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Posted: 11 Jun 2011 05:40 PM PDT

The writer recounts how his sister struggled with breast cancer before succumbing to the disease.

THIS is not just another sad cancer story, but the story of the struggles my own sister, Ilani Isahak, went through, fighting her breast cancer for three years until she succumbed to the disease in February this year. I had written a tribute to her (see http://www.thestar.com.my/lifestyle/story.asp?file=/2011/3/13/lifefocus/8183426&sec=lifefocus), in which I extolled her service to the community and nation, especially her dedication in promoting interfaith harmony. She died soon after successfully establishing the national interfaith committee, a task entrusted to her by the Cabinet.

Today, I shall focus on the health/medical aspect of her story. I hope that by sharing her experience, many other women can be helped, not only to fight the cancer, but more importantly, to take steps to detect breast cancer early if it occurs. There are also lessons that all others can learn.

It would be good if we can also advise women on how to avoid getting breast cancer, but unfortunately, apart from prophylactic mastectomy (ie removal of normal breasts) in high risk women with known mutations of the breast cancer genes, there are no other proven methods of preventing breast cancer.

There are known factors that can modify the risk of getting breast cancer. Studies have shown that obesity (especially post-menopausal weight gain), lack of exercise, late menopause, and HRT (exceeding five years) increase breast cancer risk.

A diet rich in of soy isoflavones (eg genistein, which is known to have anti-breast cancer effects), reduces breast cancer risk. A nutrient-dense diet made of fruits, veggies, legumes, grains and nuts reduces the risk of all cancers.

Get every breast lump checked

My sister had Stage 3B (ie advanced) breast cancer at the time of diagnosis. Some years back, she had a breast lump that caused much anxiety, but turned out to be benign.

So this time, when she noticed another lump on her right breast, she made the mistake of not worrying about it. She was also wrongly assured by a Traditional Chinese Medicine sinseh, whom she had she trusted over the years, that it was not cancerous, and he had given some treatment to shrink the lump.

It was only when the lump got bigger and became painful that she confided in me. An examination revealed an obvious lump adherent to the surrounding tissues, which was not a good sign. I immediately sent her for mammogram, and to the breast surgeon.

Lesson #1 – Every breast lump is cancerous until proven otherwise. While most lumps are benign, you should seek expert assessment before deciding so.

Although I am supportive of the complementary practitioners' role in healthcare, there are situations where you should always seek medical confirmation for diagnosis, as in this case. The doctors will examine and do ultrasound or x-ray mammogram (which detect the physical or morphological changes).

Other available methods include thermography, electrical impedance tomography and laser mammogram (which detect the functional changes caused by cancerous cells). If necessary, a biopsy will be done.

Nutrition support is important

Her mammogram was consistent with breast cancer, and biopsy confirmed infiltrating ductal carcinoma. After much discussion with the family, she decided to follow her doctors' advice, as well as embark on a nutritional programme. She had a modified mastectomy, followed by radiotherapy, and six courses of chemotherapy.

She was very disciplined with her nutrition – she reduced meat intake and consumed lots of freshly-made fruit juices. She also tried several natural remedies that were claimed to be anti-cancer (eg lemon grass), and consumed various nutritional supplements.

So despite the cancer, radiotherapy, and chemotherapy, until the last one month, she actually looked much healthier than she had been in the previous 20 years. She slimmed down to her ideal weight, had better complexion, and was energetic (until the last six months when the cancer went to her lungs). She was so well externally that many were surprised how she coped so well with the cancer and chemo.

Lesson #2 – if you have cancer, take care of your nutritional needs. The body needs nutrients to fight the cancer, and to fight the side-effects of the cancer treatments. Many cancer patients die of cachexia (extreme malnutrition).

Recurrent cancers are recalcitrant

But what many probably didn't know was that she still lost her hair, and her fingernails were blackened after the repeated chemo sessions. Soon after the initial six courses of chemo and one year of the "smart" drug ended, the cancer came back.

The extremely expensive "smart" drug she was given was trastuzumab, which is a monoclonal antibody that targets the HER2 receptors on the breast cancer cells.

So her oncologist put her again on chemo, plus the "smart" cancer drugs. But this time, these didn't work. A re-examination of her cancer cells then showed that she was not a good candidate for trastuzumab. The first report had been inaccurate.

