Doctordenky's Blog

Many of us are aware that exercise reduces our risk of getting heart disease but a lot of information is surfacing that exercise also lowers our risk of developing cancer.

A study done in Finland showed that men who exercised for at least 30 minutes a day decreased their risk of prematurely dying from cancer. The study is published in the British Journal of Sports Medicine.

The subjects were queried about their leisure-time physical activities over a period of 1 year and were subsequently followed up for the occurrence of cancer over a 16 year period.

The reduction in the risk for premature death from cancer was seen in men who exercised for more than 30 minutes every day, and with an intensity that was moderate to high. Examples of activities that can produce this effect are jogging, swimming, rowing, cycling, brisk walking, hiking, dancing, boxing, etc.

What is important to remember is that these activities should be done consistently and should form part of our lifestyle. Exercising regularly should be as essential as eating our meals and not to be done only “when we have time”.

I have repeatedly said that there are no absolutes in medicine. Treatments and diagnostic tests employed whether mainstream or alternative do not give absolute certainty of efficacy and must all be employed with caution.

I have been asked several times how we can prevent cancer with expectations that I will be able to tell them with all certainty the answer. Because it is part of human nature to expect certainty, it is no different whenever I am asked about cancer prevention.

We have not yet identified definitively how we can PREVENT CANCER. What we have identified are “Risk Factors” or those things that may increase a person’s likelihood of developing cancer. The evolution of cancer is so complex that it entails many many factors that are beyond our control. Our genes/inheritance, age, gender and certain environmental factors are beyond our reach. However, our lifestyle is one of those risk factors that is well within our control and should be the focus of our risk reduction strategies.

By saying that we have not yet identified how to prevent cancer is not the same as saying that we can’t do anything. Nor should we just live as we please because we will all die anyway. There is a lot that we can do but we have to always keep at the back of our minds, that in the end, whatever happens, a good dose of surrender and serenity is very important.

The choice is ours. As a doctor, I have seen what can happen and I’m telling you that it is very unpleasant. The outcome for all of us if we continue in our current ways is very very ugly, very very uncomfortable and can be very emotionally and financially devastating, not only to the patient but the entire family.

Let’s choose wisely.

The number of patients being diagnosed with cancer has been progressively increasing for the past several years. Cancer is found among the top five causes of morbidity and mortality in the Philippines.

There is a stigma attached to patients who are diagnosed with cancer. People automatically think that a diagnosis of cancer is equivalent to being sentenced to die soon even if some patients have better prognoses than patients who have moderate to severe forms of heart disease. People experience fear just by hearing the word cancer.

Cancer is no longer a death sentence. However, the psychological impact of being diagnosed with cancer can still be devastating. Having to go through the long period of treatment can be traumatic and can exert its toll on the physical, social, emotional, psychological, spiritual and financial well-being of the patient and family.

Much of the focus on cancer (and most of the common diseases) now has been on treating the cancer after it is diagnosed. Considerable efforts have also been placed on early detection. However, so much more emphasis should be given to raise awareness about CANCER PREVENTION through changes in lifestyle and we, physicians and patients, should pay very close attention and take the matter more seriously.

Answer the following questions to give you an idea of how detrimental our lifestyles are

1. Do your meals consist mainly of processed carbs (white rice, white bread, white flour) and protein (chicken, fish, beef or pork) without vegetables or only traces of vegetables serving as garnish?

2. Do you lack recommended servings (5 or more) of fruits and vegetables in your diet?

3. Do you consume a lot of cured or smoked meats or fish?

4. Do you consume a lot of sugar on a regular basis?

5. Do you live a sedentary lifestyle without any form of exercise or only very occasionally?

6. Do you smoke?

7. Do you consume more than 1 serving of alcohol per day for women, more than 2 servings for men?

8. Is your diet very high in fat or fried foods?

9. Are you sexually promiscuous especially without protection?

10. Are you always stressed out and harbor a lot of negative emotions?

11. Are you overweight?

12. Do you stay under the sun for long periods without protection?

13. Do you have a family history of cancer?

If you answer yes to any of the above questions then perhaps you need to seriously consider about changing paradigms.

I was talking to a group of patient’s relatives regarding his prognosis. It was very grim. In the group were the patient’s son, patient’s sister and the patient’s daughter holding her two year old son. The patient was dying and I was relaying that information to the family.

Expectedly, the group was distraught but something caught my attention which I found truly amazing.

The patient’s daughter’s face was covered by extreme sadness. Tears were running down her cheeks. She was not sobbing but anybody who passed by our space would know that what we were talking about was not very good.

As I was talking to them, the two year old son was as usual playful initially. However, as our conversation went on, the child started to calm down. He suddenly noticed the sadness on her mother’s face. He started kissing her. He gave her one kiss then backed down a little to see the effect it would have on her mother. Then he gave her another one and another one and another one and every time he kissed her, he would look at her response hoping that his gesture would make his mother’s face light up. When he couldn’t achieve that, he looked around with a face that said “Help me! What can I do to make my mother happy again?”.

