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Update by Natrakorn Paewsoongnern
 
 
 

Doctor's Consultation  by Dr. Iain Corness

 

Living with cancer

So you have just found out you have “cancer”. What can you do? The first thing is to sit down and take stock of your circumstances. All of us know that that piece of string called “life” eventually comes to an end, but we don’t know when. The only difference with you, is that your doctor has actually told you when your piece of “life” string is due to run out.

Now whilst the immediate thought is “How do I beat this?” there are many factors you have to consider in the time ahead, and one of the main ones is called ‘The Quality of Life’.

Now is the time to talk with family, friends and health care team. It is natural for a person with advanced cancer to feel many emotions including anger, fear, and sadness. Just as you may need time to adjust to this new phase of your illness, your family and friends may also need time. If you are having trouble talking with family and friends, ask your nurse, doctor, or counselor to gather everyone together to talk.

This talking phase should also include your getting to understand your cancer. This you do by talking with your treating doctors, and also from information from reliable internet sites. Note I say “reliable” sites. There are always plenty of sites ready to sell you snake oil.

Now is the time to manage your symptoms. Your quality of life is better if your symptoms are under control. Talk to your health care team about the best way for you and your caregivers to manage your symptoms.

Do not be afraid to ask your doctors about any proposed modalities of treatment. Getting an extra two months of life, but at the cost of the quality of life, may not be worth having. Always keep that in mind. Quality of (the remaining) life is everything.

Be as active as you can. When an illness progresses, it may be harder to do the things you have always done. Talk to your health care team about what, if any, limitations you may have. If your physical health allows, continue to exercise in some enjoyable way. Or, if you find it is too much for you, take up a new hobby or find things that you can still do and enjoy, such as reading, writing, creating a photo album, or making a video for family and friends.

Let friends and family know what they can do to help. What can you do for yourself? What is important to you? What can friends and family do for you? What can all of you do together? Where do you turn if you need extra help or care? If you are not up to being social, let people know this as well.

Make your wishes known. Making the decision to stop active cancer treatments can be a hard choice for a person with cancer and their family. These are personal choices. If you are faced with making these decisions, talk with your family and health care team about your wishes and explore all of your options. You are still able to make decisions about your life to the extent that you desire.

Maybe you want to give someone else some of the responsibilities or share decisions about what to do. You may want to create a health care proxy and/or power of attorney. This allows someone who you choose to make health care or other decisions for you. Whatever you choose, you are in control of your life and you know what will work best for you.

You may also consider creating a ‘Living Will’ or giving specific instructions on what your wishes are if your cancer progresses. This process helps make your end-of-life wishes and desires known to family, friends, and your health care team and can help ensure that your wishes are honored. These wishes may include funeral arrangements or decisions about hospice care. Discuss with your family, friends, and health care team your wishes regarding resuscitation.

Sorry if the column this week sounds a little deep and dark, but it can give assistance to those who feel as if all their options have gone.

 


The Tale of Tanujin

The item you are about to read is one of my favorite medical case histories. Bruises on a child’s body are often considered proof that a baby has been battered. A visible bruise on the buttocks, the shape of a hand and five fingers is almost ‘undeniable’ proof. Or is it?

There was a very celebrated instance of a GP in the UK having discovered that so many of the Asian babies in the practice were showing signs of being ‘battered’ that the children’s welfare people were called in and an enormous number of children taken away. However, the highly observant GP was wrong!

In Thailand, and the rest of Asia, a new-born baby with the ‘handprint’ bruise is very common, while child abuse is not common at all. The problem, or rather the condition, relates back to Genghis Khan and the Mongol hordes. It is a wonderful piece of folklore and a fine example of applied genetics.

Let’s look at the folklore first, and you are going to have to dig very deep to get this tale anywhere else! A Mongolian baby, called Tanujin, was born just over 1,000 years ago, but did not breathe. His father, in desperation, held his new-born son upside down and smacked him severely over the bottom, so much so that the baby drew breath and lived, but carried the life giving bruise for the rest of his days. That baby later became Genghis Khan, (which means King of the Earth), and by the time he died in 1227 he was the ruler of a large chunk of it, including the area which later became known as Thailand.

History has chronicled that the Mongol hordes raped, pillaged and annexed countries from China to Persia. His highly mobile troops traveled the difficult terrain of Siberia. Famous cities were captured and looted such as Tashkent, Baghdad (still a good place to stay away from, thanks George) and Bokhara. Cities that surrendered were spared but those that resisted were razed and the people slaughtered. The Mongols conquered northern India and Afghanistan. In 1222, they defeated the Russian and Bulgarian armies. At the time of Genghis Khan’s death, his empire stretched from China’s Yellow River to the Dnieper, in Russia.

