by Dr. Iain Corness
Living with cancer
So you have just found
out you have “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 friends.
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 may also consider creating a
‘Living Will’ or giving specific instructions on what your wishes are if
your cancer progresses. This process helps make your end-of-life wishes and
desires known to family, friends, 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 sounds a
little deep and dark, but it can give assistance to those who feel as if all
their options have gone.
The Tale of Tanujin
The item you are about
to read is one of my favorite medical case histories. Bruises on a child’s
body are often considered proof that a baby has been battered. A visible
bruise on the buttocks, the shape of a hand and five fingers is almost
‘undeniable’ proof. Or is it?
There was a very celebrated instance of
a GP in the UK having discovered that so many of the Asian babies in the
practice were showing signs of being ‘battered’ that the children’s welfare
people were called in and an enormous number of children taken away.
However, the highly observant GP was wrong!
In Thailand, and the rest of Asia, a
new-born baby with the ‘handprint’ bruise is very common, while child abuse
is not common at all. The problem, or rather the condition, relates back to
Genghis Khan and the Mongol hordes. It is a wonderful piece of folklore and
a fine example of applied genetics.
Let’s look at the folklore first, and
you are going to have to dig very deep to get this tale anywhere else! A
Mongolian baby, called Tanujin, was born just over 1,000 years ago, but did
not breathe. His father, in desperation, held his new-born son upside down
and smacked him severely over the bottom, so much so that the baby drew
breath and lived, but carried the life giving bruise for the rest of his
days. That baby later became Genghis Khan, (which means King of the Earth),
and by the time he died in 1227 he was the ruler of a large chunk of it,
including the area which later became known as Thailand.
History has chronicled that the Mongol
hordes raped, pillaged and annexed countries from China to Persia. His
highly mobile troops traveled the difficult terrain of Siberia. Famous
cities were captured and looted such as Tashkent, Baghdad (still a good
place to stay away from, thanks George) and Bokhara. Cities that surrendered
were spared but those that resisted were razed and the people slaughtered.
The Mongols conquered northern India and Afghanistan. In 1222, they defeated
the Russian and Bulgarian armies. At the time of Genghis Khan’s death, his
empire stretched from China’s Yellow River to the Dnieper, in Russia.
And now back to some interesting
folklore. The descendants of Genghis Khan also showed the hand-shaped bruise
on the buttocks, beginning with his four sons Ogdai, Jagatai, Juji and Tule,
who were given one quarter of the empire each after their father died. They
in turn passed on this ‘trademark’ and so this continues till today. If your
“Luk Krung” children have the sign of Genghis Khan, called Mongolian Blue
Spot, you can claim descent from the warrior king. However, there is quite a
number of you, so I think there won’t be much left in Genghis’ estate by
Now Mongolian Blue Spot, as a clinical
condition, is well documented, and I came across figures suggesting that at
least one Mongolian spot is present on over 90 percent of Native Americans
and people of African descent, over 80 percent of Asians, over 70 percent of
Hispanics, and just under 10 percent of fair-skinned infants (Clinical
Pediatric Dermatology, 1993).
Medically we describe Mongolian Blue
Spot as flat bluish to bluish gray skin markings that commonly appear at
birth (or shortly thereafter) and scientifically they are called Congenital
dermal melanocytosis. They are flat, pigmented lesions with nebulous borders
and irregular shape. They appear commonly at the base of the spine, on the
buttocks and back, but also can appear as high as the shoulders and
elsewhere. The medical text books also warn that occasionally Mongolian Blue
Spots are mistaken for bruises and questions about child abuse arise.
Obviously a text book that the UK GP did not read! Mongolian Blue Spots are
birthmarks, not bruises.
So, for all of you with children with a
peculiar blue birthmark on their bottoms, or for those interested in
checking friends and neighbors (or the young ladies dancing in the chrome
pole palaces), it seems fairly positive that the lineage is verified. You
really have found descendants of the man who conquered more of the world
than Alexander the Great. And guess what – my children have it too!
Prostate Cancer once more
I make no excuses for
running another article on Prostate cancer. Fifty percent of people in
Thailand are male and 98 percent of them have a prostate which can turn
nasty and bite them! (What happened to the 2 percent? They’ve had their
prostate removed already.)
However, a friend found that he had an
elevated Prostate Specific Antigen (PSA) and the following examinations
showed that the elevation was caused through cancer, not one of the other
causes of PSA elevation. Yes, PSA is not a go/no go test. Elevation of PSA
is a warning to go looking.
