Just in Time
It stands to reason. Early diagnosis
improves the prognosis. A news item a couple of years ago claimed that if
you lived in Taiwan you had a better chance of cancer survival, than if you
lived in the UK. This was put down to the fact that your cancer diagnosis
was done more quickly in Taiwan than it was in the UK.
If my mother’s experience of the UK National Health System was anything to
go by, you will be lucky to live long enough for the diagnosis to be made.
By the time you get given a specialist’s appointment and then wait for the
test results and then see the specialist again after another wait. But, I
suppose, if nothing else, it does help cut down the numbers on the waiting
The message is simple - timely cancer diagnosis does improve your chances of
survival. This is not really rocket science or some new breakthrough. If you
leave battery acid on your shirt long enough, it will eat a hole in the
fabric. If you leave cancer cells in your body long enough, they can eat so
many good cells your life and living is compromised.
Unfortunately, the diagnosis of cancer is generally not made (or the
diagnostic procedure even started) until the cancer produces some abnormal
symptoms. Those abnormal symptoms are also not made by the cancer itself,
but by the organs that have been attacked, or by the sheer physical size of
the cancer causing physical problems. The cough from cancer of the lung is a
good example of the first case, and constipation from cancer of the bowel is
an example of the second type.
We are actually very lucky in Thailand, as there are several centers of
excellence in the capital and in the provinces, and I include my own
hospital, the Bangkok Hospital Pattaya in this.
Now when I say “centers of excellence” I am referring to the speed of
diagnosis that is possible, not the treatments that are available. There are
many factors that can influence that speed (the following table has been
extracted from Jiwa et al, BMC Family Practice 2007 8:27):
1. Need to travel to clinics in the capital may have financial and
logistical implications for the patient and therefore lead to
2. Health professional, different gender of GP may deter some patients from
presenting with embarrassing symptoms that require intimate examination for
3. Equivocal tests necessitate repeat visits to clinic.
4. Lack of coordination for individual patients’ needs may result in
inconvenient scheduling of appointments.
5. Limited scope to obtain second opinions.
6. Access to specialists limited by distance from capital.
As you can see from the table, we are very lucky in Thailand, as the centers
of excellence can easily cover the six factors. What is also not expressed
in the six point table, is the speed of test result returns. Where we enjoy
a one hour turnaround for blood tests, patients in the UK receive their
results in days, not minutes. Similarly, our appointments for CT scans and
MRI’s can be ‘same day’ with results usually the same.
So, timely diagnosis is very possible in this country, but unfortunately
there are still instances of late diagnosis, but in the majority of cases
this has occurred through ignoring the symptoms or ignorance of the
importance of the symptoms. The simple advice is to never ignore any
deviation from ‘normal’ in your body - after all, you know your body better
than anyone else.
There is also a somewhat mistaken idea that your annual check-up will
uncover hidden or early cancers, so you don’t have to do anything until next
year. Certainly there are some cancers that are detected in this way, but
whilst the annual check-up can discover many endocrine problems, blood
problems and cardiac abnormalities, it is not going to uncover cancer in the
brain, bones or skin, unless they are very advanced and causing symptoms.
Timely diagnosis does come back to your ability to inform your doctor of
changes. Do not feel embarrassed that it “might be nothing”. All doctors
prefer telling people that they do not have a problem after diagnostic
testing, rather than the other way around!
Good Medical Practice, as opposed to Bad Medical Practice
Is orthodox medicine really that bad?
It has always been the case that people seem to like to throwing stones at
conventional clinical medicine. Claims of over-servicing, over-prescribing
and downright fraudulent practices are thrown about, citing someone whose
uncle/friend/mother (delete that which is inappropriate) suffered at the
hands of “bad” doctors, who missed the diagnosis and treated the wrong bit.
Now, there are certainly some “bad” doctors out there, just as there are
“bad” lawyers, “bad” Real Estate agents, “bad” mechanics and just about any
profession you would like to think of. But they’re not all “bad”.
How do you become a “doctor”? Take me for example, I am a conventionally
trained British/Australian style medical practitioner who has spent a
lifetime practicing EBM, otherwise known as Evidence Based Medicine.
