One of my colon cancer patient, a 55 year old lady, is undergoing treatment for metastatic colon cancer.
Brief history:
In summer of 2008 she came to me post surgery. The tumor was extending to the serosa but the 9 nodes analyzed by the pathologist were negative for metastasis. In mofussil towns, the extent of surgery and pathology reporting are a suspect but i decided to give the benefit of doubt to the patient. For multiple reasons, which i intend to discuss some day, i treated her with 5 FU and Leucovorin which benefits 3.5% of people receiving it. FOLFOX 4 the competing regimen benefits 7.2% of people when the node is positive!
The lady tolerated the chemotherapy well and returned back to her normal life. Around 1 year 8 months later in December 2010 she presented with metastasis to liver and lung confirmed by biopsy and PET-CT. PET-CT was done in Mumbai. At the same time I move out of this mofussil town to a cosmopolitan city.
As the lady, her husband and the referring surgeon wanted me to giver her treatment eventhough i was leaving the town and was going to be available only once a month, I was compelled to give her CAPOX, that is, capecitabine and oxaliplatin. After 6 cycles, with partial response, i switched to metronomic capectiabine therapy-flat 1000 mg per day. She tolerated this dose of capecitabine very well. With periodic Chest X ray and sonography of the abdomen, she continued her treatment. Her symptoms disappeared and she was/is like any other lady of her age.
On July 2012 it was reported on Chest X ray that the chest lesion had mildly increased in size.The liver lesion had reduced considerably in size. The lady and her husband were not willing for injectible medicines. For some reasons i did not push for Bevacizumab but hinted to them that they can visit their daughter in Mumbai and seek treatment there. They reiterated their trust in me and asked me to do the best i can. The lady was being monitored by telephonic calls and once in 2/3 month physical check up now.
At this juncture i added Thalidomide (phase 2 trial evidence) and Aspirin. She continued to take Capecitabine. Radiological investigation done in September 2012 indicated some objective response. I asked them to continue the same tablets. All this lead to excellent quality of life, good appetite, no symptoms or signs, and the lady wished to know when she will be stopped of medication. Tough call! I kept pushing it.
Last week i reviewed her again. The liver lesion is not to be seen on USG (sonography). The lung lesion has increased in size. She is finishing her capecetabine this week and thalidomide in another few days.
I have said i will let them know about further treatment. My question/thoughts are
1. Advice them Bevacizumab therapy? {Cost, reluctance of patient?}
2. Get PET-CT done and decide further treatment?
Surgery of both lung and liver metastases? {Emerging evidence, morbidity and also chance of surgical mortality. Why rock the boat?}
3. Enroll her in any trial? {Logistics, no study in India using new molecules like Regorafenib, most studies are with capecitabine}
4. Continue Aspirin and add Topotecan.
5. Hand her case to my partner and let him decide what is best for her. Make it very clear to the relative that I have done the best and that she will benefit more from dedicated care. {Question the role of mind, placebo etc effect of me!}
Will take some decision next week.
What is that i am aiming for this lady? Objective of treating her?
Aim for Quality of life or increasing her survival? Both.
With metastases she has lived 27 months. I wish that she crosses 60 months milestone. The best will be that she wins this battle.
Friday, March 29, 2013
Friday, March 22, 2013
Cancer-Is It Increasing?
One of the most often asked question to me is whether the incidence of cancer has increased in last 100 years. Is cancer a disease of 21st century? Is it the price we pay for pollution, toxins, plastic, radiation etc.
Cancer statistics can indicate that incidence of some cancer has increased and for some has decreased. My view on the subject is slightly different. I personally believe that "Observational bias", if that is the right term, always misinforms us.
You may hear many elders or even middle age people mentioning that diseases have increased and that they are seeing more number of people with cancer nowadays.
Some of my views:
1.Cancer has been there since time immemorial. It is mentioned from the time of 1500-1600 BC and also by Hippocrates (460–370 B.C).
2. The average life expectancy has steadily increased in the last century. Cancer being predominantly a disease of old age you have potential more number of people at risk as well as suffering from cancer.
3. Please note, if we use the numerator denominator concept, the incidence might not have really changed much. Let me explain, the population was less, less people used to live beyond 60 and therefore you had less number of people having cancer.
4. Our diagnostic modalities have significantly improved. This picks up more cancers. Previously we did not even know, who suffered, when they suffered and how they died.
5. We are also picking up cancers which would not have manifested at all! Example prostate cancer.
6. More number of people are seen in the society living with cancer or having been cured of it.
So the way i look at this is, we are living long enough to be afflicted by cancer. But this optimism is of no help unless we find ways and means to evade it, eliminate it. What is the progress we have made against cancer?
Has survival improved in the last 30 years?
Has mortality rate declined?
We will look at these questions in next few posts.
The same is true for some neurological conditions like Parkinson, Alzheimer's. They are at the other spectrum. Old age risks us to degenerative disease or a disease like cancer. A fine balance between these two kinds of diseases is "life".
References:
1. History of Cancer
2. New Yorker, Cancer World
3. Cancer Statistics
4. Inverse relationship between cancer and Alzheimer's:
a. http://www.bmj.com/content/344/bmj.e1442
b. http://roma.cshl.edu/pdfs/Sebat%20et%20al%20Science%202004.pdf
c. http://www.captura.uchile.cl/bitstream/handle/2250/10598/BEHRENS_Inverse_Association.pdf?sequence=1
Cancer statistics can indicate that incidence of some cancer has increased and for some has decreased. My view on the subject is slightly different. I personally believe that "Observational bias", if that is the right term, always misinforms us.
