 4 - 6 cycles of chemotherapy, short course of Insulin is all that maybe required.

Stop smoking. Right now.

The number of people gasping to death from emphysema and bronchitis is worse than people dying of lung cancer. Smoking destroys the lung tissue and the lung airways, along with lots of other things in the body.

Pretty gruesome end. Not worth it. Lots more to life. Stop smoking now.

Which cancers are rising?

Interestingly, the majority of cancer rates have reached a plateau or are reducing, except for cancers like lung cancer in young women. Unfortunately they seem to be a group which is picking up habits like smoking.

The problem is that by the time, it get publicised and all that, so many young women would have suffered.

Stop smoking. Everyone. Right now.

Managing Articles and Research Documents

I have struggled to organize my research papers and articles. They are placed in folders within folders within folders. The Apple operating system (Lion or prior) helped with searching documents, but it was never the same.

Recently I started using "Papers" - http://www.mekentosj.com/papers/

Brilliant piece of software - mainly for Apple OS, but they are coming out with a Windows edition too. Works with iPhone and iPad too. All the devices sync with each other. Pretty cool.

Intervening for a Friend

A few weeks ago, one of my friends in the USA was found to have recurrence of bowel cancer. She was being tossed around with scans, blood tests and a possible biopsy. It was hard to tell her that she was getting sub-optimal care and needs to see another doctor. She agreed. Saw another doctor and got a PET scan done.

Last week she was operated upon and they have taken out the cancer completely. Fantastic. I am so thrilled. I bet she is too :)

Worth pushing for.

Death or Dying

I wonder what is worse - death or dying. I suspect most people are worried about the process of dying, with regard to pain or breathlessness; but there would be a fair number of people who are also worried about what would happen after they die. What would happen to them, their families, their friends, their assets, etc.

Difficult question. Personal. As always.

Research and Clinical Trials

Clinical Trials for medications and drugs are broadly divided in four groups or phases:

Phase 1: Very early type of research. In some types, it would be a "first in human" study
Phase 2: Studies would have shown the medication to be relatively safe and it is now being tested for efficacy
Phase 3: The safety and efficacy have been shown to be favourable, and now it is being tested against the present standard of care
Phase 4: This study is primarily to gain more information about the medication, as it has already been approved for routine use in the market

Enrolling onto clinical trials is a good thing. It gives access to newer molecules or different ways of using older molecules. It is possible that the full benefits of the study medication may never be seen in the patients enrolled on the study, bur future generations would benefit from the same.

All trials are governed via Ethics Committees, which may be locally or centrally based. They are the guardians of patients and their families, and would not give permission to conduct a study, unless they are convinced about safety.

The first principle remains - "First do no harm"

Pulmonary Embolism

One of the big problems with cancer is clots in the lung blood vessels. It is a significant cause of death in cancer patients. Most people do not really know or understand it about it.

Cancer is a condition which makes blood sticky. If you combine this with the fact that the patient is not very mobile, not drinking enough of fluid, is on chemotherapy via intravenous access device, is on medication which also affects the clotting of blood... it is a fairly strong combination for clot formation.

People can develop clots in their legs, which then breaks off and there are showers of clots in the lung blood vessels. A large blood clots in the lung vessels can potentially kill the patient.

The treatment is making the blood thinner with medications - heparin, heparin like drugs or warfarin.

The important issue being awareness of the condition. Sudden shortness of breath, cough, sharp chest pain, etc are some of the main symptoms.