Random ramblings of an Oncology trainee

Thoughts on the Journey of a Cancer Patient

2008-01-28T23:37:00.000-06:00

Received an email from a patient with what sounds like metastatic esophageal cancer. He wrote me after reading my caringbridge page. I am including an edited excerpt from my emailed reply, as a glimpse into my thoughts as a cancer patient. Thoughts that I have been trying to put to paper for some time now. Thoughts that hopefully can encourage other cancer patients that stumble on to this blog.

'My personal thoughts are that if we (as cancer patients) are able to overcome the negativity of a cancer diagnosis, and continue to live (and for some even die) with grace and dignity, we will have already won the victory against cancer. Some journeys with cancer will be longer, and others short, but what matters most is how we walk that journey. That journey need not be filled with angst, bitterness, 'why me' questions, denial, rage, depression, or even in some cases an unrealistic pursuit of a cure/long life. We should not allow fear of the dreaded 'C' word to dictate how we live our lives. Rather, that journey, no matter how long or short, can be a path filled with courage, acceptance, love, hope, faith, peace, joy, fellowship, serenity, a sense of purpose, grace and dignity. We and our loved ones did not choose to be 'afflicted' with cancer, but we have a choice of how we deal and cope with this difficult diagnosis. I pray that God will grant us the courage to choose our paths wisely, the hope to live a meaningful/purposeful life, and the inner strength to live (and die) with dignity.

Wounded healer...

2007-12-18T18:15:00.000-06:00

My life took an interesting turn on Oct 19, 2007 when I was diagnosed with metastatic esophageal cancer. How roles have changed... A week prior, I was a fellow in Hematology / Medical Oncology seeing patients with cancer. Today, I myself have become a 29 year-old cancer patient.

I first noticed some mild dysphagia, always with dry food. I didn't make much of it, but did take some OTC proton pump inhibitors which seemed to help with the symptoms. A few weeks later I noticed an enlarged Virchow's node (Left supraclavicular node). I saw a hematologist/oncologist at work who subsequently referred me to an ENT surgeon who performed a needle biopsy on the spot. Things moved quickly from then. I got the preliminary pathology results showing a high-grade carcinoma later in the afternoon. We decided on proceeding with a PET/CT which was done 2 days later. This showed a Gastro-Esophageal (GE) junction mass with metastatic regional and distant lymph nodes (Left supraclavicular). The following day, I had a EGD/EUS for the definitive diagnosis. This showed a partially obstructing grade 4 adenocarcinoma of the GE junction.

Met with a Medical Oncologist, a Radiation Oncologist and a Thoracic Surgeon. As the cancer has metastasized to a distant lymph node, we decided to start on chemotherapy first. The chemo regimen is EOX (Epirubicin, Oxaliplatin and Xeloda) every 3 weeks, Xeloda is given as pills twice daily. The plan is to get a few cycles of chemo, if there is a good response with no further spread of the cancer, one would then consider chemo/radiation followed possibly by surgery.

I am currently on my 3rd cycle of chemotherapy. My journey with cancer will be chronicled on www.caringbridge.org/visit/towshungtan

This blog will likely be inactive for now. For now, I have stopped seeing patients and is currently on 'research'.

Cord banking

2007-02-25T18:14:00.000-06:00

I was interested to learn that the American Academy of Pediatrics has issued a policy encouraging parents to donate their newborn's cord blood to public cord banks (Pediatrics. 2007;119:165-170).

Finally, a coherent and sensible policy by a well-respected organization. One of my pet-peeves has been the shameless exploitation of new parents by Private Cord Banks. These for-profit companies make profit off the fear of these parents during an emotionally vulnerable time. Which new parent wouldn't be fearful of a potentially fatal disease that could strike their precious child, regardless of the actual likelihood of that disease being one that would benefit from stored cord stem cells.

These private cord banks market their services as an insurance policy in the event that the child could need it in the future. That to me is like paying expensive insurance to cover one's child from the unlikely event of getting struck by lightning. I am sure the Private Cord Banks never let out the dirty little secret that they almost never have to retrive stored cord blood.

A more rational approach would be to store as many newborn's cords as possible in public cord banks, in order to benefit as many people as possible. Obviously this brings up the issue of who would then pay the cost of storing these cord blood. Hopefully with better technology and increased volume, the actual cost would decrease. There are already public cord banks scattered around the US. Maybe one day, Malaysia will have a National Public Cord Bank Foundation to champion its cause.