Up to this day, I can still clearly see the look on the child’s face. I cannot help but be amazed by what I saw. A truly awesome and unforgettable experience!

A friend called me in a state of confusion. She said that one of her friends was diagnosed with intermediate stage breast cancer despite undergoing regular mammography. “Isn’t mammography supposed to detect breast cancer?” she asked. So why did the doctors miss my friend’s cancer?

I have previously said that none of the interventions we employ in medicine come with absolute guarantee. Similarly, the laboratory tests that we do are also not 100% fail-safe. Not all diagnostic tests are as accurate as we hope them to be. There are many factors affecting the degree of validity and accuracy of these test results such as:

• Inter-laboratory variability – different labs can produce different results.

• Intra-laboratory variability – different results on different days due to factors such as different person performing the test, use of a different brand of chemical to carry out the same test, lack of calibration of machines

• Reader or interpretation variability – interpretation of results often depend on the reader’s experience such as reading of x-rays or CT scans. The same results can be interpreted differently by different persons.

• The quality of machines or reagents used – old machines (x-rays, CT scans, MRIs, ultrasounds) though cheap, can produce substandard results

• The inherent flaws of a test – not all tests, no matter how seemingly accurate, high-tech or done at reputable centers will give 100% correctness and accuracy. Some tests are bound to miss a positive diagnosis while others can detect problems that are not really there.

Tips to Minimize the Flaws and Maximize Laboratory Results

• Make sure that you are going to reputable laboratories instead of fly by night labs which offer lower prices to lure patients

• As much as possible, stick to the same laboratory to allow to minimize inter-laboratory variability.

• When doing specialized tests such as mammography, CT scans, MRIs, etc, better inquire from your doctor whether you can go ahead with a certain diagnostic center of your choice other than where your doctor wants to have it done. Patients often scout for cheaper prices (there is nothing wrong with this but let us take a lot of caution)and find them in small diagnostic centers not knowing that the cheaper cost is because they are using outdated machines which do not provide the same accuracy as the more expensive ones and hospital-based labs do. (I’ve had patients go for cheaper CT scans or MRI’s only to have them repeated at more reputable centers because the results did not give us the information that we needed)

• For tests that are done in series or annually such as xrays, CT scans, ultrasounds, mammography, MRI, request for the same reader to interpret your results.

Isolation, loneliness, feeling of being all alone in the difficult journey are emotions that patients go through upon being diagnosed with cancer. Yet, the patient is not alone in the pain, suffering and sadness. His entire family is afflicted with the disease perhaps not literally but figuratively.

When a patient is stricken with any kind of severe illness, it is never his journey alone. The entire family is afflicted as well. When a family member undergoes surgery, his entire family also feels like they are undergoing the treatment too. When a family member undergoes chemotherapy and experiences its effects, the entire family suffers with him.

Dealing With The Family

I recently delivered a lecture about “Breaking the Bad News” to medical students. I told them that when delivering the bad news, I almost always discuss first with the family before going directly to the patient. I do this not with the intent of hiding the truth from the patient but to educate the family and facilitate their understanding and approval of the necessity of letting the patient know and have him participate in decision-making. It is very comforting for the family to understand and know that they are being considered important too. There are some who might consider this unethical since we are not supposed to discuss the diagnosis with anybody except the patient. They claim that doing so will undermine the patient’s rights.

I am strongly opposed to withholding the diagnosis from the patient. Let that be very clear. However, my experience has taught me that in order to be a good doctor, I have other things to take care of aside from the physical well-being of the patient. I cannot separate that from his emotional, social, psychological and spiritual well-being and a significant part of this well-being is in relation to his family. Part of managing patients is not only dealing with what the patient is going through but also taking care of the well-being of the relatives. The doctor not only facilitates understanding and acceptance by the patient but the family as well. Taking care of the family too makes the patient happy and gives him a sense of peace and security.

As a doctor, I deal with patients. But I must always remind myself that I also need to deal with relatives and need to see everybody as human beings who have raw emotions. Theory is very nice, very interesting, very exciting but being strictly adherent to theory is not what doctors should do. Strictly adhering to theory puts us in danger of being unable to deal with the real world, real people and human emotions. Strictly adhering to theory puts us in danger of being devoid of compassion and makes us no different from machines. We can debate about theory for as long as we want but when it comes to patients, we need to be a little bit more respectful, compassionate and understanding. At the end of the day, the patient and relatives may not necessarily remember how long they survived or whether we were excellent in following the rules but in how they were dealt with as human beings. Expressing their sincere gratitude in the face of terrible loss lets me know that I am doing the right thing.

I have said repeatedly that cancer patients are extremely vulnerable. They are in great danger of being taken advantage of.

We see alternative forms of treatment everywhere. I see nothing wrong with that. What I practice is conventional/mainstream/Western medicine and I practically know nothing of alternative or Eastern forms of treatment.

