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If you are not supportive of the mandatory health insurance by now, you should ...otherwise, the PAP-press is failing
Treatment available - but at what cost?
Wednesday, Oct 09, 2013
Mind Your Body, The Straits Times
By Dr Ang Peng Tiam
SINGAPORE - Cancer makes a dramatic and life-changing impact on patients' lives, but treating cancer, for me, is a matter of routine on most days.
I diagnose patients with advanced lung cancer, advise patients with cancer of the colon or rectum on the best way to manage the disease and give breast cancer patients further treatment after they have had surgery.
But once in a while, a patient with a really challenging medical problem will walk through the door.
In June, one such patient, Alexander, 45, was brought into my consultation room on a wheelchair.
With sunken cheeks, he looked like a malnourished war refugee.
His abdomen was distended to the size of that of a near full-term pregnant woman.
His problem began in March, when he noticed a swelling in his abdomen.
He saw doctors in Jakarta, Indonesia, who diagnosed cancer inside his abdomen.
After scanning his abdomen using computed tomography (CT), the doctor suspected that he had malignant lymphoma (cancer of white blood cells called lymphocytes) and suggested surgery.
He decided to head to Penang in Malaysia for a second opinion.
He had been there in November 2011 for surgery to remove a liver abscess, and hoped that doctors there would be able to solve his problem.
They did a CT scan, which showed a large mass inside his abdomen - nearly the size of a basketball.
They attempted to arrive at a diagnosis by passing a biopsy needle into the tumour under CT guidance, to get a sample of tissue for testing.
Unfortunately, all they managed to get was some blood and necrotic (dying) tissue.
They subsequently recommended that he should have surgery, which he promptly agreed to as the swelling was getting worse. UNCERTAIN DIAGNOSIS
In end-May, he underwent surgery.
Much to his disappointment, the doctors did not manage to remove the tumour. All they did was remove a small piece of the tumour for analysis.
But he still ended up having a long mid-line surgical wound because the tumour was so large.
Two weeks after the operation, the doctors were still not sure if the tumour was malignant.
Tests and more tests were being run on the tumour sample.
In the meantime, Alexander's condition was worsening. The growing tumour was accompanied by severe throbbing pain that prevented him from sleeping.
Desperate, he decided to come to Singapore for further management.
He came to see me because he was told that as the tumour could not be surgically removed, he should consider the option of chemotherapy.
But I felt differently. Before any treatment, I explained, I needed a firm diagnosis.
The only way to do that was to get a tissue sample from the tumour for analysis.
He was initially worried at my suggestion because he thought that meant another operation. However, I reassured him that we were often able to reach a diagnosis without open surgery.
The trick in patients with large tumours is to know where to get the tissue from.
Contrary to common understanding, a tumour is not homogenous - meaning that not all parts of the tumour mass are made up of the same tissue.
Some parts are cancerous, while other parts may be made up of dying cells and fibrous tissue.
This is where the positron emission tomography-computed tomography (PET-CT) scan can be useful. It allows us to identify the part of the tumour that is metabolically active, meaning the part that contains the cancer cells.
A PET-CT scan followed by a CT-guided biopsy was carried out the next day.
Within 24 hours, our pathologist was able to report that Alexander had a gastro-intestinal stromal tumour.
This is a rather uncommon kind of cancer that has gained much prominence since the approval of a drug called imatinib, sold under the brand name of Gleevec, in 2001.
Before that, the only treatment option for patients with gastro-intestinal stromal tumours was surgery.
This type of tumour is not responsive to chemotherapy and patients with such tumours that could not be operated on often died within six months of diagnosis.
By taking four tablets of Gleevec a day, the tumour literally melts away over time.
Alexander was started on Gleevec and within two months, his health was restored. A repeat PET-CT scan confirmed that the tumour had halved in size and was no longer metabolically active.
We were all elated.
HIGH COST OF RESEARCH
I wish this could be an unadulterated good story but there is an enormous fly in the ointment, which is the high cost of treatment. A one-month course of Gleevec costs nearly $5,000.
There are complexities in funding cancer research, including the great need for private capital to take high risks in investments, with the promise of having future patents.
At the same time, there is a tussle between private profits and the vital task of saving lives.
There are no easy answers. Indeed, the problems in this arena make my medical mysteries pale in comparison.
For me, though, the reality is clear - what I have done is not to cure the patient, but to find an expensive way to return him to good health.
Alexander has been given a reprieve, but the real challenge for him now is to find the funds to continue taking this drug. While the medical mystery has been solved, his battle is still raging on.
[email protected]
Dr Ang Peng Tiam is the medical director of Parkway Cancer Centre. He has been in practice for 30 years. In 1996, he was awarded Singapore's National Science Award for outstanding contributions to medical research.
