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The Star Online: Lifestyle: Health

Bladder cancer 101

Posted: 28 May 2014 09:00 AM PDT

Bladder cancer is not an uncommon cancer, and it usually affects men more than women.

BLADDER cancer is the sixth most common cancer among males in Malaysia, with an estimated incidence of 4.7%.

One of the biggest risk factors for bladder cancer is smoking. The risk is about four times higher in smokers compared to non-smokers.

The risk increases with the number of cigarettes smoked, and the duration one has been smoking.

Chemicals that can cause cancer are present in cigarette smoke. Some of these chemicals are absorbed into the blood and end up in the urine after being filtered by the kidneys.

The chemicals can damage the cells that line the bladder, and over many years, this may cause cancer.

Besides that, the older the person is, the higher the risk of bladder cancer. In Malaysia, the average age of a bladder cancer patient is 65 years old. If you are a male, the risk is also greater.

In a study carried out in a hospital in Malaysia, the male-to-female ratio was 9.4 to 1.

Radiotherapy is a treatment option for bladder cancer, especially if the patient has multiple medical illnesses and is not fit for surgery. - Filepic

Radiotherapy is a treatment option for bladder cancer, especially if the patient has multiple medical illnesses and is not fit for surgery. — Filepic

Exposure to certain chemicals like aromatic amines used in dye factories, rubber, leather, textiles, printing, gasworks, plastics, paints, and in other chemical industries also increases the risk.

Other risk factors include repeated urinary infections, untreated bladder stones, radiotherapy to the pelvis, cyclophosphamide (a type of chemotherapy) and family history of bladder cancer.

The most common presenting complaint of bladder cancer is blood in the urine (haematuria). This is usually visible to the naked eye (macroscopic haematuria), and is usually painless.

Sometimes, the blood is not visible and can only be detected by urine tests (microscopic haematuria).

There may also be urinary symptoms like increased frequency of going to the toilet as well as urgency (a sudden urgent desire to pass urine and not being able to put off going to the toilet).

If bladder cancer is suspected in an individual, a urine test will usually be performed to look for blood as well as cancer cells.

A flexible cystoscope (a thin tube with a camera and light on the end) will then be used to directly view the bladder. A jelly containing anaesthetic will be squeezed into the opening of your urethra to make the procedure less uncomfortable.

The doctor gently passes the cystoscope through your urethra and into the bladder and examines the whole lining of the bladder. The whole test takes a few minutes and you can usually go home after it is finished.

If bladder tumour is seen, the next step is to get the same procedure done under general anaesthesia in the operating theatre, either to take a small piece of tissue (biopsy) or to remove the tumour (transurethral resection of bladder tumour/TURBT).

The tissue specimen will then be sent to the laboratory to be examined under the microscope to look for cancer cells.

If it is proven to be cancer, it will then need to be staged to determine the extent of the cancer, i.e. whether it is localised (confined to the bladder) or advanced/metastatic (spread beyond the bladder into surrounding tissues or distant organs like the liver, lung or bone).

This would entail having radiological imaging like computerised tomography (CT) scan or magnetic resonance imaging (MRI).

Treatment will then be determined by the extent of spread.

Most of the time (about 70% of cases), the cancer is superficial. After complete resection of the tumour with a cystocope, chemotherapy drugs like mitomycin or a vaccine known as BCG (Bacillus Calmette–GuĂ©rin) will be introduced into the bladder.

If the cancer is found to be invasive but has not spread to distant organs, then either surgery (radical cystectomy) or radiotherapy is needed.

Radical cystectomy entails removing the bladder with the surrounding lymph nodes. This can be done either through open surgery, or laparoscopic/robotic surgery. In men, the prostate is removed as well.

To replace the bladder, either a urostomy (ileal conduit), continent cutaneous urinary diversion or a new bladder (neobladder) is formed.

In urostomy, the ureters are connected to a section of the small bowel, which will then divert the urine out through an opening in the abdomen.

In continent cutaneous urinary diversion, a pouch is made from the bowel to replace the bladder. The ureters are again connected to this pouch and urine is emptied by inserting a catheter (small tube) into this pouch through an opening in the abdomen.

In a neobladder, this pouch is connected to the remaining urethra instead of an opening in the abdomen.

Radiotherapy is another option, especially if one has multiple medical illnesses and is not fit for surgery.

This involves high energy rays to kill off the cancer cells. Each treatment takes about 10-15 minutes, and they are usually given Monday-Friday, with a rest at the weekend. A course of radiotherapy for bladder cancer may last four to seven weeks.