And now back to some interesting folklore. The descendants of Genghis Khan also showed the hand-shaped bruise on the buttocks, beginning with his four sons Ogdai, Jagatai, Juji and Tule, who were given one quarter of the empire each after their father died. They in turn passed on this ‘trademark’ and so this continues till today. If your “Luk Krung” children have the sign of Genghis Khan, called Mongolian Blue Spot, you can claim descent from the warrior king. However, there is quite a number of you, so I think there won’t be much left in Genghis’ estate by today.

Now Mongolian Blue Spot, as a clinical condition, is well documented, and I came across figures suggesting that at least one Mongolian spot is present on over 90 percent of Native Americans and people of African descent, over 80 percent of Asians, over 70 percent of Hispanics, and just under 10 percent of fair-skinned infants (Clinical Pediatric Dermatology, 1993).

Medically we describe Mongolian Blue Spot as flat bluish to bluish gray skin markings that commonly appear at birth (or shortly thereafter) and scientifically they are called Congenital dermal melanocytosis. They are flat, pigmented lesions with nebulous borders and irregular shape. They appear commonly at the base of the spine, on the buttocks and back, but also can appear as high as the shoulders and elsewhere. The medical text books also warn that occasionally Mongolian Blue Spots are mistaken for bruises and questions about child abuse arise. Obviously a text book that the UK GP did not read! Mongolian Blue Spots are birthmarks, not bruises.

So, for all of you with children with a peculiar blue birthmark on their bottoms, or for those interested in checking friends and neighbors (or the young ladies dancing in the chrome pole palaces), it seems fairly positive that the lineage is verified. You really have found descendants of the man who conquered more of the world than Alexander the Great. And guess what – my children have it too!



Prostate Cancer once more

I make no excuses for running another article on Prostate cancer. Fifty percent of people in Thailand are male and 98 percent of them have a prostate which can turn nasty and bite them! (What happened to the 2 percent? They’ve had their prostate removed already.)

However, a friend found that he had an elevated Prostate Specific Antigen (PSA) and the following examinations showed that the elevation was caused through cancer, not one of the other causes of PSA elevation. Yes, PSA is not a go/no go test. Elevation of PSA is a warning to go looking.

However, prostate cancer is common. The statistics show that by age 50, almost 50 percent of American men will have microscopic signs of prostate cancer. By age 75, almost 75 percent of men will have some cancerous changes in their prostate glands. Do the maths. By 100 we’ve all got it!

So does this mean that life really ends at around 76? Fortunately no. Most of these cancers stay within the prostate, producing no signs or symptoms, or are so slow-growing, that they never become a serious threat to health. The good news is you die of something else before the prostate gets you! You die with it, rather than from it. That is an important fact to take in. This we call watchful waiting and serial PSA’s are the way to go, as well as getting friendly with our local urologist.

The real situation is that a much smaller number of men will actually be treated for prostate cancer. About 16 percent of American men will be diagnosed with prostate cancer during their lives; 8 percent will develop significant symptoms; but only 3 percent will die of the disease. Put another much more positive way, 97 percent won’t die from their prostate cancer.

While some prostate cancers can be ‘aggressive’, breaking out from the prostate gland itself and attacking other tissues, including brain and bone, fortunately this is the minority scenario. The great majority of prostate cancers are slow growing, and it can be decades between the early diagnosis and the cancer growing large enough to produce symptoms. That’s the second important fact to take in.

So let’s look at diagnosis and get the “blood test” out of the way first. The blood test is called Prostate Specific Antigen, or PSA for short (we medico’s love acronyms). Up till then we had another test called DRE (digital rectal examination), which, quite frankly, was not all that popular. As medical students, we were taught “If you don’t put your finger in it, you’ll put your foot in it!” Despite this, ‘buyer resistance’ was high, so when news came through about a “blood test”, millions of men began rejoicing and the sale of rubber gloves plummeted. Unfortunately, as I said earlier, PSA is not a go/no-go test. A normal range test doesn’t guarantee you haven’t got it, and an elevated result doesn’t automatically mean that you are about to claim early on your life insurance (or your dependents, anyway).

However, there is good news. Serial PSA examinations can show the rate of cancer growth, and the rate of increase is more significant.

Like many other cancers, prostate cancer can only be fully diagnosed and ‘staged’ by biopsy. ‘Staging’ has four main grades. Stage I cannot be felt and is diagnosed through pathological testing. Stage II can be felt, but it is confined to the prostate. Stage III is coming out of the gland and Stage IV has grown into nearby tissues.

