Immunology for Oncology and Others

Recently found an excellent Immunology course in Sydney - Immunology for BPTs (Basic Physician Trainees).

Held once a year, over a weekend. Covers all the stuff needed for most of us.

Immunology is taking over bits of Oncology and thus is vital to understand.

www.immunology4bpts.com

Gestational Trophoblastic Cancer Chemotherapy

Affects younger women in the child bearing age. Monitored by checking HCG levels.

Usually chemotherapy with methotrexate is adequate.

If the hormones levels do not return to normal or keep rising, the patient needs to be switched over to the EMA-CO procotol - Etoposide, Methotrexate, Dactinomycin - Cyclophosphamide, Vincristine (alternating week regimen).

Curable diseases must always be treated.

KRAS mutation in colorectal cancer

KRAS mutation analysis is a vital part of the treatment algorithm for metastatic bowel cancer. The absence of the KRAS mutation means that medications like Cetuximab and Panitumumab can be used effectively in these patients.

Presence of the mutation does not always mean that these medications cannot be used. The mutation in G13D might still have benefit with Cetuximab (still under investigation).

Worth discussing with your Oncologist.

The Cost of Cancer Drugs from CBS News

Amazing bit of journalism. Worth a watch. More about this soon.

CBS news: Cost of Cancer Drugs

Web site creation

I am trying to create a website to link everything together. Fascinating project. Found a website creation site - www.weebly.com and then had to think of a site name. Harder than I thought. The content creation is great. Am loving it as of now.

Project underway.

http://medicaloncology.weebly.com

Decoding Annie Parker: Movie regarding the BRCA gene

Recently watched the movie "Decoding Annie Parker". Was really touched by the movie. Not so much by the content, but for some reason it struck a chord with me regarding the suffering a person goes through. Recommend watching the movie. One of the most significant cancer discoveries in the past few decades. The determined Dr King and her team. The amazing Annie Parker. Well done.

Cancer is horrible and I hope that it would just disappear. The joy on the patient and their families faces, when we tell them that the disease has gone away. Hope the joy remains forever.

Best First Line HER2+ Breast Cancer Chemotherapy Regimen

The best first line chemotherapy regimen for a patient with HER2+ breast cancer is now Herceptin + Perjeta + Docetaxel. The data was presented recently in Madrid at the European Cancer Conference (ESMO) as part of the CLEOPATRA study. The data revealed a nearly 17 month survival benefit!!

It is so rare to see such massive benefits in cancer treatments that it would be hard for funding agencies to ignore this data.

Well done to all the patients, their families, friends and all the medical personnel who made this possible in collaboration with the pharmaceutical companies.

The Fault in Our Stars: Cancer based Movie

Saw the movie "The Fault in Our Stars" today. Nicely done. Good acting. More importantly taught me about the the "person suffering" as compared to the "patient with an illness".

What about life beyond doctors visits, chemotherapy sessions, support groups, etc? What about friendship circles? What happens to relationships? What about families? Parents, brothers, sisters, Husbands, Wives, Children? The trauma of the entire process of treatment and poor prognosis (several times).

Good movie.

Best Cancer Chemotherapy Reference Website in the World

I think that the best true cancer chemotherapy reference website in the world is www.eviq.org.au

It is a free registration for access, and gives you detailed information about chemotherapy regimes, protocols, patient information sheets, supportive care data, etc.

Brilliant site.

Women and the Cancer Gene - ABC

Nice article from the ABC by Elise Worthington. This highlights the issues with BRCA1 genes.
 
http://www.abc.net.au/news/2014-05-07/worthington-deadly-decisions-women-and-the-cancer-gene/5432570

Look Good Feel Better - for cancer patients

Look Good Feel Better - www.lgfb.org.au

For patients with cancer who feel dreadful about their appearance, this workshop is great. I personally think that it is not so much for the make-up and cosmetics that help them.... as much as the fellowship of knowing that there are so many other people in the same boat as them.

Massive boost to their esteem and confidence.

This is an initiative of the Australian cosmetic industry for cancer patients in Australia.

A definite suggestion to patients.

from www.lgfb.org.au

Alternative Medicine in Curable Cancer

One of the most frustrating things in the clinic is meeting with patients and their families who refuse standard proven treatment in favour of options which may not have any logical or scientific basis.

It gets worse when the cancer is completely curable with standard treatment.

Most of us can reason with patients to an extent, after which it is their call. Their life. Their responsibility.

Or is it?

Do we as a medical community need to increase awareness about wrong information being dissipated amongst patients and their families? Or do we already have enough work than to spend time on this. This is a relatively small proportion of patients who are so extreme. Should we just leave them to their thoughts and ideas?

Recently I met a lady who had a breast mass but refused all treatment including a biopsy. After lots of chatting, she told me that her spiritual leader had not given her permission for treatment. We negotiated and ultimately she agreed that God has given us common sense. Prayer is vital for everything. We also need to use our brains for decisions. She agreed for treatment in the end.

"Dr Web-browser" seems to have the answers. Depends on what we are looking for.

How to say No More Cancer Treatment?

One of the hardest things for me as a doctor to to tell the patient and family that there is no more active treatment available. The simplest thing is usually to keep giving some treatment or the other. The harder thing is to say NO.

