Aspirin and Colon Cancer

Aspirin is well known drug. In recent years evidence has accumulated to show that aspirin has beneficial effect on colon cancer patient. If you are a colon cancer patient or relative of colon cancer patient it is time you asked your doctor whether you should be taking aspirin.
The potential side effects of aspirin are gastrointestinal ulcers and stomach bleeding. But the risk benefit ratio is definitely tilting towards aspirin being used to prevent as well as treat colon cancer patients.
You may also participate in Aspirin trial as molecular testings are further defining who will benefit from Aspirin.

References:
1. Harvard
2. BJC and Nature
3. NEJM
4. Lancet

Aspirin also has action on other cancers which requires more research before aspirin is routinely recommended.

Second Opinion-A Story Of Cervical Cancer Patient

January is the Cervical Cancer Awareness Month, let me share a story of one of my patient.

One afternoon in 2007 post lunch, I had a knock on the door. It is a common practice for patients, patients relatives to seek consultation at doctor's residence. They normally would be from nearby village and the need to catch bus/train back home compels them to disturb doctor during his personal/private time.

This time it was a bunch of people with MRI scan and other reports in hand. The MRI showed mass in the cervical region extending into the bladder. MRI is not a part of FIGO staging but widely done scan. There is a learning curve to interpret MRI's and I had to rely on the report given by Radiologist to get more out of the MRI report. The description mentioned cervical mass invading the bladder. The histopathology report had confirmed it as squamous cell carcinoma. They had consulted a gynecologist who based on the reports had counselled them that it was Stage 4 cervical cancer and the best treatment would be symptomatic care. Looking at the reports, I also opined that it is Stage 4, Surgery and Radiation both would cause more harm. Benefit from chemotherapy is doubtful. One of the relative insisted on getting the patient examined by me. I reluctantly agreed. 

The same day evening I examined the patient. On pelvic examination, to my surprise, found the anterior fornix completely free. You cannot have the bladder invaded with the tumor without the anterior fornix being involved. The physical examination did not match the MRI report. The clinical diagnosis was Cervical cancer stage II B. This was potentially treatable and curable. But what was that in the bladder? 

CT scan and Urology opinion made us realize that it was a big stone in the urinary bladder.

The patient had surgery for the removal of the stone. When the wound had healed she received Radiation both external and brachytherapy. During external radiation she also received weekly Cisplatin chemotherapy. 

It is five years now since she got treated.  She has occasional urinary tract infection has subcutaneous fibrosis. Probably she can be considered cured of her cancer. Last year her third son got married and he was quite emotional.

The patient and her family hail from the rice growing region in Karnataka. They have constantly shown their gratitude by supplying me with free rice. I call her lucky and i am even more lucky!

Learning:

1. Clinical examination is a must. Scans cannot substitute clinical examination.

2. It is a good idea to get second opinion.

3. PAP Smear screening will reduce/eliminate diagnosis at late stage. Early stage diagnosis or pre malignant lesions are completely curable.

"Cancer is curable, if treated early".

Godspeed!

Lance Armstrong-What do we learn?

The community at large but cancer community specifically feels let down by the confessions made by Lance Armstrong. He was a poster boy for cancer survivors. An inspirational figure providing hope. Yuvraj Singh, Indian cricket player provides the same kind of hope and inspiration.
Everybody has heard the story but what is that we learn from this.

1. Human behavior is dictated by environment as well as self. Peer pressure affects at every stage of our life. Few have the self-confidence and a sense of self worth to be not affected by peer pressure.

Few examples of people succumbing to trends....

a)  Everybody smokes, so let me also smoke! Occasional rationalizing.

b)  Drinking is socially acceptable and is part of marketing, networking!!

c) Ragging is harmless when done inn limit. No one knows when it goes beyond limit.

One can further this theory to good things also.

Let us promote healthy living at all fronts.