This is where you need to discuss your options with our doctors. If you are a young man with stage IV, then you have to make up your mind quickly. But if you are 75 with stage I or II, then you have more time, as you will most likely die of other causes before the prostate cancer gets you. For these people, “Watch and Wait” has much going for it, but you must be prepared to get to know your urologist, so pick a young one.

To increase your knowledge, Bangkok Hospital Pattaya is running a free information seminar on Men’s Health on Saturday 21st of March from 9am.-12 noon. Be quick to register. Limited seats and for first 50 persons, you will get a free PSA and Testosterone tests. Telephone: 061- 386-6153 Email: [email protected]



Is EBM good for you?

The practice of Medicine is a fascinating story that has unfolded over thousands of years. “Healers” have been part of most societies, and in ancient China, for example, you paid the doctor to remain well, not for treatment of your ailment. Now there’s an incentive bonus for you!

Then there are different kinds of “medicine” given such names as “conventional”, “alternative” and “complementary”.

These different ways at looking at the same subject (making you well) can be quite confusing, and for me much hangs on the term EBM, which stands for Evidence Based Medicine.

Mind you, it has also always been the case where people like to throw stones at conventional clinical medicine. Claims of over-servicing, over-prescribing and downright fraudulent practices are thrown about, citing someone whose uncle/friend/mother (delete that which is inappropriate) suffered at the hands of “bad” doctors who misdiagnosed the illness and the patient died.

Now, there are certainly some “bad” doctors out there, just as there are “bad” lawyers, “bad” real estate agents, “bad” mechanics and just about any profession you would like to think of. But they’re not all “bad”.

And me? I am a conventionally trained British/Australian style medical practitioner who has spent a lifetime practicing EBM. Practices that have been proven to work. Call it “good” medicine, if you like.

I am also proud of my final exams taken in the Royal Colleges of Physicians and Surgeons in London. I have the honor to have my name listed in the ‘great book’ with luminaries such as Hunter, Jenner and Lister. I am also indebted to my tutors during the 12 months of ‘pre-registration’, where you apply your knowledge under the supervision of accredited specialists. An arduous road, but one that is a safeguard for you, the general public.

The ‘powers that be’ are also ensuring that we keep up to date with a process called Continuous Medical Education (CME). That medical education continues through to today, with CME lectures being attended by my hospital’s doctors, and myself. Fortunately for me, the slides are in English.

Those ‘powers that be’ also try to ensure that we prescribe drugs that are efficacious, that have been tested, and the evidence points to this. It is not anecdotal evidence, but true scientific evidence shown by research in many countries, with hundreds of thousands of patients. It is following that type of evidence that I can recommend with all good faith that 100 mg of aspirin a day is “good” medicine. I also know that if you are prescribed a ‘statin’ drug it will lower your cholesterol levels. They have been tested.

I am also the first to admit that we have sometimes managed to get it wrong. The Thalidomide story still has living examples of this. However, the medical world-wide network is cohesive enough to ensure that this drug was withdrawn. It is the checks and balances system that has kept conventional medicine afloat.

I am often asked my opinion on “alternative” medicine, and I try to avoid direct confrontation over this. If devotees have found that they can diagnose tumors by looking at patient’s auras through their third eye in the middle of their foreheads, then I am genuinely pleased, in fact delighted, provided that they have subjected the method to scientific scrutiny.

If various groups can actually cure cancer, epilepsy, halitosis or lock-jaw by inserting dandelions into a fundamental orifice, then again I am delighted. This is a medical break-through, but as such, must be subjected to medical scrutiny. If the method stands true scientific examination (not to be confused with anecdotal ‘evidence’) then it will be adopted by everyone, complete with thanks to those clever people who picked the dandelions in the first place. Ignore the claims that “Big Pharma” is suppressing cancer treatments. If someone has the answer, they will be multi-millionaires overnight.

As far as the majority of ‘folk’ remedies is concerned, I work on the principle that if you ‘think’ it is doing you good, then it probably is. But don’t ask me to endorse something that has not been scientifically tested.

When the ‘alternative’ group spends more time proving their methods, instead of complaining about non-acceptance, EBM practitioners will give them more credence.


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Falling off the bed

Ever turned over in bed and the room began to spin? And you were sober? It could have been Benign Paroxysmal Positional Vertigo (BPPV).

This is a very distressing condition, and much more common than you imagine. If you have it, after you move in a particular way, you feel that the room spins around you and you cannot stop it. It is like being so drunk that when you lie down on the bed the spinning rotation is so bad you grip the edges of the bed to stop falling off? That is what BPPV is like – but without the hangover the next morning!