Chemotherapy may be given in combination with surgery or radiotherapy.

If the cancer has spread to other sites or organs, then treatment will not be curative. It will depend on the symptoms involved and may require a combination of radiotherapy, chemotherapy, or rarely, surgery.

Bladder cancer is notorious for recurrences, even when it is superficial. Therefore, careful and regular follow up is essential.

Cystoscopes and urine examination are needed during clinic appointments, and sometimes CT scans are also required.

Most superficial cancers do well after proper treatment. Those who have poor survival are usually diagnosed late and have advanced cancer that has spread beyond the bladder.

Therefore, early diagnosis and prompt treatment is mandatory. Do not procrastinate. See your doctor if you have any of the symptoms described above.

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 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.

Self-harming is on the rise among youth

Posted: 27 May 2014 09:00 AM PDT

The rise in poor mental health among young people needs to be addressed.

THERE has been a three-fold increase in the number of teenagers who self-harm in England in the last decade, according to a World Health Organisation collaborative study.

The Health Behaviour in School-Aged Children (HBSC) report, due to be published in the autumn, will reveal that of the 6,000 young people aged 11, 13 and 15 surveyed across England, up to one in five 15-year-olds say they self-harm.

There is no comparative data from other countries as England is the first country to ask this question on self-harm since the global study, which is conducted every four years, began in 1983. The decision to include it follows a rise in anecdotal evidence from teachers in secondary schools across the country.

The last comprehensive study of self-harm in England was published by the British Medical Journal in 2002. It surveyed around 6,000 15- and 16-year-olds in 41 schools and found that 6.9% of them said they had self-harmed over the past year. This compares with the 2013-2014 WHO study, which puts the figure at 20% of 15-year-olds.

Self-harm includes actions such as cutting, burning and biting oneself. Professor Fiona Brooks, head of adolescent and child health at the University of Hertfordshire, is the global study's principal investigator for England. She says: "Our findings are really worrying, and it's (self-harm) considerably worse among girls. At age 11, both girls and boys report a good level of emotional well-being. But by the age of 15, the gap has widened and we get 45% of adolescent girls saying they feel low once a week compared with 23% of boys."

She warns of a ticking time-bomb unless the rise in poor mental health among young people is addressed. "We don't yet know enough about why this (poor mental health) is but parents are busy and stressed, and children's lives are becoming more pressurised. They know they need better grades to get to university, but there's no guarantee of a job at the end of it all."

Brooks believes that young people are "turning to strategies such as self-harm to manage stress in the short term".

"Although there has been a decline in traditional risk behaviours like smoking and drug and alcohol abuse, there hasn't been a transition to more positive health behaviours," she says.

Grace, 16, appears to be a bubbly and confident teenager who loves music, singing and netball. However, when she was 12, Grace began self-harming.

"I began cutting my wrists using scissors and razor blades, which I disinfected myself," she says. "As time went on and I got worse, it progressed all the way up my left arm and my upper thighs. I just bandaged it up and left it."

Years of cutting have left her with deep scars that she covers up when around people she doesn't know very well. "At my worst, I was hurting myself once a week or even more. Sometimes it was once a month. It just depended what was going on around me," she explains. "It calmed me down but then I'd immediately wish I hadn't done it as it hurts and you need to hide it."

Grace never confided in her mum, but finally a teacher noticed.

"I was hauled into the headteacher's office one morning, and my mum and my teacher and the head were all sitting there. I was totally bowled over when they said they knew what I'd been doing," she recalls. As a result of the meeting, Grace retreated further into her world, self-harmed more and concealed it better. "Even when I wanted to stop, I couldn't – and it took me longer than I care to admit to get things under control," she says.

She did receive counselling via her school, but says it didn't help because she couldn't relate to the older counsellor.

Although her mum says she feels she has failed her, Grace doesn't blame anyone for what she went through. "It's no one's fault. I just wish I'd been able to cope with things better," she says.

"When I was 12, my mum was moving in with my now stepdad, I wasn't getting on very well with anyone at school, and the few friends I did have weren't being very kind. I struggle with change, so from all aspects it was hard. It had always been me, my mum and my sister, and it was all so new with my stepdad. My real dad worked abroad a lot so I felt I didn't have anyone to talk to and I didn't have any way of dealing with it."

Of her gradual recovery, Grace says: "Maybe I just got used to the changes around me and things got better at school. I have a close group of friends, and for the first time I have a best friend which I've never had before. My family has been very supportive, too."