Doctors seeking greener pastures

2007-02-04T21:29:00.000-06:00

Was reading TIME magazine when I came across an interesting article titled 'Doctors without Dollars'. The author writes about a number of his doctor friends who had left medicine for greener pastures here in the US.

From selling 'magnetized' water to body hair removal, doctors in the US are leaving medical practice for more lucrative fields.

Unfortunately, some doctors are going into quasi-medical fields which the author terms as NRWATS or "nothing-really-works-anyway therapies". These doctors often give undeserving credibility to these unproven therapies. The lay public is then deceived into thinking that since it is endorsed by a M.D. that it actually works. Personally, I have also been approached by people who would tempt me with easy money to lend my name to promote such products.

What a SCAM!

Thanksgiving phone call

2006-12-03T10:58:00.000-06:00

Here in the US, we just celebrated Thanksgiving day, which falls on the last Thursday of November. The 1st Thanksgiving day was observed in 1621, after the Pilgrims had a bountiful harvest that year. In more recent times, it has become one of the major holidays of the US calendar. Family get together for a meal, and reflect on the 'blessings' they have enjoyed in the past year. That's the theory anyways.

I wanted to share about a phone call I received on Thanksgiving evening. I was oncall for Hematology, when I received a call through the hospital operator from a patient's wife. Accessing his medical records (I was at the hospital anyways for an emergency consult), I found out that Mr. X has relapsed follicular lymphoma that was progressing. He had undergone an autologous hematopoetic stem cell transplant a 6 months ago for the lymphoma, but was found to have relapsed recently and his condition was declining quickly, despite experimental therapy.

One of her first words over the phone was ' I am not even sure why I am calling you, but...' She went on to tell me how her husband was feeling really tired, not eating, sleeping a lot, and not as interactive as usual. We talked about his symptoms. They were non-specific, and it could have been anything from dehydration, infection to tumour progression. However, as we were talking, reading through the lines, it become apparent to me that she did not want a diagnosis, or a medical spiel about his condition.

She wanted someone to talk to on a day usually filled with laughter, joy and hope. She wanted a shoulder to lean on because her husband's was giving way. Above all, I think she wanted someone else to give her 'permission', to tell it is okay for her to let go and to allow her beloved husband to give up a fight he was suffering through but not winning.

So, we talked more. Over the phone, I tried to convey as much empathy as I could. To try to comfort her with words, to provide a 'virtual' shoulder to lean on, a 'virtual' hug of comfort. I told her it was okay for her not to have to subject Mr. X to more tests, interventions, chemotherapy. I told her that hospice and comfort care were reasonable options. I gave her 'permission' to keep Mr. X comfortable at home on Thanksgiving, rather than bringing him to a hospital.

She cried, and I almost did. But by the end of the phone conversation, I want to think that she was more at peace with the decision that she knew she wanted to make all along. She thanked me and wished me a happy Thanksgiving. After I put down the phone, I said a little prayer for Mrs. X, for comfort, peace and strength, to do a most difficult task, that is to let go of a loved one.

Woohoo!! I passed my boards...

2006-11-18T18:07:00.000-06:00

ABIM (American Board of Internal Medicine) recently released pass/fail status to it's 2006 examinees through a secure website... Woohoo!! I passed my internal medicine boards!!

Phew... what a relief... I don't have to spend another USD 1000 to retake the exam next year. So 4 board exams down (USMLE 1,2,3 and ABIM), 2 more to go. Next up are the Medical Oncology and Hematology boards.

Unlike the the UK specialty exams, ABIM board certification is good for 10 years, after which one would need to recertify. The recertification process includes at-home CME-like modules and a final exam at 10 years. In fact, currently most of the major specialties require recertification here in the US. This process is separate from the CME (continuing medical education) requirements for medical licensure. I suppose it forces physicians to keep up to date on current practice, which can only be a good thing for patients.

Passing the boards doesn't change my life by much unless I leave my fellowship to work as a board-certified Internist. I don't get a promotion, nor a pay rise. I don't even get more alphabets behind my name :).

I'll just go out for a low key celebration... nothing fancy... movie with friends and maybe a meal tomorrow in the Twin Cities... then I have to start preparing for my Oncology boards... hahaha...

