All pain is not the same in cancer. Different types of pain requires different medications:
Anti-inflammatory medications - paracetamol, ibuprofen
Opioids - morphine, oxycodone, fentanyl, hydromorphone, methadone
Neuropathic agents - pregabalin, gabapentin, amitryptilline
Most times it is a combination of these drugs which would help.
Monday, 31 March 2014
Twitter and Cancer
I just signed up with Twitter. Am trying to figure this whole social media thing out :)
My Twitter account is @Med_Oncology
See you on Twitter!!
My Twitter account is @Med_Oncology
See you on Twitter!!
Medical Indemnity and Insurance
All doctors working in public and private hospitals should get the best possible medical indemnity insurance for themselves. Most doctors working in the public system have insurance with the govt health dept, but they also need extra insurance to cover themselves.
I think it is worth the effort. Also it is tax deductible.
I think it is worth the effort. Also it is tax deductible.
COSA Asia Pacific Mentoring Cancer Fellowship Program
The 2014 Fellowship program which supports a 10 - 12 week program at an Australian Cancer Institution. Details available at:
https://www.cosa.org.au/grants-awards/asia-pacific-mentoring-program/fellowships.aspx
Close date: 4th July 2014
https://www.cosa.org.au/grants-awards/asia-pacific-mentoring-program/fellowships.aspx
Close date: 4th July 2014
Low Bacterial Diet and Chemotherapy
What is the evidence of low bacterial diet in patients with chemotherapy for solid tumours? I could not really find anything conclusive in the data available.
Can someone help me out here.
Most of the data is anecdotal about a patient getting this illness or that illness, but the majority of the patients get along fine with clean, cooked food. This concept of scaring patients and their families into only eat this or that and avoid this and that.... it a complete overkill.
Now patients undergoing a bone marrow transplant with sustained neutropenia... that is a completely different story. I am talking only about patients with solid tumours undergoing chemotherapy. The period of neutropenia is relatively short and patients bouncy back fairly soon.
Eat well. Stay strong and healthy.
Can someone help me out here.
Most of the data is anecdotal about a patient getting this illness or that illness, but the majority of the patients get along fine with clean, cooked food. This concept of scaring patients and their families into only eat this or that and avoid this and that.... it a complete overkill.
Now patients undergoing a bone marrow transplant with sustained neutropenia... that is a completely different story. I am talking only about patients with solid tumours undergoing chemotherapy. The period of neutropenia is relatively short and patients bouncy back fairly soon.
Eat well. Stay strong and healthy.
Australian Medicine
Medicine in Australia is top class. It may not be as cutting edge as some hospitals in the US or Western Europe, but for all practical purposes... medicine in Australia is fantastic.
There is a talk about dearth of the latest molecules, but in terms of being pragmatic and the true value for the dollar... there is almost everything available. When I talk about being available, I am talking about being funded by the government (which means free to the patient). Everything, which is not funded by the government, is available on the market (for a price).
The quality of care even in remote towns is great. If a facility is not available or there is a emergency, the Royal Flying Doctors help out.
There is a talk about dearth of the latest molecules, but in terms of being pragmatic and the true value for the dollar... there is almost everything available. When I talk about being available, I am talking about being funded by the government (which means free to the patient). Everything, which is not funded by the government, is available on the market (for a price).
The quality of care even in remote towns is great. If a facility is not available or there is a emergency, the Royal Flying Doctors help out.
Working Overtime and Medicine
How do most of doctors deal with working overtime? I am really not sure. Most of us... just work. I am learning that I need to protect myself and stick to time schedules.
Work never gets over. Ever.
We need to do as much as possible and get out of the workplace to come back the next day to do the remaining.
Take time for yourself and your family/friends. Absolutely vital.
Work never gets over. Ever.
We need to do as much as possible and get out of the workplace to come back the next day to do the remaining.
Take time for yourself and your family/friends. Absolutely vital.
Adjuvant Herceptin / Trastuzumab Treatment 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 a few 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).
- taken from my older blog
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).
- taken from my older blog
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 MedicalOncologist for discussion.
- taken from my older blog
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 MedicalOncologist for discussion.
- taken from my older blog
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.
- taken from my older blog
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.
- taken from my older blog
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.
- taken from my older blog
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.
- taken from my older blog
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 urinary protein while on this medications, as it does have a potential to damage the functioning of the kidney. In case, the kidneys are secreting increased amounts of 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.
- taken from my older blog
It is very important to check the urinary protein while on this medications, as it does have a potential to damage the functioning of the kidney. In case, the kidneys are secreting increased amounts of 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.
- taken from my older blog
Infections from Doctors
Infections can be transmitted from doctors and nurses to patients. It is 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.
- taken from my older blog
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.
- taken from my older blog
Doctors as Patients: VIP syndrome
One of the nightmares for medical units across the world is to have a doctor as a patient. Everything 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".
- taken from my older blog
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".
- taken from my older blog
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.
- taken from my older blog
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.
- taken from my older blog
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!!
- taken from my older blog
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!!