Other drugs were then tried, and there was some response, but internally the cancer was encroaching into her rib cage, and onto the lining of the lungs (pleura).

The other drugs she was given included bevacizumab, which is also a monoclonal antibody that prevents new blood vessel formation (anti-angiogenesis), thus preventing new cancer growth.

Back in July 2010, the US FDA had evidence that bevacizumab was not suitable for breast cancer. In December 2010, the US FDA officially revoked its approval for the use of bevacizumab for breast cancer, saying that it is neither safe nor effective in breast cancer patients. The available data shows that bevacizumab neither prolonged overall survival nor slowed disease progression sufficiently to outweigh the risk it presents to breast cancer patients.

Lesson #3 – If the cancer patient is not cured after the first course of chemo, she is unlikely to be cured at all. Cancer cells which are resistant to the first chemo are most likely resistant to further chemo. Although each subsequent chemo may drastically reduce the number of cancer cells, the tough resistant ones will multiply and manifest their presence soon enough.

Lesson #4 – Before agreeing to expensive drugs, be sure that the lab reports are accurate, and be sure that the drugs are safe and effective as claimed.

Rapid deterioration of end-stage cancer

Until the last six months of her life, my sister was relatively well, which means she had about two years of reasonably "good quality" life. Then she started to have chronic coughs.

At first, she still managed to do her normal chores, but she gradually deteriorated, and became breathless easily. A pleural effusion (fluid in the space covering the lungs) was diagnosed, but the first attempt to drain the fluid failed to relieve her symptoms.

At this time, the family considered bringing her to China to try the latest treatments being done there, as the doctors here could not do anything more to treat her cancer. Doctors in China are allowed to give treatments which are considered experimental elsewhere, and therefore not available to the public.

Unfortunately, while the planning was being done, her condition got really bad. Exactly one month before her death, she had to be admitted to the hospital, and had permanent drainage tubes inserted into both sides of the rib cage, and she required the oxygen mask continuously.

The doctors also decided that she could have palliative care only, with no further active treatment. After one whole month of suffering, she died.

My sister died because the cancer spread to a vital organ – her lungs. There was copious pleural effusion that repeated and even continuous drainage could not solve. The effusion meant that her lungs gradually collapsed.

With the reduced oxygen supply, the heart had to work harder, and soon it also succumbed. Although there were discussions to attempt surgery to seal the pleural cavity (thus preventing the formation of the effusion), by that time, her poor general condition made any major surgery unsafe.

Lesson #5 – If you plan to have treatment overseas, do so when you are still reasonably well, because there will be the added problems of being fit for long-distance travel, and having adequate assistance in a foreign land.

What about complementary therapy?

Some people asked me why I allowed my own sister to undergo chemo, when I am so critical of it? The answer is that I never interfere with a patient's decision. I only remind them of the facts I know, and that while some cancer patients have recovered through various types of nutritional and complementary therapies, the latter lack sufficient scientific evidence, while chemotherapy is backed by many scientific studies.

What is important is that whatever their decision, they need adequate nutritional support to survive the cancer, and to withstand the chemo.

What about nutritional therapy – since I had written about certain nutritional therapies that had helped some cases? Well, cancer nutritional therapies are also expensive, and are usually taken by patients who refuse chemo, or only after they have completed chemo (some oncologists also dissuade them from having concurrent therapy as the nutritional therapy may interfere with the chemo).

I have also been asked why didn't I help her with qigong? Actually she did learn qigong, but she was too busy to practise it enough to hope for recovery through it. Those who recovered through qigong did so after intensive and consistent practice (my advice is to start with four hours a day if possible). Even though recovery is not guaranteed, it is possible.

My only regret is that I didn't have the opportunity to get her to try herbal medicine, as she was already trying so many things suggested by many people, and adding another therapy would certainly be overdoing it.

In conclusion, both conventional medicine and complementary therapies still do not have satisfactory answers for cancer. For the sake of the cancer patients (and many more who will get cancer in future), both sides should work together. A holistic, integrated approach is more likely to enable us to find the elusive solution.

With that in mind, I invite readers to attend the 1st Malaysian International Conference on Holistic Healing for Cancer, to be held in Petaling Jaya on June 8. It is organised by Cansurvive, a non-profit organisation that provides guidance and support to cancer patients, their families and friends. Admission is free, but you must pre-register. Please go to www.cansurvive.org.my for details.