The symptoms of BPPV include the dizziness (vertigo), lightheadedness, imbalance, and nausea. Activities that bring on symptoms will vary, but are almost always produced by a rapid change of position of the head. Getting out of bed or turning over in bed are common ‘problem’ motions. Because people with BPPV often feel dizzy and unsteady when they tip their heads back to look up, BPPV is sometimes called ‘top shelf vertigo.’ Women with BPPV may find that having a shampoo can bring on the symptoms. It also tends to be recurrent. So until you read further, don’t look up or get your hair washed!

To understand BPPV, you have to understand the workings of your inner ear. You have three semi-circular canals aligned in different directions, which act like spirit levels (the builders type, not the three fingers on the glass barman type) which have cells with fine hairs bathed with fluid as your head moves in different directions. The movement of the fine hairs sends electrical impulses to the brain to tell it (and you) which way is “up”.

However, with BPPV, the natural movement inside the semi-circular canals is disrupted, so the fine hairs send the wrong signals to the brain, and being unable to work out which way is really “up” the sufferer falls over, totally unable to save themselves from hitting the floor. Debilitating and embarrassing! Ask anyone who has had BPPV.

The commonest cause of interruption to the normal ebb and flow in the semi-circular canals is produced by something we have called “ear rocks”. These are made up of crystals of calcium carbonate, and we medicos call these ear rocks “otoconia”. Imagine these rocks to be like sugar crystals in the bottom of your coffee cup. These now swish around every time you move your cup, and likewise your “ear rocks” swish around every time you move your head.

However, it is not all that simple (it never is, is it?) as the commonest cause of BPPV in people under 50 is head injury. In older people, the most common cause is degeneration in the semi-circular canals of the inner ear. BPPV becomes much more common with advancing age, but in 50 percent of all cases, BPPV is called ‘idiopathic’, which is a fancy word we use when we don’t know!

Viruses can be accused too, such as those causing vestibular neuritis, minor strokes such as those involving anterior inferior cerebellar artery (AICA) syndrome, and Meniere’s disease are significant but unusual causes. Occasionally BPPV follows surgery, where the cause is felt to be from a prolonged period of lying on the back with the chin raised (for the anaesthetic tubes to slip down your throat), or ear trauma when the surgery is to the inner ear. The simple situation is that we can make the diagnosis, but it can be harder for us to exactly pinpoint the cause. To make it even harder, an intermittent pattern is common. Your BPPV may be present for a few weeks, then stop, but then come back again.

Is there any treatment? Yes there is, if ear rocks are the cause. Treatment usually consists of a series of maneuvers you are put through which are designed to move the ‘ear rocks’ around till they no longer cause problems. These are demonstrated by the Ear, Nose and Throat (ENT) specialists and usually result in around a 90 percent cure rate. The most common is called the Epley maneuver or the particle repositioning or canalith repositioning procedure, but have your ENT specialist show you how to do this.


The will you make in the living not in the after-life?

I’m sorry, but I have it on good authority that you can’t take it with you. And that’s the reason why I’m not going. But to cover all eventualities, I have made out a will. And so should you. That’s your dying will – but you need to make another, and that’s called your “Living Will”.

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However, there is confusion in the minds of many people, as to what a “Living Will” actually is and what it covers. First off, it is not euthanasia. I repeat, it is not euthanasia. Borrowing from the Mayo Clinic in the US, it states on their website “This written, legal document spells out the types of medical treatments and life-sustaining measures you do and don’t want, such as mechanical breathing (respiration and ventilation), tube feeding or resuscitation.” The important words to note are “life sustaining” and “resuscitation”. Neither of these concepts imply medically assisted suicide.

Once again from the Mayo Clinic, “Injury, illness and death aren’t easy subjects to talk about, but by planning ahead you can ensure that you receive the type of medical care you want, to take the burden off your family of trying to guess at what you’d want done.”

Remember that we are talking about terminal situations here. Not situations from which it would be reasonably expected that you will recover and still have a good quality of life. A fractured hip when you are 90 is a serious situation, but provided you are healthy otherwise, then it would be expected that you would recover. You might need a stick for a while, but you would still be able to have a beer with your mates or whatever your pursuits were before the incident. In other words, the expectancy of a reasonable quality of life is there.

However, if you are in the terminal phase of metastatic cancer, which has progressed despite treatment, the future quality of life is not there. Artificially prolonging life under that situation is then covered by the Living Will.