Oncology Fellowship

2006-11-11T23:18:00.000-06:00

Fellowship has been a roller-coaster ride. There were some awfully busy months with 15 hour days and patients that drive me up the wall. But there are also many days that makes me realize how blessed I am to be able to pursue oncology as a vocation.

So, no regrets yet about going into oncology.

Anyways, currently on the Hematology Consult service. Interesting/educational consults have included:
HIT-T (Heparin induced thrombocytopenia with thrombosis), post cardiac surgery presenting with pulmonary embolus and thrombocytopenia.
CNS relapse of Burkitt's-like lymphoma, presenting with cranial nerve neuropathies.
New diagnosis of Burkitt's-like lymphoma.
MAHA (microangiopathic hemolytic anemia) of unknown cause.
Factor XI deficiency presenting with post op bleeding without prior bleeding history.

A long hiatus...

2006-11-04T09:59:00.000-06:00

It has been a long time since I last blogged... since I last blogged, I survived the Lymphoma service, went on to a month in the Coagulation service and just started on the Hematology Consults service.

Just an update about the lady with the Ifosphamide cerebritis, although she made a full recovery from her cerebritis, she passed away recently from complications of her lymphoma. She and her family were special wonderful people. The kind of 'ideal' patients that doctors all pray that we have. During the time she was comatose from Ifosphamide, instead of reacting with anger, blame, the family was full of understanding, grace. They were hopeful for her recovery, but yet were realistic about a possible negative outcome. Unfortunately, although she did recover from her cerebritis, her lymphoma continued to progress, eventually leading to multi-organ failure. During that time, I did pay them social visits in the hospital, and I was always greeted with a warm welcome. Although it was a difficult time for them, what struck me was the way the patient and her family conducted themselves, with dignity, courage and full of grace. Although our time together was brief, it was indeed meaningful.

I need a vacation...

2006-09-23T20:49:00.000-05:00

Haven't blogged in a while... have been busy, as usual.

Internal Medicine boards are over!!!! Wooohooo!!!! Now all I need to worry about is passing it.

Started on one of our hematology inpatient services. The service usually admits lymphoma, myeloma, CLL, amyloid patients. Running a 'huge' census of 28 right now. Thankfully we have 3 good internal medicine residents. The team is made up of 3 residents, 1 consultant and 1 hematology/oncology fellow.

Have been pulling 14-15 hour days for the past 2 weeks, often skipping meals. Thankfully, we have a policy that the consultant takes over the service pager for a 24 hour period every week to allow the fellows some rest... I need some sleep!!

Learning how toxic chemo can be, and how needy cancer patients are.

Just had a case of ifosphamide cerebritis/encephalopathy. A lady with relapsed lymphoma getting ICE (Ifos, Carboplatin, Etoposide). Right after finishing the Ifos infusion, she was confused, delirious and rapidly progressed into a comatose state. I started her on methylene blue infusions, gave her lots of IV fluids to try to flush the drug out and even gave her a dose of steroids (didn't know what else to do). She was comatose for 2 days before finally waking up. We thought we had lost her. Although the family was so understanding about the whole situation, I had a lot of guilt about almost killing her (since I write all the chemo on the service). Now everytime I write for Ifosphamide, I think of her and start sweating.

I need a vacation...

A long break...

2006-08-31T10:24:00.000-05:00

Taken a long break from blogging... have been busy with preparations for my Internal Medicine boards... 6 more days to go...

Transfusion Medicine has been a good rotation... lots of free time to study for boards...

Overall it has been a good month... certainly the exposure to how blood banking works has been educational to say the least. A field of medicine that I have had very little exposure to in medical school and residency.

Things I have learnt in Transfusion Medicine (TM):

1. The word 'Clinician' is often a bad word in TM. It is often amusing to hear what the TM folks say about us 'consumers' of their precious products. The term 'Clinician' is also often accompanied by a smirk, and rolling of the eyes.

2. Cross matching can sometimes be a long, complicated process when patients have all kinds of allo-antibodies. I will have to learn to be patient when ordering blood products the next time.

3. Platelet refractoriness, the methods to test for it (FLAP, Luminex), and the ways to get around the allo-immunization. Often an area of disagreement with the 'clinicians' as well.