Treatment available - but at what cost?
Wednesday, Oct 09, 2013
Mind Your Body, The Straits Times
By Dr Ang Peng Tiam
SINGAPORE - Cancer makes a dramatic and life-changing impact on patients' lives, but treating cancer, for me, is a matter of routine on most days.
I diagnose patients with advanced lung cancer, advise patients with cancer of the colon or rectum on the best way to manage the disease and give breast cancer patients further treatment after they have had surgery.
But once in a while, a patient with a really challenging medical problem will walk through the door.
In June, one such patient, Alexander, 45, was brought into my consultation room on a wheelchair.
With sunken cheeks, he looked like a malnourished war refugee.
His abdomen was distended to the size of that of a near full-term pregnant woman.
His problem began in March, when he noticed a swelling in his abdomen.
He saw doctors in Jakarta, Indonesia, who diagnosed cancer inside his abdomen.
After scanning his abdomen using computed tomography (CT), the doctor suspected that he had malignant lymphoma (cancer of white blood cells called lymphocytes) and suggested surgery.
He decided to head to Penang in Malaysia for a second opinion.
He had been there in November 2011 for surgery to remove a liver abscess, and hoped that doctors there would be able to solve his problem.
They did a CT scan, which showed a large mass inside his abdomen - nearly the size of a basketball.
They attempted to arrive at a diagnosis by passing a biopsy needle into the tumour under CT guidance, to get a sample of tissue for testing.
Unfortunately, all they managed to get was some blood and necrotic (dying) tissue.
They subsequently recommended that he should have surgery, which he promptly agreed to as the swelling was getting worse. UNCERTAIN DIAGNOSIS
In end-May, he underwent surgery.
Much to his disappointment, the doctors did not manage to remove the tumour. All they did was remove a small piece of the tumour for analysis.
But he still ended up having a long mid-line surgical wound because the tumour was so large.
Two weeks after the operation, the doctors were still not sure if the tumour was malignant.
Tests and more tests were being run on the tumour sample.
In the meantime, Alexander's condition was worsening. The growing tumour was accompanied by severe throbbing pain that prevented him from sleeping.
Desperate, he decided to come to Singapore for further management.
He came to see me because he was told that as the tumour could not be surgically removed, he should consider the option of chemotherapy.
But I felt differently. Before any treatment, I explained, I needed a firm diagnosis.
The only way to do that was to get a tissue sample from the tumour for analysis.
He was initially worried at my suggestion because he thought that meant another operation. However, I reassured him that we were often able to reach a diagnosis without open surgery.
The trick in patients with large tumours is to know where to get the tissue from.
Contrary to common understanding, a tumour is not homogenous - meaning that not all parts of the tumour mass are made up of the same tissue.
Some parts are cancerous, while other parts may be made up of dying cells and fibrous tissue.
This is where the positron emission tomography-computed tomography (PET-CT) scan can be useful. It allows us to identify the part of the tumour that is metabolically active, meaning the part that contains the cancer cells.
A PET-CT scan followed by a CT-guided biopsy was carried out the next day.
Within 24 hours, our pathologist was able to report that Alexander had a gastro-intestinal stromal tumour.
This is a rather uncommon kind of cancer that has gained much prominence since the approval of a drug called imatinib, sold under the brand name of Gleevec, in 2001.
Before that, the only treatment option for patients with gastro-intestinal stromal tumours was surgery.
This type of tumour is not responsive to chemotherapy and patients with such tumours that could not be operated on often died within six months of diagnosis.
By taking four tablets of Gleevec a day, the tumour literally melts away over time.
Alexander was started on Gleevec and within two months, his health was restored. A repeat PET-CT scan confirmed that the tumour had halved in size and was no longer metabolically active.
We were all elated.
HIGH COST OF RESEARCH
I wish this could be an unadulterated good story but there is an enormous fly in the ointment, which is the high cost of treatment. A one-month course of Gleevec costs nearly $5,000.
There are complexities in funding cancer research, including the great need for private capital to take high risks in investments, with the promise of having future patents.
At the same time, there is a tussle between private profits and the vital task of saving lives.
There are no easy answers. Indeed, the problems in this arena make my medical mysteries pale in comparison.
For me, though, the reality is clear - what I have done is not to cure the patient, but to find an expensive way to return him to good health.
Alexander has been given a reprieve, but the real challenge for him now is to find the funds to continue taking this drug. While the medical mystery has been solved, his battle is still raging on.
[email protected]
Dr Ang Peng Tiam is the medical director of Parkway Cancer Centre. He has been in practice for 30 years. In 1996, he was awarded Singapore's National Science Award for outstanding contributions to medical research.