Dr Amir Farid Isahak is a medical specialist who practises holistic, aesthetic and anti-ageing medicine. He is a qigong master and founder of SuperQigong. For further information, e-mail starhealth@thestar.com.my. The views expressed are those of the writer and readers are advised to always consult expert advice before undertaking any changes to their lifestyles. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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The health contract

Posted: 11 Jun 2011 05:40 PM PDT

Though healthcare is increasingly driven by the prospect of profits, the patient-doctor social contract must prevail.

THE social contract between patients and doctors must prevail in Malaysia as it is a time-proven model for quality, affordability, and compassionate care for patients, said Dr Steven Chow, president of the Federation of Private Medical Practitioners' Association, Malaysia (FPMPAM).

The traditional social contract governing the patient-doctor encounter guided by the simple dictum of Sir William Osler, ie, to cure sometimes, to comfort always, but never to harm, is increasingly eroded by the dictates of commercialised medicine, driven by bottomline turnover, profit, and return on investment.

Private practitioners in a dilemma

"Today, medical care is being touted as a lucrative business commodity to be bought and sold, with corporate visions of exponential growth and billion-dollar turnover," observed Dr Chow.

In the current healthcare scenario, the basic needs of patients and the aspirations of compassionate doctors are no longer a contractual priority. Instead, the turnover generated by doctors and their corporate patients has become the implicit driver of business-driven contracts.

This is the cross-road that now faces both the public and doctors, he explained.

Paradoxically, the reason for the need for this change being marketed to the public is the so-called rising cost in healthcare, and the dire need for cost-containment to ensure sustainability.

On the contrary, the evidence paints a different picture – healthcare cost is on a rising trend that will seriously overtake our ability to provide basic quality, affordable healthcare for the less fortunate, Dr Chow emphasised.

Over the years, we have seen the progressive commercialisation of all aspects of healthcare, starting with medical education, all the way to the delivery of tertiary and primary healthcare. In tandem with this is the alarming rise in the cost of providing medical care, which affects both private and public sectors, he said.

"There is, thus, some important fundamental issue regarding the way our healthcare system is being regulated. It is important that this issue is addressed urgently. FPMPAM finds this trend extremely alarming."

The public is of the perception that a high hospital bill is due to hefty doctors' fees. Hence, they call for more regulations to oversee the practitioner, rather than the business of medicine.

However, in reality, the professional fees for doctors have already been capped by law. It should also be noted that the average doctor's professional fees account for about 10% to 15% of the overall private hospital bill.

In contrast, there are no provisions in the Private Healthcare Facilities and Services Act (PHFSA) 1998 and Regulations 2006 to regulate hospital bills, Dr Chow said.

"Doctors trained in the traditional mould of medical care will have problems coping with this change. The new laws and regulations regulating the so-called business of medicine, with its countless threats of massive fines and imprisonment for non-compliance, do not augur well for the traditional genuine, compassionate social contract-based patient-doctor relationship."

Thus, he called on the Ministry of Health (MOH) to uphold the spirit of the PHFSA 1998 and Regulations 2006, which states that medical care should be in the hands of doctors, eg, Part XIV states that the Board of Management of any private hospital is the ultimate authority governing all aspects of medical care in that hospital.

Two members of this board must be doctors appointed from the Medical/Dental Advisory Committee (MDAC), which is supposed to represent all doctors practising in hospitals and whose function is to ensure that the medical management of patients vests in registered medical practitioners.

"Hospitals have many ways and means to dilute the implications of this requirement," said Dr Chow.

Moving on to Part XV of the PHFSA, Dr Chow said contracts between healthcare facilities and managed care organisations (MCOs) must not alter the power of the doctor in providing medical care. Most doctors in the private sector are bound by contracts with hospitals or MCOs, or directly with employers and companies.

The dilemma now is that when doctors start work at private hospitals, the hospitals themselves may have already entered into contracts with MCOs, in which some of the contractual provisions are in contravention of the PHFSA. The doctors themselves have no access to these contracts, but nevertheless, are involuntarily bonded to them by virtue of their contract with the hospital.

"We advise doctors that it is their right to refuse any contract that interferes with their independent medical care of patients. Should they be coerced, FPMPAM will fully support their action to refer such contracts to the MOH," Dr Chow emphasised.