For most patients and their families - ongoing treatment means ongoing hope (however small it may be). When we say no, we are dashing that hope.

There are ways to dilly dally with words and talk about best supportive care and symptom management and stuff like that.

Hard decisions. Hard implementation.

Social Media and Doctors

Where do we stand as far as social media is concerned? How many doctors/nurses have accounts for Facebook, Twitter, Pinterest, MySpace, etc, etc etc? More importantly how many doctors/nurses have been contacted by patients, their friends or relatives to become "friends".

Where does the line of professionalism and personal info blur? I think this is dangerous. Be very careful.

Most hospitals in Australia would not want staff to have social media accounts giving or discussing information about patients or about the hospital activity.

Social media is a great source of engagement and information with friends and family. Stick with that :)

Learning Cancer Research and Protocol Development

Research seems simple to do. We read about it daily... someone has found something somewhere, etc etc etc. Learning to do a proper research in a scientific manner is a completely different ball game.

One of the best learning experiences I had was at the ACORD workshop - Australia and Asia Pacific Clinical Oncology Research Development Workshop. This is held every two years in Queensland, Australia for seven days.

Each of the applicants submit a concept which is evaluated by a panel and 70 participants are selected. The workshop teaches us to take the concept and develop it into a proper protocol, complete with statistics and everything needed to launch a study.

Absolutely phenomenal. The 2014 workshop's last date to apply is over, but worth looking out for the future.

www.acord.org.au

Alphabets for Doctors

Several doctors write very poorly with regard to their handwriting. Some doctors who have a good handwriting seem to be folk, who missed their illegible handwriting course!!

I received this picture from a friend today and am not sure about the origin of the picture (thus cannot acknowledge the author).

Asia Pacific Cancer Mentoring and Fellowship Program in Australia

COSA - Clinical Oncological Society of Australia is now open for applications for a fellowship to support a 12 week teaching program at an Australian Cancer Centre. This is for cancer personnel who are from a developing nation in the Asia Pacific region.

Definitely worth the effort. All the best.

Social History and Cancer Patients

In the setting of incurable cancer... over time most of us learn about the more important things versus the not-so-important things. Hugs from grandchildren are more important than the risk of infections.... an overseas holiday is more important than completing that last infusion of chemotherapy.

It is so important to take a proper social history - who is at home with the patient, spouse (lives along or not), who supports the patient. Do children support their parents - or just weekend hellos?

We learn over time that we as humans take social issues to be vital.

Nurses and Doctors

I wonder if nurses and doctors can work together in a true sense. Are nurses intimidated by doctors? Do doctors try and show superior theoretical knowledge to prove a point? Do doctors raise their voices to seem better? Do nurses clan together to protect themselves?

Not sure.

Am looking for answers.

Praying with patients

How many doctors or nurses pray with their patients? Not many, but there are some who do so. Most doctors either do not care, are you convinced or are worried about the system. I need to start praying with my patients and their families. There are so many reports of the peace and the calm which is brought in.

Found a great book called " Gray Matter: A Neurosurgeon Discovers the Power of Prayer... One Patient at a Time" by David Levy and Joel Kilpatrick. Worth a read.

Gray-Matter

If I do not pray with the patient and their families, at least I should at least pray for them.

Generic versus Innovator Medicines

There are so many generic molecules available worldwide, yet we in Australia do not realize the extent of the same. In the past few months, the generic molecules are being pushed more by chemists (yet might charge patients/medicare for the innovator molecule).

Is there a true difference in the salt or preparation? I am really not sure. Would I use a generic for myself... probably not, would prefer the original molecule. My impression is that the big pharma guys who made the molecule, also invest heavily in removing impurities. This is hardly ever mentioned in the data presented. Everyone talks about the amount of the active pharmacological moiety, which needs to be at a concentration of at least 90%.

The biggest problem is the cost. Even after the big pharma have made their zillions on a molecule, yet flog the cost to a point that generics take over.

What do you think? I think it is a personal decision for people.

Best Research Masterclass Sessions in the World

The best research masterclass sessions in Oncology are:

# ACORD - Asia Pacific
# Vail - USA
# Flims - Europe

If possible... attend one in a lifetime. Will change your perspective of research and analysis.

Social Issues and Cancer

The spectrum of social issues explodes in some patients and their families.

As you get to know the patient better and the family trust you, details come out. Who is truly supportive, who is the true carer, who matters in the time of trouble, etc etc. Sad. Very sad most times. There are others, whom you would love to be a part of your family. They leave everything and are there for their parents or family or friends. Fantastic.

A social worker's job is quite phenomenal as they must be taking in all this stuff day-in-and-day-out. Wonder how they cope with this. Really. How do they cope with all this?

Family matters. Stick close.

Really good social media site - Quora

I found this really good site called - Quora.com

Great concept. Good layout.

Worth a visit.

Social Media and Oncology Blogs

I am totally thrilled... just signed up for a bunch of social media sites. Some are just so cool. Tumblr, Stumble Upon, etc etc.

In the next few weeks, I will slowly learn about these better and work my way around them.

Will keep you posted.

Best Pain Killer Medications in Cancer

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.

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!!

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.

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

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.

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.

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.

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

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

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

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

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

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

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

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