You may hear many elders or even middle age people mentioning that diseases have increased and that they are seeing more number of people with cancer nowadays.
Some of my views:
1.Cancer has been there since time immemorial. It is mentioned from the time of 1500-1600 BC and also by Hippocrates (460–370 B.C).
2. The average life expectancy has steadily increased in the last century. Cancer being predominantly a disease of old age you have potential more number of people at risk as well as suffering from cancer.
3. Please note, if we use the numerator denominator concept, the incidence might not have really changed much. Let me explain, the population was less, less people used to live beyond 60 and therefore you had less number of people having cancer.
4. Our diagnostic modalities have significantly improved. This picks up more cancers. Previously we did not even know, who suffered, when they suffered and how they died.
5. We are also picking up cancers which would not have manifested at all! Example prostate cancer.
6. More number of people are seen in the society living with cancer or having been cured of it.
So the way i look at this is, we are living long enough to be afflicted by cancer. But this optimism is of no help unless we find ways and means to evade it, eliminate it. What is the progress we have made against cancer?
Has survival improved in the last 30 years?
Has mortality rate declined?
We will look at these questions in next few posts.
The same is true for some neurological conditions like Parkinson, Alzheimer's. They are at the other spectrum. Old age risks us to degenerative disease or a disease like cancer. A fine balance between these two kinds of diseases is "life".
References:
1. History of Cancer
2. New Yorker, Cancer World
3. Cancer Statistics
4. Inverse relationship between cancer and Alzheimer's:
a. http://www.bmj.com/content/344/bmj.e1442
b. http://roma.cshl.edu/pdfs/Sebat%20et%20al%20Science%202004.pdf
c. http://www.captura.uchile.cl/bitstream/handle/2250/10598/BEHRENS_Inverse_Association.pdf?sequence=1
Wednesday, March 13, 2013
Deep Vein Thrombosis & Cancer
Deep Vein Thrombosis (DVT) is a serious complication in many diseases. It is a common post-surgical complication which with the righ prophylaxis is taken care of.
Deep vein thrombosis is clot in the deep vein and when this gets dislodged and move can cause stroke, pulmonary embolism and also damage to heart.
DVT is seen in upto 50% of cancer patients but unfortunately is underdiagnosed. DVT in cancer patients can be because of various reasons. Some cancers like lung, colon, ovary, pancreas, stomach and endometrium have greater risk of DVT because of increased viscoity of blood. Few treatments can increase rik of DVT, example tamoxifen.
DVT can present insidiously. At times one can have redness, pain when the veins in the thigh are involved. If pulmonary embolism ha happened there can be dry cough, breathlessness.
Any perosn with cancer needs to be aware of DVT and should ask his treating Oncologist about the same and be on vigil.
Primary and seconadry prophylaxis have their own challenges. One needs to tell the treating phyician about all the medications one is taking as drug interactions are very common.
Take home message is:
1. Be on vigil
2. Drug interactions are common, so ask your doctor about the same when you are taking multiple medications.
3. Be active, exercise helps blood circulation and also in many other ways.
4. Be hydrated always.
5. Take extra precautions on long haul flights.
Be aware and ask right questions!
References:
1. http://www.cancerresearchuk.org/cancer-help/about-cancer/cancer-questions/cancer-and-the-risk-of-blood-clots
2. http://annonc.oxfordjournals.org/content/16/5/696.long
3. http://www.telegraph.co.uk/health/healthnews/9357487/Blood-clot-patients-to-receive-routine-cancer-checks.html
4. http://www.cancer.gov/ncicancerbulletin/062910/page5
5. http://www.webmd.com/cancer/features/exercise-for-cancer-patients
Deep vein thrombosis is clot in the deep vein and when this gets dislodged and move can cause stroke, pulmonary embolism and also damage to heart.
DVT is seen in upto 50% of cancer patients but unfortunately is underdiagnosed. DVT in cancer patients can be because of various reasons. Some cancers like lung, colon, ovary, pancreas, stomach and endometrium have greater risk of DVT because of increased viscoity of blood. Few treatments can increase rik of DVT, example tamoxifen.
DVT can present insidiously. At times one can have redness, pain when the veins in the thigh are involved. If pulmonary embolism ha happened there can be dry cough, breathlessness.
Any perosn with cancer needs to be aware of DVT and should ask his treating Oncologist about the same and be on vigil.
Primary and seconadry prophylaxis have their own challenges. One needs to tell the treating phyician about all the medications one is taking as drug interactions are very common.
Take home message is:
1. Be on vigil
2. Drug interactions are common, so ask your doctor about the same when you are taking multiple medications.
3. Be active, exercise helps blood circulation and also in many other ways.
4. Be hydrated always.
5. Take extra precautions on long haul flights.
Be aware and ask right questions!
References:
1. http://www.cancerresearchuk.org/cancer-help/about-cancer/cancer-questions/cancer-and-the-risk-of-blood-clots
2. http://annonc.oxfordjournals.org/content/16/5/696.long
3. http://www.telegraph.co.uk/health/healthnews/9357487/Blood-clot-patients-to-receive-routine-cancer-checks.html
4. http://www.cancer.gov/ncicancerbulletin/062910/page5
5. http://www.webmd.com/cancer/features/exercise-for-cancer-patients
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