Practices that have been proven to work. Call it “good” medicine, if you
I am proud of my training. Six years at an Australian university that had a
good name, and still does, despite undergraduates like me. I am also proud
of passing the exams in the Royal Colleges of Physicians and Surgeons in
London. I have the honor to have my name listed in the ‘great book’ with
luminaries such as Hunter, Jenner and Lister. I am also indebted to my
tutors during the 12 months of ‘pre-registration’, where you apply your
knowledge under the supervision of accredited specialists. An arduous road,
but one that is a safeguard for you, the general public.
The ‘powers that be’ are also ensuring that we keep up to date with a
process called Continuous Medical Education (CME). That medical education
continues, with CME lectures being attended by my hospital’s doctors (and
myself). Fortunately for me, the slides are in English, even though
sometimes the lecture is not.
Those ‘powers that be’ also try to ensure that we prescribe drugs that are
efficacious, that have been tested, and the evidence points to this. It is
not anecdotal evidence, but true scientific evidence shown by research in
many countries, with hundreds of thousands of patients. It is following that
type of evidence that I can recommend with all good faith, that 100 mg of
aspirin a day is “good” medicine. I also know that if you are prescribed a
‘statin’ drug it will lower your cholesterol levels. They have been tested.
And these days, very rigorously indeed.
I am also the first to admit that we have sometimes managed to get it wrong.
The Thalidomide story still has living examples of this. However, the
medical world-wide network is cohesive enough to ensure that this drug was
withdrawn. It is the checks and balances system that has kept western
medicine afloat. This is not to be equated with the checks and balances
system that have been incorrectly applied in the banking industry that sees
those institutions on the brink of sinking!
I am often asked my opinion on “alternative” medicine, and all its diverse
areas of ‘specialization’. I try to avoid direct confrontation over this. If
devotees have found that they can diagnose tumors by looking at patient’s
auras through their third eye in the middle of their foreheads, then I am
genuinely pleased, in fact delighted, provided that they have subjected the
method to scientific scrutiny.
If various groups can actually cure cancer, epilepsy, halitosis or lock-jaw
by inserting dandelions into a fundamental orifice, then again I am
delighted. This is a medical break-through, but as such, must be subjected
to medical scrutiny. If the method stands true scientific examination (not
to be confused with anecdotal ‘evidence’) then it will be adopted by
everyone, complete with thanks to those clever people who picked the
dandelions in the first place. After all, penicillin was tripped over, not
designed. But it has had a very rigorous scientific scrutiny since.
As far as the majority of ‘folk’ remedies is concerned, I work on the
principle that if you ‘think’ it is doing you good, then it probably is. But
don’t ask me to endorse something that has not been scientifically tested.
When the ‘alternative’ group spends more time proving their methods, instead
of complaining about non-acceptance, EBM practitioners will give them more
Quality of Life
A bit “deep” this week, but for many,
an important message. So you have been told you have terminal cancer. What
can you do? The first thing is to sit down and take stock of your
circumstances. All of us know that that piece of string called “life”
eventually comes to an end, but we don’t know when. The only difference with
you, is that your doctor has actually told you when your piece of “life”
string is due to run out.
Now whilst the immediate thought is “How do I beat this?” there are many
factors you have to consider in the time ahead, and one of the main ones is
called ‘The Quality of Life’.
Now is the time to talk with family, friends and health care team. It is
natural for a person with advanced cancer to feel many emotions including
anger, fear, and sadness. Just as you may need time to adjust to this new
phase of your illness, your family and friends may also need time. If you
are having trouble talking with family and friends, ask your nurse, doctor,
or counselor to gather everyone together to talk.
This talking phase should also include your getting to understand your
cancer. This you do by talking with your treating doctors, and also from
information from reliable internet sites. Note I say “reliable” sites. There
are always plenty of sites ready to sell you snake oil.
Now is the time to manage your symptoms. Your quality of life is better if
your symptoms are under control. Talk to your health care team about the
best way for you and your caregivers to manage your symptoms.
Do not be afraid to ask your doctors about any proposed modalities of
treatment. Getting an extra two months of life, but at the cost of the
quality of life, may not be worth having. Always keep that in mind. Quality
of (the remaining) life is everything.
Be as active as you can. When an illness progresses, it may be harder to do
the things you have always done. Talk to your health care team about what,
if any, limitations you may have. If your physical health allows, continue
to exercise in some enjoyable way. Or, if you find it is too much for you,
take up a new hobby or find things that you can still do and enjoy, such as
reading, writing, creating a photo album, or making a video for family and
Let friends and family know what they can do to help. What can you do for
yourself? What is important to you? What can friends and family do for you?