Stumbled about something on peer pressure, http://books.wwnorton.com/books/Join-the-Club/

Inequality in Cancer Clinical Trials

In past few weeks multiple instances have prompted me to ponder over inequalities in life. Those interested in them can read here and here.
A recent article published in JCO talks about inequality in recruitment of patients for clinical trials. It is well know that older patients are underrepresented in clinical trials. This get compounded further if they are economically poor. In short poor, elderly patients do not get to participate much in clinical trials. Also if you are less educated chances are you will not participate in a clinical tril.

Musings:
1. Older population needs to be adequately represented in clinical trials to ensure that in "real life" they do not suffer. This is essential for many reasons like, their cardiac, renal reserves are different from young patients. So the effect of drugs need to be know in older patients. Also they are on multiple medications and drug interactions are a common problem.

2. Why income is a barrier to participate in clinical trials? This needs deeper thought. Referring physicians need to be made more aware to ensure patients participation in clinical trials.

A long way to go................

Cervical Cancer Awareness Month-January

January is the Cervical Cancer Awareness Month. Half the month has gone by and I have not heard much about this from hospitals, doctors or media. Probably my observational bias!
Without the support of the doctors, patients, media, pharmaceutical companies, awareness campaigns are a failure. The fact that Cervical cancer does not get the same kind of attention as breast cancer is because there is not much money in Cervical cancer. We all are aware of pink ribbon, October as Breast Cancer Awareness month and lot of celebrities endorse the campaign in October and throughout the year. Let me stop ranting and devote few lines towards Cervical cancer. You can also visit this http://www.nccc-online.org/index.php/january.
Cervical cancer is preventable. Without dwelling on risk factors and other things it is recommended that every female gets PAP smear  screening test done. If you are above 30 years of age please get a PAP smear done. This has the potential to save your life. Consult your doctor/hospital today.
If you are post menopausal lady get your annual checkup done. Post menopausal bleeding is an ominous sign and should lead to gynecological consultation.

Cervical cancer is preventable, prevent it!

Cervical cancer is curable if diagnosed early!

Are you at high risk for Breast Cancer?

Defining people at risk for cancer will become more refined and defined in days to come. To know the risk for breast cancer there are multiple tools. Once we know we are at high risk, what to do? Those who are at high risk for breast cancer are now officially being recommended tamoxifen. Most newspapers have covered this news of NICE's recommendation-Guardian, BBC, Telegraph.  As our attention span is getting shorter and shorter, let me highlight the safety and precaution. Nice is recommending that pre-menopausal women at high risk should be offered tamoxifen unless they have a history of thromboembolic disease or endometrial cancer,

So if you have thromboembolic disease or endometrial cancer, or history of same, or at risk for these, please ask question to your doctor before you take tamoxifen.

Markets, Prosperity Determine Research-Cervical carcinoma

Pharmaceutical companies focus their research on the most lucrative markets. This is nothing wrong but leaves a huge disparity in the kind of diseases suffered by the rich and the poor. I am tempted to say that some agencies or government should focus on health issues suffered by poor. I am referring to a recent report which mentions that the number of molecules in pipeline for cervical cancer is the least. Lung, leukemia and lymphoma are the top three. Cervical carcinoma is the second common cancer in females but the burden is in Asia and Africa. They are not lucrative markets!It can be argued that GSK and MSD have come up with HPV vaccine which should take care of cervical carcinoma in coming years. But the fine print is that the vaccine is effective against few variants of HPV, especially HPV 16, 18, 31 and 45. They are the risky ones but there is a possibility that other HPV strains can become more virulent when they do not have competition from the regular aggressive ones.
Let me change the direction of thought towards what can be done to decrease the diseases of the poor. The rich benefited  better health  because of various reasons. Cervical carcinoma, tuberculosis, malaria, dysentery etc decreased in the affluent much before effective treatment for the same emerged. Bill and Melinda Gates foundation is doing a great job by focusing on these diseases but at times I have my doubt. Improvements in sanitation, hygiene, living standards, housing, diet have helped the affordable to conquer these diseases. The rise in household income also brings in better female literacy, optimum marriage age!, lower fertility rate, better nutrition. I guess i have stressed my point. Better socio-economic conditions will help the cause of health.