But she adds that being diagnosed with depression a year ago was a huge relief and she believes that an earlier diagnosis would have helped. "It stopped me being confused about why I felt this way," she says. "Although it sucked to have a label, being diagnosed helped me to realise that there was a reason behind what I was doing and once I dealt with the reasons, I knew I wouldn't have to revert to self-harm anymore." is a website set up in 1993 to support the emotional and social needs of all young people. It provides a forum where self-harmers can seek advice and feel connected with others going through similar experiences. Grace was asked to pilot its Alumina scheme, which provides weekly online meetings with counsellors and doctors and she participates in various activities that help to analyse what she is doing.

Prof Brooks believes research is telling us a closer look is needed at what has caused such a dramatic increase in self-harm in the past decade. "We need to know what strategies to put in place to help young people navigate adolescence successfully." – Guardian News & Media

Untapped treasures in herbal products

Posted: 27 May 2014 09:00 AM PDT

Part 1: Mining for bio-billion$

Concluding our two-part series on Malaysia's potential genetic gold mine of medicinal herbs.

LAST week, we met a team of scientists working to transform misai kucing, a local plant with a long history of traditional medicinal uses, into a cancer-fighting herbal extract. Yet this Penang-based team is an anomaly in the landscape of Malaysia's herbal industry.

We are still a long way from producing anything more than general and medium-claim health supplements that offer "improved vitality", "maintenance of good health", or "promote healthy bones".

For our herbal drug development industry to grow past infancy, it needs to overcome numerous challenges: from Asian superstitions and popular psychology to risk-averse corporations and a lack of coordination across institutions.

Gung-ho about herbs

Where would you look for the next big anti-cancer or hypertension drug?

Nature has provided us with the materials for plenty of revolutions: life-saving antibiotics, game-changing antimalarials, immunosuppressant drugs that enable us to perform organ transplants, anti-cancer drugs ... the list goes on.

Malaysia is one of the richest places on Earth in terms of biodiversity. It is home to about 12% of all plant species, and about 2,000 of those found locally are already known to possess medicinal qualities.

In 2010, the Government announced its intention to make the country a serious player in the high-value herbal products business.

The industry's global market value had more than tripled in just eight years, hitting US$200bil (RM642bil) by 2008.

And it is expected to balloon to 20 times that amount over the next few decades, according to estimates by the World Bank (US$5tril, or RM16tril, by 2050).

This makes the herbal products industry a prime candidate to drive Malaysia's emerging bioeconomy.

The Government made development of the herbal industry a priority under Entry Point Project 1 (EPP1) of Agriculture, one of 12 National Key Economic Areas.

Initially, the focus was on five plants known to Malay traditional medicine – tongkat ali, misai kucing, hempedu bumi, dukung anak and kacip fatimah.

Since then, six more – mengkudu, roselle, ginger, mas cotek, belalai gajah and pegaga – have been added to the list.

The ideal situation would be to replicate what happened with Korean Ginseng which, thanks to a careful government-coordinated research and marketing plan, is world renowned.

From roadside to store

Research is expensive, but necessary; it adds credibility so products can compete on the international market. First, there needs to be demand and support for such products on home ground – but the reality is that there couldn't be a more difficult market to penetrate.

Tradition-minded South-East Asia tends to be very accepting of unregistered herbal medicines and products. Herbal remedies and supplements are ubiquitous, sold in street markets, shops and e-commerce sites, and bought by many.

The trade in unregistered supplements and medicine is booming – not surprising, considering that the region has historically been a confluence of Malay, Chinese and Ayurvedic traditional medicines. Culturally, communities maintain strong ties with traditional beliefs and practices; consulting traditional healers and witch doctors such as bomohs is not uncommon.

Culturally, there is little demand for oversight of the validity of product claims.

It is perhaps ironic that our ready acceptance of herbal medicines is, in fact, partly why it is so hard to drag the industry out of its infancy.

It all boils down to what makes sense as a financial investment.

This is how Prof Dr Ibrahim Jantan, a senior professor at Universiti Kebangsaan Malaysia who heads the university's Natural Products Research Cluster, explains the psychology behind local investors: "Why should they spend on R&D when products already flooding the market are making so much money?"

It's a toss-up – selling your product overseas may fetch a higher price, but generally, developed markets demand quality.

Herbal remedies have been used for thousands of years around the world. The 1960s heralded a global shift towards synthetic medication; but plants are back in vogue as a medicinal source. 	- Calsidyrose/Creative Commons

Herbal remedies have been used for thousands of years around the world. The 1960s heralded a global shift towards synthetic medication; but plants are back in vogue as a medicinal source. -calsidyrose/Creative Commons.