To be continued...

Transfusion Medicine

2006-08-06T22:38:00.000-05:00

1 month down, 35 more months of my fellowship to go...

This month I am doing transfusion medicine. Starting a few days late, as I had been covering the BMT service for a colleague who was ill. Looks like a easy month. Spent the 1st day learning how to do cross-matches and blood typing. Most of the month will be spent in lectures and the lab, and hopefully lots of free time to study for the Internal Medicine boards.

Sigh... another exam... like most of the normal, sane people out there, I hate exams... unfortunately, I think if not for exams I don't think I will study...

Anyways, going back to Transfusion Medicine (TM)... it is interesting to note that TM here in the US is often in the domain of pathology and laboratory medicine, rather than Hematology. Even Hematology here is really 'Clinical Hematology' as hemepath is also within the domain of pathology and laboratory medicine (as compared to the UK system). I don't think we do more than a few months is heme path, cytology etc.

Sometimes you get what you wished for...

2006-08-01T23:03:00.000-05:00

and I thought today was the last day of my BMT month... sigh...

I had mentioned in my previous blog that I wished I had learnt a little more about Allogenic Transplants... guess what? Just found out that I have to go back to the Allogenic Service to cover for an colleague who is out sick... I guess sometimes you get what you wished for :)

My colleague who was suppose to start the Allo service tomorrow has been ill for the past few days. I offered to cover for him, and he initially declined. He just called to say that he will take me up on the offer... so... looks like I will have to wake up at 5.30 again tomorrow...

Actually, at least I know that my colleague is someone that won't take advantage of me... he is someone that would have come in if he felt he could make it... so... back to BMT... probably for a day or two... maybe I will get my wish fulfilled and learn something :p

The Allo patients are sick though... everything from horrible opportunistic infections, CMV reactivation, graft-versus-host, failure to engraft, serositis, to just being plain sick. I don't think I would want an allogenic transplant performed to me...

Anyways, got to go to sleep... long day ahead...

Last day of BMT!!

2006-08-01T22:47:00.000-05:00

Phew... initially I thought the month would never end... but today is the last day of my BMT rotation... woohoo!!! At least I can sleep in tomorrow... can wake up at a decent time like 7 am...

Overall, it has been a good experience, though I kinda wished I learnt a little more about Allogenic transplants. I spent the month on the Autologous service, and although I had to cross-cover the Allo service at night, I did not have much to do with them.

One of my patients had asked me whether I found the month on BMT a useful learning experience.. I think that looking back now, the experience of seeing the patients at the different stages of their transplant was certainly educational... having the benefit of having patients ranging from pre-tranplant through to the immediate and latter phases of stem cell transplantation gave me a little insight into the often complicated process.

Certainly fell a lot more comfortable discussing stem cell transplantation with patients now...

Looking forward to call-free month of transfusion medicine... have to start studying for my internal medicine boards though...

BMT...

2006-07-25T11:20:00.000-05:00

Has been a hectic few weeks... almost getting used to waking up at 5.30 am in order to be able to start rounding at 6.15 am. Learning lots...

Funny how different people face challenges so differently. Have had quite a number of patients on the service who had the same disease, same conditioning regimen, same chemotherapy side effects, same complications and yet have such a different outcome... one stays in the hospital for 5 days and the other 15 days...

The emotional, psychological state is so important when facing a life-threatening diease. The right attitudes, approach, mental fortitude can often make a difference between recovery and illness...

The WHO defines health as...
Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity
.

I must admit, as physicians we are often so focused on the physcical that we forget the mental, emotional and social aspects of health.

Interestingly even this definition under debate, in fact, there have been various attempts to modify, edit this definition. Found a paper recently by Sussela Bok a senior visiting fellow from the Harvard School of Public Health which discusses the historical context of the definition, as well the various efforts to 'update' this definition. Found it to be of a somewhat interesting read. Included here is the link to the PDF.

http://www.hsph.harvard.edu/hcpds/wpweb/Bok_wp1407_3.pdf

Day off...!

2006-07-15T21:27:00.000-05:00

Day off today... didn't do much today, slept in, watched TV, surfed the net, emailed, napped...

Looks like a we are going to get hit by a heat wave here in minnesota...

Got to go to bed... early day again tomorrow... 6.30 am...