However, prostate cancer is common. The
statistics show that by age 50, almost 50 percent of American men will have
microscopic signs of prostate cancer. By age 75, almost 75 percent of men
will have some cancerous changes in their prostate glands. Do the maths. By
100 we’ve all got it!
So does this mean that life really ends
at around 76? Fortunately no. Most of these cancers stay within the
prostate, producing no signs or symptoms, or are so slow-growing, that they
never become a serious threat to health. The good news is you die of
something else before the prostate gets you! You die with it, rather than
from it. That is an important fact to take in. This we call watchful waiting
and serial PSA’s are the way to go, as well as getting friendly with our
The real situation is that a much
smaller number of men will actually be treated for prostate cancer. About 16
percent of American men will be diagnosed with prostate cancer during their
lives; 8 percent will develop significant symptoms; but only 3 percent will
die of the disease. Put another much more positive way, 97 percent won’t die
from their prostate cancer.
While some prostate cancers can be
‘aggressive’, breaking out from the prostate gland itself and attacking
other tissues, including brain and bone, fortunately this is the minority
scenario. The great majority of prostate cancers are slow growing, and it
can be decades between the early diagnosis and the cancer growing large
enough to produce symptoms. That’s the second important fact to take in.
So let’s look at diagnosis and get the
“blood test” out of the way first. The blood test is called Prostate
Specific Antigen, or PSA for short (we medico’s love acronyms). Up till then
we had another test called DRE (digital rectal examination), which, quite
frankly, was not all that popular. As medical students, we were taught “If
you don’t put your finger in it, you’ll put your foot in it!” Despite this,
‘buyer resistance’ was high, so when news came through about a “blood test”,
millions of men began rejoicing and the sale of rubber gloves plummeted.
Unfortunately, as I said earlier, PSA is not a go/no-go test. A normal range
test doesn’t guarantee you haven’t got it, and an elevated result doesn’t
automatically mean that you are about to claim early on your life insurance
(or your dependents, anyway).
However, there is good news. Serial PSA
examinations can show the rate of cancer growth, and the rate of increase is
Like many other cancers, prostate
cancer can only be fully diagnosed and ‘staged’ by biopsy. ‘Staging’ has
four main grades. Stage I cannot be felt and is diagnosed through
pathological testing. Stage II can be felt, but it is confined to the
prostate. Stage III is coming out of the gland and Stage IV has grown into
This is where you need to discuss your
options with our doctors. If you are a young man with stage IV, then you
have to make up your mind quickly. But if you are 75 with stage I or II,
then you have more time, as you will most likely die of other causes before
the prostate cancer gets you. For these people, “Watch and Wait” has much
going for it, but you must be prepared to get to know your urologist, so
pick a young one.
To increase your knowledge, Bangkok
Hospital Pattaya is running a free information seminar on Men’s Health on
Saturday 21st of
March from 9am.-12 noon. Be quick to register. Limited seats and for first
50 persons, you will get a free PSA and Testosterone tests. Telephone: 061-
386-6153 Email: [email protected]
Is EBM good for you?
The practice of
Medicine is a fascinating story that has unfolded over thousands of
years. “Healers” have been part of most societies, and in ancient China,
for example, you paid the doctor to remain well, not for treatment of
your ailment. Now there’s an incentive bonus for you!
Then there are different kinds of
“medicine” given such names as “conventional”, “alternative” and
These different ways at looking at
the same subject (making you well) can be quite confusing, and for me
much hangs on the term EBM, which stands for Evidence Based Medicine.
Mind you, it has also always been
the case where people like to throw 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 misdiagnosed the illness and the patient
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”.
And me? I am a conventionally
trained British/Australian style medical practitioner who has spent a
lifetime practicing EBM. Practices that have been proven to work. Call
it “good” medicine, if you like.
I am also proud of my final exams
taken 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 through to
today, with CME lectures being attended by my hospital’s doctors, and
myself. Fortunately for me, the slides are in English.
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.
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 conventional medicine afloat.
I am often asked my opinion on
“alternative” medicine, and 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. Ignore the claims that “Big Pharma” is suppressing cancer
treatments. If someone has the answer, they will be multi-millionaires
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 credence.
Falling off the bed
Ever turned over in bed and the room
began to spin? And you were sober? It could have been Benign Paroxysmal
Positional Vertigo (BPPV).
This is a very distressing condition,
and much more common than you imagine. If you have it, after you move in a
particular way, you feel that the room spins around you and you cannot stop
it. It is like being so drunk that when you lie down on the bed the spinning
rotation is so bad you grip the edges of the bed to stop falling off? That
is what BPPV is like – but without the hangover the next morning!