So growth is what is urgently required in Asia and Africa. But how should one deal with the issue. They tend to go hand in hand. How does one allocate resources? What percentage should go towards building infrastructure, improving income of the people versus investing in the research of the diseases suffered by them. Much of this also related to governance and political will/systems, but that will be digressing too far!!

Chemotherapy-Patients' Expectations

We have made lot of progress in the last 40 years in treatment of cancer. The survival has improved for most stages in most cancers. We still have a long way to go as nothing short of cure from cancer is what we all are aiming at. It will be even better to nip it in the bed and do not allow cancer to happen in the first place.

Let us get back to present. Each person dreads the word cancer. When one is diagnosed of it, all one wants/hopes is that he gets cured of it. We go to great lengths to get this cure. Hope is good and it is documented that hopeful people respond better to treatment and live longer.
But at the same time is it justifiable to promise cure in metastatic cases?  Many metastatic patients receiving chemotherapy may take it under the false belief that it may be curative, when all that may be giving is few weeks to few months to live and in anecdotal cases few years!
An article published in NEJM, New England Journal of Medicine talks about the same. They report that 69% of patients with lung cancer and 81% of those with colorectal cancer did not report understanding that chemotherapy was not at all likely to cure their cancer.

Bubbles in Education, Healthcare & Research?

Few years back we witnessed the housing bubble coming to an end. Its effects are still being felt. The internet bubble in 2000-2001 led to the creation of infrastructure.Japanese are still to recover from the bubble which ended in 1989.  There have been numerous bubbles and busts in history documented. Also considered as business cycle this is considered by some as inevitable and also beneficial. The governments try their best to avoid this as it brings the survival of the fittest to a very crude form! We are yet to learn the art of growing without creating bubbles. Trade, economics and financial market have made their contribution and we need to be thankful to them. In the new era we will have to learn the art of creating mini bubbles from which survival is easier and the pain is short lived.
The latest making the rounds is education bubble and healthcare bubble  in US. It will be interesting to see if there is a bubble, and when it will burst. Can we anticipate the consequences of this bubble burst?
There are lot of countries in the world which would aspire to have a bubble in their education and healthcare sector!
Similarly can scientific research suffer from bubbles? The link is to an article which predicted something like that in 2010 http://chronicle.com/article/Will-the-Biomedical-Research/124981/ Bubbles predicted too early have limited impact on the behavior of people. 
It is happening with respect to NIH funds. What will be the impact and when the impact will happen are questions which require more analysis and some speculative work. Does the nature of certain research demand that they have bubbles. Without the failures we would not have had our successes? How do i calculate the return on investment of Human Genome Project? What time frame should one be looking at?
Researchers do have fiscal responsibility. But how does one define it?

Similar thoughts can be expressed about healthcare. Solutions can be varied but difficult to implement as they require behavioral changes. Most behavioral changes happen because of pain or right incentives provided at the inflection point. What incentives can be provided to hospitals, doctors, pharmaceutical industry and patients to contain the so called emerging bubble?

The bubble in education will create bonded laborers new era. There are efforts to prevent this.

Why is it so difficult to learn from bubbles in other sectors? Why is it difficult to contain bubbles after having recognized their formation?
Does nature operate through bubbles?

"Unbridled growth in any sector acts as cancer to the ecosystem called life" Pruning either by nature or by humans, if they can, reduce malignant insults.

Head and Neck Cancer and HPV

As mentioned in the previous post there are multiple viruses responsible for malignancy. In recent years the role of HPV virus in head and neck cancer has become more clear. Patients having HPV positive cancer tend to be 10 years younger, non-smokers, non-alcoholics. They present in stage 3 or stage 4 but have better prognosis compared to non-HPV positive head and neck cancer. Treatments are getting better defined for this subgroup of patients.Trials will determine dose and other details of chemotherapy and radiotherapy for this patients.
It does appear that having HPV positive cancer has better prognosis but the real challenge will be in its prevention. Vaccines are being touted to do this but the pros and cons will have to be weighed.