Medical Oncology / Hematology Fellowship

2006-07-12T22:06:00.000-05:00

I am tired... only 3 days into my clinical fellowship and I am already tired... not a very auspicious start huh??

Starting out on the BMT (blood and marrow transplant service) has been tiring... taking call from home, and since the BMT service does not have inhouse coverage so all the pages get directed to me at night... sigh... I suppose to put a positive spin on things, at least I get to sleep in my own bed at night, between pages anyways... The BMT service can be busy... we do more than 300 stem cell transplants a year... that usually equates to a lot of sick patients...

(BMT = aggressive treatment for diseases like blood cancers, stem cells are collected from either the bone marrow or circulating blood and infused back to the patient after intense chemotherapy / radiation that is intended to wipe out all the cancer cells. The stem cells then repopulate the bone marrow to produce good blood cells. They can be either stem cells collected from the patient or from a donor.)

Actually, complaning aside, I am quite excited at starting my fellowship... looking forward to learning much about oncology and hematology... starting off with 6 months of hematology, it will be a steep learning curve the next 6 months... will be rotating through BMT, Inpatient lymphoma and leukemia services, Hematology consulting service, Transfusion medicine and Coagulation service.

Anyways, got to go get some sleep before I get paged...

Sense of wonderment

2006-07-09T12:18:00.000-05:00

Been wanting to starting blogging for some time now.. just didn't know where to start. Never really kept a journal growing up, not consistently for any real length of time anyways..

Anyways.. Just as I am about to embark on a new phase in my training (a clinical fellowship in Medical Oncology / Hematology), a sense of wonderment came over me.. 'What am I doing here?' I suppose the real question is how did an ordinary guy from a small town in Malaysia end up working as a physician in one of the largest academic medical centers in the US.. I wonder myself..

'Was I smarter..?' I don't think so.. 'Was I more hardworking..?' Definitely not.. 'Was I lucky..?' I don't believe in luck.. 'Do I deserve it..?' No.. then 'What was it..?', I asked myself..

I am blessed.. blessed with parents that were willing to make sacrifices that allowed me to make it to medical school abroad.. Not just financial sacrifices, but lifelong sacrifices from the day I was born.. The sacrifice of time, finances, career, energy.. etc.. The time spent to nurtue, support, teach, talk to, advise, encourage, play with, travel together and role model was not spent in vain. Big and small sacrifices that through the years molded and shaped my thoughts and character.. Because of it all, I have become the person I am today, and I look back at my formative years with gratitude..

I am blessed.. blessed with friends that were willing to help, support and encourage me to achieve my dreams, even though they may have seemed a little out-of-reach.. friends that I have turned to for comfort and advice, for companionship and friendship..

I am blessed.. blessed with teachers and mentors who could see beyond the obvious to look for potential and were willing to invest the time to provide guidance and good advice..

I am blessed.. blessed with God's grace and good health that has allowed me to devote my energies to pursuing my dreams..

In summary, I am where I am because I have been blessed.. I do not know the reason that I was blessed with this opportunity, but one day I will find out.. and I pray that at that time of reckoning I will be found adequate.. and willing to put all the sacrifices that my parents, family, friends and teachers to good use.. and that their investments in me will be fruitful and worthwhile..

Vulnerable..

2005-09-12T22:50:00.000-05:00

Today I experienced just a fraction of how vulnerable it feels to be a patient lying on the hospital bed waiting to be examined.

Currently spending some time on the Rheumatology consult service, and volunteered to be a 'simulated patient' for a teaching session on the musculoskeletal exam. Since it was an impromptu session held in a small classroom, there was no proper examining table and I had to spend a significant amount of time lying on a hard table.

It was awkward to say the least, even with the luxury of being fully clothed. Lying in an uncomfortable position, with people staring and prodding at me, I was vulnerable, insecure and self-conscious.. .

Weird thoughts started crossing my mind.. 'Is he/she staring at my crotch?'.. 'What if I fart?'.. 'I should have worn the other shirt/pants.'.. 'I should have used more deodorant.'..I was glad when the session was over, and I literally jumped off the table in a hurry..

I think it was a valuable and insightful time for me.. to remind me of the precious trust that patients place in our hands.. giving us the license to poke and to prod their bodies.. often times invading their privacy and modesty..

May we as physicians never forfeit our patient's sacred trust in us..