That's where legal use of the label "clinically proven" really begins to matter, and that's one of the goals EPP1 is striving for.

The problem is that R&D increases costs, so why bother with it if the sole objective is to make money, and there are many willing buyers in Asia?

A report published by the Global Science Advisory Council last year is telling. Entitled Public Research Assets Performance Evaluation: Unlocking Vast Potentials, Fast Tracking The Future, it notes that little is spent by industry, especially SMEs, on R&D.

This indicates that companies in Malaysia generally have a low rate of innovation, and little focus on product development. They want "ready-made" technologies from public research institutions without any cost.

As Ibrahim puts it: "What's happening now is that generally, we are not coming up with our own products – we are trading products."

Hidden dangers

Most countries do not regulate traditional medicine and health supplements.

Like so many of them, Malaysia has less stringent criteria for such products. These read like an abridged version of pharmaceutical product registration criteria.

Which makes sense, if the goal is to nurture growth within a fragile new industry with market incentives stacked against it.

The upshot is that products are evaluated based on their safety and quality, not their efficacy.

As it stands, the active ingredients of many herbal products are not even known.

This leads to a rather bizarre situation: there is no real way of measuring/testing a product to ensure it contains the appropriate dosages in standardised extracts to achieve its claims. Government seed funding encourages R&D and identification of the active ingredients, as well the concentrations required for efficacy.

There's another reason why moving towards more clinically-backed products is important: safety.

Professor Ibrahim Jantan from Universiti Kebangsaan Malaysia talks about the challenges thrown up by purchasing habits of Malaysian consumers, where a lack of demand for scientifically proven, registered  herbal products means manufacturers have less incentive to invest in R&D.

Professor Ibrahim Jantan from Universiti Kebangsaan Malaysia talks about the challenges thrown up by purchasing habits of Malaysian consumers, where a lack of demand for scientifically proven, registered herbal products means manufacturers have less incentive to invest in R&D.

Just because something has been consumed for hundreds of years doesn't mean there are no chronic toxicity or side effects, Ibrahim points out.

After all, practitioners are more likely to only notice and make a clear connection between the consumption of a specific herb if the ensuing symptoms are acute.

This also applies to safe dosages: "Let's say the herb is supposed to reduce blood pressure; the question is, does it reduce it to a therapeutic level?"

Either way, there is plenty of merchandise being sold, sometimes at exorbitant prices, to gullible consumers.

So improving standards within the industry will benefit both health and pocket.

The first step is to try and change consumer habits. Products approved by the Drug Control Authority (DCA) may not need to prove efficacy, but safety tests are needed to guard against harmful adulteration – a big problem in the vast market of illegal and unregistered herbal supplements and drugs.

Often the products are bogus; confiscations and tests have showed up poisons, heavy metals and slimming agents.

Prescription drugs such as paracetamol, antihistamines, steroids, anti-diabetics, and synthetic PDE-5 inhibitors (sex stimulants) have also been found, presumably as a deliberate action to produce some sort of therapeutic effect.


As the global herbal supplement industry continues to grow, standards and oversight measures are likely to come under closer scrutiny.

Science has shown that many herbs have a huge amount of medical potential, so the target should be to encourage a more science-based approach to the herbal industry, bringing it up to par with conventional medicines.

Public perception and trust in traditional medicines continue to fuel growth, despite widespread media reports about expensive supplements exposed for misleading claims.

It will be a huge challenge to convince local industry players to move away from the temptation to make a quick buck by scrimping on R&D costs, to simply manufacture low- and general-claim products.

With the wealth of promising local herbs, the prize for creating a "killer" scientifically-backed product could be big.

Six EPP1 champion companies have been partnered up with research institutions to bring local herbal products to market.

Only two of the six, however, have their eyes on the high-claim (disease risk reduction) products – Natureceuticals Sdn Bhd, with its anti-angiogenic Misai Kuching extract Canssufive, and Nova Laboratories Sdn Bhd, with its Hepar-P Capsule, a liver protection agent. The two hope to have completed clinical trials by 2017 and 2015 repsectively.

If their work does prove a success, they will be the first Malaysian companies to come up with high-claim herbal products.

For now, however, a better informed public and a crackdown on illegal products and misleading claims (that defy regulations like the Sale of Drugs Act), may go a long way to helping that cause.

Check if a herbal product is legitimate:

> Registered products are affixed with a hologram

> Cross-reference the product registration numbers against the National Pharmaceutical Control Bureau database ( by doing a QUEST search.

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