What can all of you do together? Where do you turn if you need extra help or
care? If you are not up to being social, let people know this as well.
Make your wishes known. Making the decision to stop active cancer treatments
can be a hard choice for a person with cancer and their family. These are
personal choices. If you are faced with making these decisions, talk with
your family and health care team about your wishes and explore all of your
options. You are still able to make decisions about your life to the extent
that you desire.
Maybe you want to give someone else some of the responsibilities or share
decisions about what to do. You may want to create a health care proxy
and/or power of attorney. This allows someone who you choose to make health
care or other decisions for you. Whatever you choose, you are in control of
your life and you know what will work best for you.
You should consider creating a ‘Living Will’ giving specific instructions on
what your wishes are as the cancer progresses. This process makes your
end-of-life wishes and desires known, and your health care team and can help
ensure that your wishes are honored. These wishes may include funeral
arrangements or decisions about hospice care. Discuss with your family,
friends, and health care team your wishes regarding resuscitation.
Sorry if the column this week was a trifle dark, but it can give assistance
to those who feel as if all their options have gone.
Elixir of Youth next week!
There was an article in the Pattaya
Mail a couple of weeks back about my extra-curricular activities on the
motor racing circuits. I said that it was race driving that keeps me young,
or put another way - growing old disgracefully.
I have a book on my desk called ‘Geriatric Medicine’ and what a depressing
start to the day that can be! Gloom, doom and disaster! However, the picture
is not really as bad as all that, so I thought that this week I would go
through the aging process, and then what we can do about it. The recipe for
the elixir of youth is not enclosed as I am still trying to perfect it, but
instead, I will give you some ways you can stay feeling ‘young’ while
waiting till next week!
Let’s begin with the depressing news that you have actually been going
downhill since the age of 14 (mentally) and from the age of around 30
(physically). That bar-room ditty that relates to what you used to do all
night, now taking all night to do, can be too close to the mark for some of
us. But don’t despair, help is at hand (no pun intended).
The book suggested that the aging of our individual organs is influenced by
diet, environment, personal habits and genetic factors. Read that again -
did you notice that three of them (diet, environment, personal habits) are
actually under our control, so the angle of the slippery slide can be
changed. Good News number one.
The physiological changes associated with aging do include an increase in
body fat, a difficulty in reading (called presbyopia) and a clouding of the
optic lens (called a cataract). Glucose metabolism goes a little awry as
well, as we get older. In the lungs, the elasticity goes out of the lung
tissue, meaning that the lungs don’t absorb the oxygen as well as they
It doesn’t end there. This elasticity thing gets increasingly important. The
arteries become less elastic too, so the heart has to pump harder to force
the blood around, increasing blood pressure and enlarging the heart.
Then the liver doesn’t cope as well with the toxic chemicals we meet as it
used to, and the bowel gets a little lazy as well, leading to constipation.
For men, the prostate slowly enlarges and makes it difficult for the bladder
to empty properly, so you have to get up to pee a few times a night. The
awful statistics are that 50 percent of all men will have some degree of
enlargement by the time they are 50 years old, 60 percent by 60, 70 percent
by 70, and you don’t have to be Albert Einstein to do the math for the time
you are 100.
Finally, the brain shrinks and you begin to forget things, “I’ll never
forget what’s-her-name” being a real problem! You lose the recent memory
first, and then the long term memory second.
So what to do? The main thing is to make sure your organs get enough oxygen
to work properly. Oxygen gets into the blood via the lungs. Clogged air sacs
in the lungs is a big problem. Answer? Stop smoking - immediately, and get
some exercise every day, so that you start to use the lungs, and their
Now we have some oxygen back in the blood we have to circulate the magic red
fluid. Cholesterol build-up in the arteries produces blockages. Reverse it
by lowering cholesterol in your diet. You do this by decreasing animal fats
and increasing vegetables. That’s not too difficult either, is it?
Now the sugar problems. Another one with an easy fix - cut out all the
‘extra’ sugar in your diet. You don’t have to use sugar in your coffee, and
chocolates should be a very occasional indulgence only.
The liver? The main toxic substance it has to deal with is ethanol,
otherwise known as alcohol. Give the liver one day a week to recover. That’s
your AFD (alcohol free day).
So look at the three items again under your control - diet, environment,
habits. The answer to counter aging is there. Begin with fags, fat, booze
and fancy foods. It’s the right start.
