Why Angie gets my BP up....

Why Angie gets my BP up....

 So this morning while signing the attendance register i ran into a friend of mine from another specialty- a surgical oncologist- which is the medical term for a surgeon who deals with cancer patients and we ended up walking together to the canteen to get our early morning booster shot of caffeine before heading to our respective departments to start the work day. Among all the medical specialties I have the greatest respect for cancer specialists as oncology is one of the toughest specialties to practice if you are a caring doctor. There is so much you wish you can do for your patients but you are unable to do much practically and you have to be satisfied with just small victories. I have known oncologists who celebrate their patients 5 year survival rates (still alive 5 years after surgery) as big celebrations. As i said i respect them very much but I wouldn't like to be one of them, for i feel too much for my patients to ever develop the detachment to watch a two year old child die slowly before my eyes in such pain. That’s just not me.

Anyway after exchanging personal updates on each other’s lives the talk slowly veered around to the latest stunt pulled by that stupid "celebrity"(this wasn’t the first or the tenth word i typed, but this is a family friendly blog hence all those other words describing her were censored) Angelina Jolie who is singlehandedly doing such a disservice to cancer care everywhere (read my earlier post here on her breast cancer stunt). The news is- for her next stunt Angie is going to get her uterus removed even though she doesn’t have uterine cancer. What does one say about a woman who goes on an organ removal spree just because a genetic test indicated a "possibility", I repeat "only a possibility" that she may develop cancer sometime in the future or far future?  And what does one say about doctors who pander to her depraved wishes? Well, let’s leave it at that.

As i was sipping a strong filter coffee and chatting with my oncologist friend the talk veered around to the newer tests being developed for cancer diagnosis- the BRCA gene test and stuff like that. As I had written in my earlier blogpost, the economics of such tests prices them out of the reach of the average Indian patients especially as they are just screening tests and offer no conclusive (strong) diagnosis. It’s quite a gamble to spend lakhs and lakhs of rupees just to screen yourself on the possibility of being diagnosed for cancer when there are other better tests available for economic (Indian) rates. And this enormous economic disparity also extends to the availability of therapeutic drugs (treatment). Right now as we speak, there are tests available which can suggest medicines perfectly suited for your individual body cells but unfortunately they are not yet available in India or even affordable to us for they cost a minimum of 25 lakhs a pop to tell us which medicine works faster for our body.

To explain this further I would like to give you a brief overview on the treatment for cancer. Feel free to skip this para and move on directly to the next if you are not interested. As you know cancer cells are just normal body cells gone wild due to a variety of causes, none of which we can state with certainty right now. And currently we have three options to treat cancer cells - we can surgically cut and remove the diseased cancer cells or sometimes the whole organ to prevent the caner from spreading to the nearby cells. Or we can give massive doses of radiation -designed to kill all living cells in the vicinity of the cancer cells hoping to kill the cancer cells along with the surrounding normal cells. Or we can give what’s called chemotherapy- drugs which kill the cancer cells - by targeting the growing cells and as cancer cells are the fastest growing cells in the body they are killed far faster than the other growing cells in the body like the hair, nail and tooth cells - which is why cancer patients often have a bald look.

What the Americans have done recently is they have manufactured a test whereby small bits of cancer cells taken from a patient’s body are treated with small drops of the different cancer drugs. Based on the test report which shows which drug kills the cancer cells of the patient's the fastest that drug alone can be given to the patient instead of giving the other drugs one by one on a trial and error basis as we do right now. This targeted delivery of drugs help in faster cure rates but unfortunately the cost is prohibitive - it costs upwards of 25-30 lakhs of rupees to just find out which drug works best and then you have to factor in the cost of the drug itself and the total treatment becomes very costly for the average cancer patient. So we muddle along as we always do and only hope that the newer tests become cheaper with time for us to use.

So after talking with my friend on cancer trends what do I advise the average patient? Simple. Cancer is easily deductible in its earlier stages. Any general health check up done at regular intervals can easily pick up the earliest signs of cancer before they metastasize (spread) throughout the body. At the earliest stage it is easy to kill the cancer cells and cure the patients fully. So just like the western countries do, we Indians should make a habit of having annual health checkups. In fact it’s even more necessary for us Indians because unlike the Americans we don’t have an affordable health care act (heard of Obamacare?) to take care of all our medical bills free. Here we pay our own bills and most medical care is un-affordable for the average Indian salaries. So be wise and get that check up done. End of advice session. As for Angelina Jolie, oh hell, I got nothing to say.

Angelina Jolie’s Breast Surgery….

Angelina Jolie’s Breast Surgery….

By now everyone- on both sides of the fence- has had their say on the Angelina Jolie preventive breast removal. If you are one of the rare species of mankind who has missed out on hearing about it (or reading about it), the news last week was that Angelina Jolie has had bilateral radical mastectomy which is trade-speak for surgical removal of both breasts to prevent cancer. This is a rarely used technique of cancer prevention, which is sometimes mentioned to patients as one more option but very rarely as a serious option.