What “the expert” Says

I do not claim to know all about diseases, specifically cancer, so I do not claim to be the only expert in this field and neither are my colleagues. If there is anyone who can offer my patients real alternatives, I am very much open to them and will gladly point my patients towards them if I see fit.

However, I think other forms of treatment are not being presented in a very truthful manner. I am specifically talking about treatments that claim themselves to provide “guarantee of cure” specifically those that claim to “cure all”; or any form of treatment, whether alternative or mainstream, that claims to eradicate all forms of disease or all forms of cancer. Those claims are not completely true. Some of them are malicious, deceitful and with the sole intention of luring patients and selling products.

Almost all forms of treatments, whether alternative or mainstream, have the potential to cause adverse effects. All medicines, whether synthetic or natural can alter the processes in the body.

The Other Side

I have seen patients whose kidneys and livers have been damaged by “natural” medicines. I have encountered patients who have experienced adverse effects from alternative forms of treatment in much the same way as patients who are given synthetic drugs have suffered side effects. I have had countless patients who went into alternative treatment only to come back to us with their diseases disseminated all over and sorry that they did not heed us.

I do not blame them nor tell them “I told you so” because that will be like rubbing salt on their wounds. However, I plead for them to take lots of caution.

Where I Stand

Am I against other treatments that I do not know of nor espouse? Definitely not. As a physician, I always take the side of the patient. I am for whatever will do the patient good even if I am not the one giving it or even if it proves that what I am saying is wrong.

What I am after is transparency and giving the patient the opportunity to choose by providing enough information.

At the end of the day, the patient is only answerable to himself. Only he can own up to what he chose. What he chooses is actually none of our business. But again, I plead for them to take lots of caution and go ahead for themselves and not for someone else.

The Final Word

None of us can claim that we are the best or that we know everything there is. True experts are always the first to admit to the fact that we know very little. If someone is offering you any form of treatment that “guarantees cure” or promises absolute certainty, better start running away for he is likely after your business not your well-being.

Healthcare system in the Philippines is mostly out of the patient’s pocket. Very very few Filipinos have health insurance. Even among those who are insured, coverage is often meager and not enough to pay for all the health care costs. Many patients end up shouldering the remainder of the costs themselves.

Modern medicine is riddled with so many laboratory tests. They have become an integral part of how we manage patients. It has enhanced our ability to diagnose diseases and improve patient’s outcomes. However, many tests have become invasive of patient’s bodies and cost a lot of money. Sad to say, some tests are also not judiciously used.

Should patients question doctors regarding the use of these tests? I believe so. Patients have to understand why they are undergoing them and how the results will affect the management of the disease and the overall outcome.

When the test is quite expensive or when it is very invasive and uncomfortable, I think the patient should discuss this thoroughly with the doctor. The following are tips as to what the patients should ask their doctor:

1. Will it improve the patient’s condition or overall outcome?

2. Will it affect or alter how the patient is managed?

3. What are the risks of the test to the patient?

4. Will the benefits outweigh the risks?

5. What will happen if the test were not carried out?

6. What will happen next whether the result is positive or negative?

7. If after the test, a patient needs to undergo surgery or other forms of treatment, will the patient tolerate that kind of treatment?

A patient was brought to my clinic after having hopped from one doctor to another in search of the holy grail. When the patient was brought to me, he was so thin and frail and had difficulty speaking because of severe weakness.

I asked the relative what they wanted to achieve in bringing the patient to me. I picked up that the relative, at this point in the status of the patient, was hoping to cure the patient from the disease. Apparently, he was not yet ready to throw in the towel and was looking for all possible avenues, despite the patient’s very very deteriorated condition.

I felt the intense emotions of this relative for the patient. My heart bled almost non-stop and found it hard to look for the right words to discuss the situation with the patient and relative.

A Time To Know

As a physician, I consider it my responsibility to give hope whenever I can. However, I need to make sure that the kind of hope that I give is that which is just enough and not cross the line into malicious falsity.

At some point in our treatment, I need to let the patient and relatives know that science will no longer help in the cure. The role of science has to change from one of might and power to cure to one of compassion and provision of comfort.

Discerning the Boundaries

I think “hope” has been over used and abused by many entities in our society. There are businesses that take advantage of the patient’s desire for hope by offering treatments that claim unfounded effects of cure. Many are malicious and take advantage of the patient’s sensitivity and vulnerability. We must always be careful and watch out for them.

What is also important is for us to examine ourselves and our own motives as to the path we choose. I always tell my patients that no option in cancer management is incorrect as long as that option has been carefully thought out and discerned to most suitably fit the person, his beliefs, his values and all that the person is about.

Are we really doing what is good for the patient or what is good for us? Doctors and relatives have to be extra-cautious of our recommendations to the patient because there is an extremely thin line between what is good for the patient and what we think is good for the patient. We need to be certain that what we recommend or choose is not a projection of our own wishes in the guise of choosing the best for the patient. We need to ask ourselves the very painful question of whether we are really protecting the patient and not ourselves.

The boundaries are so blurry but the boundaries do exist. We just need to be diligent and extremely careful.