WHO targeting 17 tropical diseases
The World Health Organization (WHO)
urges affected countries to scale up their investment in tackling 17
neglected tropical diseases in order to improve the health and well-being of
more than 1.5 billion people.
This investment would represent as little as 0.1 percent of current domestic
expenditure on health in affected low and middle income countries for the
Neglected tropical diseases cause blindness, disfigurement, permanent
disability and death, particularly among the poor. WHO’s new report,
“Investing to Overcome the Impact of Neglected Tropical Diseases”, outlines
an investment case and essential package of interventions for these
“Increased investments by national governments can alleviate human misery,
distribute economic gains more evenly and free masses of people long trapped
in poverty,” says WHO Director-General Dr Margaret Chan.
Unfortunately, with the current “epidemic” of terrorist activity amongst the
poorer nations in Sub-Saharan Africa, for example, this concept of forward
thinking does not have much chance of being implemented. Boko Haram is not
renowned for worrying about social welfare.
Listed below is a short description of the 17 neglected tropical diseases,
also accessible at
Dengue: A mosquito-borne infection causing flu-like illness that may
develop into severe dengue and cause lethal complications.
Rabies: A preventable viral disease transmitted to humans through the
bites of infected dogs that is invariably fatal once symptoms develop.
Trachoma: A chlamydial infection transmitted through direct contact
with infectious eye or nasal discharge, or through indirect contact with
unsafe living conditions and hygiene practices, which left untreated causes
irreversible corneal opacities and blindness.
Buruli ulcer: A debilitating mycobacterial skin infection causing
severe destruction of the skin, bone and soft tissue.
Yaws: A chronic bacterial infection affecting mainly the skin and
Leprosy: A complex disease caused by infection mainly of the skin,
peripheral nerves, mucosa of the upper respiratory tract and eyes.
Chagas disease: A life-threatening illness transmitted to humans
through contact with vector insects (triatomine bugs), ingestion of
contaminated food, infected blood transfusions, congenital transmission,
organ transplantation or laboratory accidents.
Human African trypanosomiasis (sleeping sickness): A parasitic
infection spread by the bites of tsetse flies that is almost 100 percent
fatal without prompt diagnosis and treatment to prevent the parasites
invading the central nervous system.
Leishmaniases: Disease transmitted through the bites of infected
female sandflies that in its most severe (visceral) form attacks the
internal organs and in its most prevalent (cutaneous) form causes facial
ulcers, disfiguring scars and disability.
Taeniasis and neurocysticercosis: An infection caused by adult
tapeworms in human intestines. Cysticercosis results when humans ingest
tapeworm eggs that develop as larvae in tissues.
Dracunculiasis (guinea-worm disease): A nematode infection
transmitted exclusively by drinking-water contaminated with
parasite-infected water fleas.
Echinococcosis: Infection caused by the larval stages of tapeworms
forming pathogenic cysts in humans and transmitted when ingesting eggs most
commonly shed in feces of dogs and wild animals.
Foodborne trematodiases: Infection acquired by consuming fish,
vegetables and crustaceans contaminated with larval parasites.
Clonorchiasis, opisthorchiasis and fascioliasis are the main diseases.
Lymphatic filariasis: Infection transmitted by mosquitoes causing
abnormal enlargement of limbs and genitals from adult worms inhabiting and
reproducing in the lymphatic system.
Onchocerciasis (river blindness): Infection transmitted by the bite
of infected black flies causing severe itching and eye lesions as the adult
worm produces larvae and leading to visual impairment and permanent
Schistosomiasis: Trematode infections transmitted when larval forms
released by freshwater snails penetrate human skin during contact with
Soil-transmitted helminthiases: Nematode infections transmitted
through soil contaminated by human feces causing anemia, vitamin A
deficiency, stunted growth, malnutrition, intestinal obstruction and
In 2013, Colombia became the first country where WHO verified the
elimination of river blindness (onchocerciasis), followed by Ecuador in
Bangladesh and Nepal are poised to eliminate visceral leishmaniasis as a
public-health problem by the end of 2015.
And Dengue and Rabies can be found in Thailand!
The number of new cases of sleeping sickness (human African trypanosomiasis)
has dropped to fewer than 10,000 annually and this for the first time in 30
years with 6 314 cases reported in 2013.
In 2009 approximately 30 percent of children in need of preventive treatment
for soil-transmitted helminthiases were receiving it. Reaching 50 percent of
children with this treatment by end 2015 is achievable.