"The onus is on the MOH to act its part as the regulator. However, the major hospitals are now mainly owned by government-linked companies (GLCs), ie the government, being the regulator, is also an operator in the industry via its GLCs. In a situation like this, there is clearly a blurring of the line between the regulator and the operator," Dr Chow commented.

In addition, as a measure to boost profits, some hospitals, MCOs and other third parties in healthcare have resorted to extracting mandatory discounts from doctors' professional fees in their contracts.

The FPMPAM calls this "fee-splitting", an exercise which is in contravention of the PHFSA and Regulations. "FPMPAM is committed to initiate all action necessary against any party trying to extract such discounts from our doctors."

In the past, Dr Chow said, the FPMPAM had highlighted to the MOH the difficulties doctors were facing with contracts. "We hoped that the MOH would act swiftly and decisively.

"In 2006, we also proposed important regulations to the PHFSA and Regulations so that all the business components of healthcare are regulated synchronously to protect the public from over-exuberant commercialisation."

This article is courtesy of the Federation of Private Medical Practitioners' Association, Malaysia.

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Breakthrough for prostate cancer

Posted: 11 Jun 2011 05:38 PM PDT

Two new therapies for advanced prostate cancer reflect the enthusiasm that doctors hold for the future treatment of this disease.

CANCER of the prostate (CaP) is the most common cancer (other than skin cancer) in males in Western countries. In the US, it has been estimated that about 200,000 men were diagnosed with CaP in 2009, with more than 27,000 dying from the disease.

The prevalence of CaP in Asian countries is rapidly increasing as a result of the increased consumption of Western-style meals (diet has been strongly implicated as a risk factor for CaP).

In Taiwan, currently, CaP is the third most common cancer in men, and the numbers affected are still on the rise.

A question of castration

Cancer of the prostate is an androgen-receptor dependent disease, and the treatment for advanced prostate cancer is androgen deprivation therapy (ADT), or in layman's term, depriving the cancer of testosterone.

For decades, ADT has been the most effective and successful treatment for prostate cancer. However, in nearly all cases, the cancer eventually progresses after 12 to 48 months despite ADT, depending on how extensive the disease, host factors, and inherent tumour characteristics or biology.

The cancer invariably develops new tumour characteristics and clinical behaviours after treatment with ADT. This newly evolved cancer is known as castration-resistant prostate cancer (CRPC), which is inevitably fatal. The transformed and fiercer cancer thrives and spreads rapidly despite the body having very low testosterone levels.

The current treatment for CRPC is chemotherapy, using a standard docetoxel-based regime. However, the prognosis remains poor, and median survival with chemotherapy is less than two years.

There is currently no standard of care for patients who fail chemotherapy, and the results of all existing therapies are very poor.

This pathetic and pessimistic scene is going to change within the next few years. Over the past few months, the US Food and Drug Administration (FDA) has approved three new drugs for terminal stage CRPC, and two have already demonstrated the potential of extending patients' lives.

Further, a whole host of revolutionary therapies, mainly oral medications, will come soon. Many of these new targeted or boutique drugs, which include denosumab, cabozantinib, MDV 3100, ARN-509, and TAIC-700, are in the late stages of development, and are near to final regulatory approvals.

We are certainly living in very exciting times where the bleak future of advanced castration-resistant prostate cancer patients are showered with optimistic rays of hope.

Becoming hormone refractory

How do prostate cancer cells evolve, grow, and spread rapidly despite very low testosterone levels in the body? Several things can result in this change:

· Genetic changes in the prostate cancer cells, or mutation resulting in more or different androgen receptors, result in the tumour thriving on very low levels of testosterone.

· The prostate cancer cells acquire the ability to produce their own testosterone from cholesterol molecules. This was certainly an unexpected discovery by medical researchers.

· The cancer cells develop mechanisms to evade detection by the body's immune system, thus the body's immune system is unable to recognise the tumour. The cancer cells can do this by creating changes that keep the immune killer cells in an immature state, allowing the tumour cells to spread throughout the body with impunity.

The recent launch of two innovative therapies for CRPC has brought about tremendous interest and excitement to urologists and oncologists worldwide. This is truly the beginning of many new effective therapies for end-stage prostate cancer patients, bringing realistic hope to these terminally-ill patients.