The basic requisite for this surgery is that the patients must have confirmed genetic markers for breast cancer- brca1 & brca2 genes - which indicate that the person has a very high chance of getting breast cancer and there must also be documented history that the patients mother or grandmother must have had breast cancer in the past. When both conditions are present- a positive family history and a positive genetic presence of disease- the patient is offered the option of removing the breast tissue before cancer develops.

Not many patients choose to do so as they fancy their chances and wait to see if they do indeed develop the disease or not, for a chance is just that- a probability- there is no certainty that each and every patient will develop that disease. They may or may not. So most patients prefer the option of careful vigilance and frequent testing for presence of suspicious lumps and then decide to undergo surgery if necessary.

But a few rare patients like Jolie prefer to remove their fear once and for all by total removal of all breast tissue to reduce their chance of cancer. Because once past the childbearing and breast feeding age the breast serves only a cosmetic purpose and not a physiological purpose. Loss of breast is disfiguring but it’s not life threatening, so it’s every individual’s choice. But preventive removal of body parts is so extreme a concept that even doctors hesitate to advocate this treatment as a  routine procedure and hedge their bets by offering other choices first - prescribing drugs like Tamoxifen which taken regularly reduces the chances of developing breast cancer.

The one thing which complicates breast cancer compared to other cancers is the presence of silent (distant) secondaries- clumps of cancer cells which move away from the breast into other parts of the body where they develop into further cancers. This needs chemotherapy and irradiation and even then we are not sure that the whole thing has gone away, complicating the assurance given to the patient that they can henceforth lead a normal life from that point on. So all in all, this is pretty confused issue where the blind leads the blind.

Angelina Jolie has celebrity status and hence whatever she says has high recall value among the public all over the world. By publicly talking about her surgical breast removal she makes one wonder how many others will now follow her example?  And if it’s at all necessary? Or even possible for every single BRCA carrier to undergo this preventive breast removal? 

 

Although the statistics which Angelina Jolie quoted in her speech about breast cancer genes brca and cancer possibilities is frightening at first glance- like 12% of all patients have this gene and 80% of those with the gene develop cancer, let me state that these statistics are based on association studies. For those who are not familiar with association studies- it means that in a given patient - these two separate factors are present and there may be a possibility of them being linked together.

Let’s take a local example. On a Sunday morning at 7AM there is a big crowd of people at the Marina Beach (famous beach in Madras city). If someone did an association study based on the above fact they can extrapolate the data to say

1) Sunday mornings are crowded at marina beach.

2) A big crowd worships the sun god at marina beach every Sunday at 7Am

3) The sun god makes an appearance at marina beach at exactly 7am every Sunday to meet his devotees.

4) Only if there is a big crowd on the marina beach at 7 am will the sun rise on Sundays.

The first point above is the observational data, the others are just assumptions, some more fanciful than the rest. Most observational studies are just like this; you take two facts and try to link them using your imagination and probabilities. Some may turn out to be true; some may be just random association and some you know to be true but can’t think up a single valid reason on why it should be so.  Hence to give too much credence to association studies is not very wise.

 So what if you are still worried about the possibility of getting it and still want to test yourself on the off chance of it being true. Before you pressurize your doctor into ordering this test for you, you should know that one important factor about this gene test which is not much talked about is that a single biotech company in the USA has patented this Brca gene and hence they are exclusive manufacturers of the gene test. Because of that monopoly the test costs three thousand (or $3000) dollars in the USA and translated to Indian money it would work out to one and a half lakhs (or Rs.1,50,000) rupees in hard currency. For that amount all you get is knowledge about the presence or absence of the BRCA gene in your body cells. And sleepless nights. For with a positive result- if the gene is present- you might get cancer. Then again, if the gene is present- you might not get cancer. You never know, either way.

Don’t get me wrong, I am not advising against taking this test. All I am doing is simply stating that one test is not conclusive evidence that you will definitely end up getting cancer. There are lots of factors, many of them still unknown, involved in cancer. Read this- my earlier post about the cancer scare. But the cancer crusaders are definitely doing a disservice by creating too much hype and over-scaring people. A little commonsense goes a long way when you are struggling with the decision to believe all the hype or not.

So to come back to Angelina Jolie's decision, all I can say is- it’s her body, she has every right to it- to do whatever she wants- to get a tattoo, to get body piercings or to remove a breast or two. In her long career of wacky decisions this is just one more. Let’s not read more into this than just that. Let’s not turn her into a crusader of cancer health and insist that others follow her example. What’s good for the goose, errr, in this case, for Angelina Jolie, may not be good for everyone else. Women- make your own decisions please.