The symptoms of BPPV include the
dizziness (vertigo), lightheadedness, imbalance, and nausea. Activities that
bring on symptoms will vary, but are almost always produced by a rapid
change of position of the head. Getting out of bed or turning over in bed
are common ‘problem’ motions. Because people with BPPV often feel dizzy and
unsteady when they tip their heads back to look up, BPPV is sometimes called
‘top shelf vertigo.’ Women with BPPV may find that having a shampoo can
bring on the symptoms. It also tends to be recurrent. So until you read
further, don’t look up or get your hair washed!
To understand BPPV, you have to
understand the workings of your inner ear. You have three semi-circular
canals aligned in different directions, which act like spirit levels (the
builders type, not the three fingers on the glass barman type) which have
cells with fine hairs bathed with fluid as your head moves in different
directions. The movement of the fine hairs sends electrical impulses to the
brain to tell it (and you) which way is “up”.
However, with BPPV, the natural
movement inside the semi-circular canals is disrupted, so the fine hairs
send the wrong signals to the brain, and being unable to work out which way
is really “up” the sufferer falls over, totally unable to save themselves
from hitting the floor. Debilitating and embarrassing! Ask anyone who has
The commonest cause of interruption to
the normal ebb and flow in the semi-circular canals is produced by something
we have called “ear rocks”. These are made up of crystals of calcium
carbonate, and we medicos call these ear rocks “otoconia”. Imagine these
rocks to be like sugar crystals in the bottom of your coffee cup. These now
swish around every time you move your cup, and likewise your “ear rocks”
swish around every time you move your head.
However, it is not all that simple (it
never is, is it?) as the commonest cause of BPPV in people under 50 is head
injury. In older people, the most common cause is degeneration in the
semi-circular canals of the inner ear. BPPV becomes much more common with
advancing age, but in 50 percent of all cases, BPPV is called ‘idiopathic’,
which is a fancy word we use when we don’t know!
Viruses can be accused too, such as
those causing vestibular neuritis, minor strokes such as those involving
anterior inferior cerebellar artery (AICA) syndrome, and Meniere’s disease
are significant but unusual causes. Occasionally BPPV follows surgery, where
the cause is felt to be from a prolonged period of lying on the back with
the chin raised (for the anaesthetic tubes to slip down your throat), or ear
trauma when the surgery is to the inner ear. The simple situation is that we
can make the diagnosis, but it can be harder for us to exactly pinpoint the
cause. To make it even harder, an intermittent pattern is common. Your BPPV
may be present for a few weeks, then stop, but then come back again.
Is there any treatment? Yes there is,
if ear rocks are the cause. Treatment usually consists of a series of
maneuvers you are put through which are designed to move the ‘ear rocks’
around till they no longer cause problems. These are demonstrated by the
Ear, Nose and Throat (ENT) specialists and usually result in around a 90
percent cure rate. The most common is called the Epley maneuver or the
particle repositioning or canalith repositioning procedure, but have your
ENT specialist show you how to do this.
The will you make in the
living not in the after-life?
I’m sorry, but I
have it on good authority that you can’t take it with you. And that’s
the reason why I’m not going. But to cover all eventualities, I have
made out a will. And so should you. That’s your dying will – but you
need to make another, and that’s called your “Living Will”.
However, there is confusion in the
minds of many people, as to what a “Living Will” actually is and what it
covers. First off, it is not euthanasia. I repeat, it is not euthanasia.
Borrowing from the Mayo Clinic in the US, it states on their website
“This written, legal document spells out the types of medical treatments
and life-sustaining measures you do and don’t want, such as mechanical
breathing (respiration and ventilation), tube feeding or resuscitation.”
The important words to note are “life sustaining” and “resuscitation”.
Neither of these concepts imply medically assisted suicide.
Once again from the Mayo Clinic,
“Injury, illness and death aren’t easy subjects to talk about, but by
planning ahead you can ensure that you receive the type of medical care
you want, to take the burden off your family of trying to guess at what
you’d want done.”
Remember that we are talking about
terminal situations here. Not situations from which it would be
reasonably expected that you will recover and still have a good quality
of life. A fractured hip when you are 90 is a serious situation, but
provided you are healthy otherwise, then it would be expected that you
would recover. You might need a stick for a while, but you would still
be able to have a beer with your mates or whatever your pursuits were
before the incident. In other words, the expectancy of a reasonable
quality of life is there.
However, if you are in the terminal
phase of metastatic cancer, which has progressed despite treatment, the
future quality of life is not there. Artificially prolonging life under
that situation is then covered by the Living Will.