As an example, note the following:

The Living Will is made while of sound mind. It is not something you scribble out while lying in God’s waiting room. An example of a Living Will. “Being of sound mind and understanding all the implications, I ask that this document be brought to the attention of any medical facility in whose care I happen to be, and to any person who may become responsible for my affairs.

“This is my ‘Living Will’ stating my wishes in that my life should not be artificially prolonged, if this sacrifices my Quality of Life.

“If, for any reason, I am diagnosed as being in a terminal condition, I wish that my treatment be designed to keep me comfortable and to relieve pain, and allow me to die as naturally as possible, with as much dignity as can be maintained under the circumstances.

“As well as the situation in which I have been diagnosed as being in a terminal condition, these instructions will apply to situations of permanently unconscious states and irreversible brain damage.

“In the case of a life-threatening condition, in which I am unconscious or otherwise unable to express my wishes, I hereby advise that I do not want to be kept alive on a life support system, and I do not want resuscitation, nor do I authorize, or give my consent to procedures being carried out which would compromise any Quality of Life that I might expect in the future.

“I ask that you are sensitive to and respectful of my wishes; and use the most appropriate measures that are consistent with my choices and encompass alleviation of pain and other physical symptoms; without attempting to prolong life.”

Now those are only examples. The Bangkok Hospital Pattaya has a pro forma Living Will, which was also repeated in the Pattaya City Expats website, I believe.

The take home message is that a Living Will is not euthanasia, and that you must lodge it, before you need it! The responsibility is yours, as nobody else can say any procedure was what you wanted (or didn’t want), if in the terminal stage of your life.


Lies, damned lies and then there is statistics

Will you live forever? I’m sorry to disappoint you, but statistically you have a 100 percent chance of dying. Yes, forget about “health” medications, statistics will prove it. Did you know, for example, that everyone dies within six months of their birthdays? They do, either before or after (do the math). Did you know that 95 percent of all the people who died in Pattaya last year wore shoes? The statistics would then have you believe that shoes were the greatest killer of mankind (not sure where that puts flip-flops).

A couple of years ago, the Cancer Council of Australia produced a sober warning message (at this time of year anyway), “Quit drinking to cut cancer risk.” The Cancer Council went on further to proclaim, “New evidence reveals the extent of alcohol’s contribution to cancer.”

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Now, having been photographed with the odd glass of wine in my hand on more than one occasion, I was immediately interested. Should I go on the wagon tomorrow? (“Today” was being a bit soon, I thought.)

I continued reading, “Cancer Council Australia has revised dramatically upwards its estimate of alcohol’s contribution to new cancer cases and issued its strongest warning yet that people worried by any link should avoid drinking altogether.”

It appeared that the cancers involved were bowel and breast and the figures indicated that these were nearly two-thirds of all alcohol-related cancers, overtaking those of the mouth, throat and esophagus.

More chilling news was that the Convener of the Public Health Association of Australia’s alcohol expert group, said he would write to the Australia and New Zealand Food Regulation Ministerial Council, to request it mandate health warnings on bottles. (It may be of interest to you that in Thailand there is an anti-alcohol group as well as the anti-smoking lobby).

Now there are many individuals predicting the end of the world, as well as Scandinavian teenagers, so how great a threat was this really? The group media release went on, “New evidence implicating alcohol in the development of bowel and breast cancer meant drinking probably caused about 5.6 percent of cancers in Australia. This was nearly double the 3.1 percent figure it nominated in its last assessment, in 2008.”

Using their own figures we are looking at 94.4 percent were not caused by alcohol.

So now we are getting to the nitty-gritty of all this. If we accept that they have managed to “prove” (beyond reasonable doubt) that alcohol does indeed “cause” 5.6 percent of cancers, what does this mean? Since breast and bowel cancers are only two thirds of the alcohol-related cancers (their mathematics, not mine), this means that together they make up 3.7 percent of the cancers in Australia. Let’s split the figure and make it 1.85 percent each. I remain somewhat underwhelmed, I am afraid. These figures can be read to suggest that 98.15 percent of breast cancers are not related to alcohol ingestion, and similarly the figures for bowel cancer.

Now don’t get me wrong here. I am not advocating we all get smashed every night, and indeed I do not think we should drink alcohol every day. However there are greater risks from alcohol intake than breast or bowel cancer. Liver damage for starters.

So if you are a person who likes a drink or three and would like to check your liver function we do have a GI and Liver Center that would be happy to check for you. Telephone 1719 for an appointment.


HEADLINES [click on headline to view story]

Living with cancer

The Tale of Tanujin

Prostate Cancer once more

Is EBM good for you?

Falling off the bed

The will you make in the living not in the after-life?

Lies, damned lies and then there is statistics