- taken from my older blog
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.
- taken from my older blog
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.
- taken from my older blog
Gastro Intestinal Stromal Tumours - GIST
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. The main markers are c-kit (CD117) and DOG1
Treatment is to completely remove the tumour by surgery. This is possible while it is in an 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.
Once Glivec stops working, there are other medications (Sunitinib) available.
Game changer. Looking for more such miracles.
- modified from my older blog
Treatment is to completely remove the tumour by surgery. This is possible while it is in an 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.
Once Glivec stops working, there are other medications (Sunitinib) available.
Game changer. Looking for more such miracles.
- modified from my older blog
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 they 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.
- taken from my older blog
I have found it quite effective to let the angry patient rant about everything. When they 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.
- taken from my older blog
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.
- taken from my older blog
Difficult question. Personal. As always.
- taken from my older blog
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 an 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"
- taken from my older blog
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 an 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"
- taken from my older blog
Pulmonary Embolism - PE
One of the big problems with cancer is clots in the blood vessels of the lungs. It is a significant cause of death in cancer patients. Most people do not really know or understand the condition.
Cancer is a condition which makes blood stickier. 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 break off and shower small clots in the blood vessels of the lungs. A large blood clot in the lung vessels can potentially kill the patient.
The treatment is making the blood thinner with medications - heparin, heparin like drugs (Clexane, Fragmin) 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.
- modified from my older blog
Cancer is a condition which makes blood stickier. 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 break off and shower small clots in the blood vessels of the lungs. A large blood clot in the lung vessels can potentially kill the patient.
The treatment is making the blood thinner with medications - heparin, heparin like drugs (Clexane, Fragmin) 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.
- modified from my older blog
Negatives and Positives
English and Medicine are not always the most complimentary areas.
Patients are told by their doctors that:
- The disease has progressed - patients are happy, progress is a good word - but doctors mean that the disease has increased
- The lymph nodes are positive - patients are happy, positive is a good word - but doctors mean that the cancer has spread
- HER2 gene is positive - patients are happy, positive is a good word - but doctors mean that the cancer is more aggressive
- KRAS is positive - patients are happy, but negative KRAS is better
- EGFR is mutant - patients are sad, but mutant is better
- modified from my old blog
Oncology and Sympathy
Most people who realize that I work with cancer patients, are quite sympathetic towards me. Their logic is that most patients would die with cancer. The problem is that most people never hear about the brighter side of oncology care. They rarely hear about patients who are cured and live long and fulfilling lives. They never hear about women and men, who go through chemotherapy and go on to have children and families.
Oncology is a good field. I can cure some. Give hope to others. Care for all of them.
Oncology is a good field. I can cure some. Give hope to others. Care for all of them.
Pancreatic cancer and breast cancer
The advert by the Pancreatic cancer UK campaign is sad, but well thought out.
http://www.dailymail.co.uk/health/article-2552308/I-wish-I-breast-cancer-Pancreatic-cancer-charitys-campaign-slogan-causes-outrage-sufferers-disease.html
It managed to create the buzz that was so desperately needed for cancers like pancreatic (which no one except the sufferers seems to care about).
Well done.
Children and Cancer
I find it extremely difficult to deal with children who have cancer, and their families. It is the single biggest reason why I do not treat kids. Too hard. The doctors and nurses who treat paediatric malignancies are absolutely fantastic. More power to them.
The only favourable point about kiddie cancers are that they are relatively more treatable as compared to the adult cancers. The horrible part is failing.
- this is taken from my old blog
The only favourable point about kiddie cancers are that they are relatively more treatable as compared to the adult cancers. The horrible part is failing.
- this is taken from my old blog
Friends and Professionals
What do I do when a friend of mine is on treatment and I am pretty sure that they are not getting optimal treatment? Do I keep intervening on my friend's behalf and undermine their primary doctor? Difficult. Very difficult.
- this is copied from my old blog
- this is copied from my old blog
What does the doctor feel?
I realize that most patients and their relatives are petrified by the first appointment with their cancer doctor. A fair number of times, they have not been clearly told about the diagnosis. Ever wonder what the doctor must be feeling at the start of the new conversation?
- this is taken from my old blog and copied here
- this is taken from my old blog and copied here
Medications available
Cancer therapy is treated via:
Slowly working towards cure or at least prolonged remission/stable disease.
- cytotoxics
- biologicals
- targeted agents
- hormonal manipulation
- best supportive care
Slowly working towards cure or at least prolonged remission/stable disease.
Sunday, 30 March 2014
Previous work
Some of my previous work is on - http://medicaloncology.blogspot.com.au/
I'll copy and paste some of the previous blogs and update them. Might help some folk.
The idea is give information and help people. Communicate. Interact. See what happens!!
I'll copy and paste some of the previous blogs and update them. Might help some folk.
The idea is give information and help people. Communicate. Interact. See what happens!!
Starting Life Again
Long break. I wrote a bit a couple of years ago and then stopped. Extreme case of laziness. Am starting again. Let's see what happens now.
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