As an example, note the following:
The Living Will is made while of
sound mind. It is not something you scribble out while lying in God’s
waiting room. An example of a Living Will. “Being of sound mind and
understanding all the implications, I ask that this document be brought
to the attention of any medical facility in whose care I happen to be,
and to any person who may become responsible for my affairs.
“This is my ‘Living Will’ stating
my wishes in that my life should not be artificially prolonged, if this
sacrifices my Quality of Life.
“If, for any reason, I am diagnosed
as being in a terminal condition, I wish that my treatment be designed
to keep me comfortable and to relieve pain, and allow me to die as
naturally as possible, with as much dignity as can be maintained under
“As well as the situation in which
I have been diagnosed as being in a terminal condition, these
instructions will apply to situations of permanently unconscious states
and irreversible brain damage.
“In the case of a life-threatening
condition, in which I am unconscious or otherwise unable to express my
wishes, I hereby advise that I do not want to be kept alive on a life
support system, and I do not want resuscitation, nor do I authorize, or
give my consent to procedures being carried out which would compromise
any Quality of Life that I might expect in the future.
“I ask that you are sensitive to
and respectful of my wishes; and use the most appropriate measures that
are consistent with my choices and encompass alleviation of pain and
other physical symptoms; without attempting to prolong life.”
Now those are only examples. The
Bangkok Hospital Pattaya has a pro forma Living Will, which was also
repeated in the Pattaya City Expats website, I believe.
The take home message is that a
Living Will is not euthanasia, and that you must lodge it, before you
need it! The responsibility is yours, as nobody else can say any
procedure was what you wanted (or didn’t want), if in the terminal stage
of your life.
Lies, damned lies and then there is statistics
Will you live forever?
I’m sorry to disappoint you, but statistically you have a 100 percent chance
of dying. Yes, forget about “health” medications, statistics will prove it.
Did you know, for example, that everyone dies within six months of their
birthdays? They do, either before or after (do the math). Did you know that
95 percent of all the people who died in Pattaya last year wore shoes? The
statistics would then have you believe that shoes were the greatest killer
of mankind (not sure where that puts flip-flops).
A couple of years ago, the Cancer
Council of Australia produced a sober warning message (at this time of year
anyway), “Quit drinking to cut cancer risk.” The Cancer Council went on
further to proclaim, “New evidence reveals the extent of alcohol’s
contribution to cancer.”
Now, having been photographed with the
odd glass of wine in my hand on more than one occasion, I was immediately
interested. Should I go on the wagon tomorrow? (“Today” was being a bit
soon, I thought.)
I continued reading, “Cancer Council
Australia has revised dramatically upwards its estimate of alcohol’s
contribution to new cancer cases and issued its strongest warning yet that
people worried by any link should avoid drinking altogether.”
It appeared that the cancers involved
were bowel and breast and the figures indicated that these were nearly
two-thirds of all alcohol-related cancers, overtaking those of the mouth,
throat and esophagus.
More chilling news was that the
Convener of the Public Health Association of Australia’s alcohol expert
group, said he would write to the Australia and New Zealand Food Regulation
Ministerial Council, to request it mandate health warnings on bottles. (It
may be of interest to you that in Thailand there is an anti-alcohol group as
well as the anti-smoking lobby).
Now there are many individuals
predicting the end of the world, as well as Scandinavian teenagers, so how
great a threat was this really? The group media release went on, “New
evidence implicating alcohol in the development of bowel and breast cancer
meant drinking probably caused about 5.6 percent of cancers in Australia.
This was nearly double the 3.1 percent figure it nominated in its last
assessment, in 2008.”
Using their own figures we are looking
at 94.4 percent were not caused by alcohol.
So now we are getting to the
nitty-gritty of all this. If we accept that they have managed to “prove”
(beyond reasonable doubt) that alcohol does indeed “cause” 5.6 percent of
cancers, what does this mean? Since breast and bowel cancers are only two
thirds of the alcohol-related cancers (their mathematics, not mine), this
means that together they make up 3.7 percent of the cancers in Australia.
Let’s split the figure and make it 1.85 percent each. I remain somewhat
underwhelmed, I am afraid. These figures can be read to suggest that 98.15
percent of breast cancers are not related to alcohol ingestion, and
similarly the figures for bowel cancer.
Now don’t get me wrong here. I am not
advocating we all get smashed every night, and indeed I do not think we
should drink alcohol every day. However there are greater risks from alcohol
intake than breast or bowel cancer. Liver damage for starters.
So if you are a person who likes a
drink or three and would like to check your liver function we do have a GI
and Liver Center that would be happy to check for you. Telephone 1719 for an