Two new drugs

Below are the two therapies recently approved by the FDA that have proven to increase patients' survival:

· Provenge is the first FDA-approved immune-boosting treatment that prolongs the life of advanced prostate cancer patients. In pivotal clinical trials, the Provenge-treated patients lived significantly longer than men treated in the control group. A 22.5% reduction in the risk of death was recorded.

Treatment with Provenge, also known as Sipuleucel-T, involves removing a small quantity of patient immune cells in a specialised centre. These cells are sent to the company's manufacturing facility. After about three days, the patient returns to the centre to receive an infusion of the boosted immune cells, which aim to kill off prostate cancer cells.

These newly boosted cells are also able to recruit other immune fighters or killer cells in eradicating prostate cancer cells. The entire Provenge treatment is repeated three times over a period of about four weeks.

The most common side effects that occur with Provenge treatment occurs one day after the infusion of the boosted immune cells. These side-effects include chills (7% of the patients), fever (23%), fatigue (16%), nausea (14%) and headache (11%). Most of these flu-like symptoms are temporary. In the clinical trials, less than 1% of the patients stopped treatment because of side effects.

The median survival benefit of Provenge therapy is about 4.1 months. About a third of the men in the pivotal trials were still alive three years after the treatment.

· The other breakthrough treatment for CRPC approved by the FDA about a month ago is Abiraterone. This is a pill with a low rate of side effects and has been shown to improve the life of CRPC patients who have failed all other treatments, including chemotherapies.

The oral medication is able to suppress androgen production in the adrenal gland, the testes, as well as in the prostate cancer cells. It is otherwise known as a true "de novo" androgen synthesis inhibitor, which practically wipes out all androgen manufacturing processes in the entire body of cancer prostate patients.

In clinical trials, patients were given 1,000mg (four pills) per day for a 28-day cycle in combination with prednisone 5mg. This regime has proven to be safe and effective in prolonging the life of CRPC patients.

There was a 35% reduction in the risk of death as compared with placebo plus prednisone, with a median survival of 14.8 months among patients who received abiraterone acetate plus prednisone, versus 10.9 months among patients who received placebo and prednisone.

The Abiraterone group of patients also show significant improvement in x-ray findings, a longer time to disease progression, and longer progression-free period. Side effects include hypertension, low potassium levels, and lower-limb swellings, are generally tolerable, and can be controlled with low dose prednisolone.

The Abiraterone research has enable medical scientists to understand in detail the biology involved in the progression of metastatic CRPC and this augurs well for researchers to develop more effective targeted approaches to further improve the outcome of treatment for CRPC patients.

Bright future

With the advent of truly effective therapies which can prolong survival of CRPC patients, the light at the end of the tunnel is ever brighter. The knowledge leading to the development of these two totally different therapies for CRPC has certainly opened up new pathways for the development of many more new targeted therapies.

There is every hope that the future management of CRPC or prostate cancer will follow the developmental paths of treating advanced testicular cancer, which was a fatal disease before the development of an effective chemotherapy regime. The early chemotherapy trials for advanced testicular cancer prolonged life by about four months, (like Provenge and Abiraterone). But today, more than 90% of all advanced testicular cancer cases are curable.

Testicular cancer is one of the few cancers that is considered totally curable and the patients go on to live a normal, full healthy life. In the coming decade, we will definitely see many more targeted therapies which could prolong lives. Using a combination of these therapies, which are proven to prolong survival, there is every hope that nearly all cases of prostate cancer at any stage may be totally curable.

The hope is even brighter when these innovative therapies are non-invasive and may just require taking a few pills per day.

These recent spectacular breakthroughs in treatment of CRPC have brought back memories of a dear friend and colleague who battled CRPC for a couple of years. We had tried practically every therapy available, including current hormonal and chemotherapies. He succumbed to the battle just weeks before the availability of these two FDA approved revolutionary therapies.

The battle against many cancers has taken centre stage. We are certainly racing against time to bring hope to the lives of patients who are unfortunate to have incurable cancer at this point in time.

This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public. The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. For more information, e-mail starhealth@thestar.com.my. The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader's own medical care. The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article.

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Kredit: www.thestar.com.my

Ahad, 12 Jun 2011

The Star Online: Lifestyle: Health

The Star Online: Lifestyle: Health

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