In this fascinating Khan Academy video Dr. David Agus, a professor of Medicine and Engineering at USC postulates on thinking of having cancer as a dynamic state of existence rather than of having some malignant cells gone awry. I’m not sure just how to make use of his discussion, but he makes an interesting case for focusing on the body as a habitat that may be either a place where cancer cells can thrive or where they die off as an inhospitable environment. How this related to the movements towards nutritional, emotional and physical modulations as a part of cancer treatment and prevention is unclear, but it is food for thought.
Leave a comment to let us know what you think about the comments of Dr. David Agus comments on cancering.
Cancer touches every soul in one-way or another. There are many treatments available for both the mind and the body when living with this disease but the most important treatment option can often be overlooked. With chemotherapy, radiation, surgery, medications and rehabilitation, it is easy to forget that exercise can be a cancer patient’s greatest ally.
Extreme Fatigue is one of the most common complaints heard from patients during chemotherapy treatments but there are ways to help alleviate this uncomfortable side effect without adding additional medications into their day. Numerous studies have shown the merits of exercising throughout treatment to help maintain a normal level of activity. These studies have also shown that continuing to follow an exercise program after treatment may help cancer survivors maintain a quality of life similar to that found before diagnosis.
Exercise can do more than just help reduce fatigue. It can also help many patients address the emotional issues that come with a cancer diagnosis and treatment. Issues such as weight gain, muscle loss, and postoperative healing can create a distorted body image, which may lead to depression. It is widely known that exercise can aid in weight loss and that weight bearing exercises can increase muscle mass but during exercise, the body also releases endorphins that create an elevated mood. This elevated mood could help patients see their situation in a more positive light and aid in their recovery.
Although some form of activity is recommended daily, each patient will require a different exercise program dependent on his or her disease and current treatments or if they are currently in a survivorship plan. For example, a patient receiving Mesothelioma treatment must be more cautious of activities that apply a greater strain on the heart or lungs while a patient being treated for Bone Cancer would avoid any high impact exercises that could lead to a fracture.
Because of these risks, many people choose to have a trainer help them design an appropriate exercise routine. This is a wonderful idea but it is important to remember that the trainer must understand the specific requirements of cancer patients. According to an article published on the National Cancer Institute’s website, the American Cancer Society has developed a certification program for trainers wishing to help cancer patients and survivors. This program ensures that cancer patients and survivors are receiving the best care possible.
by David Haas. David is a writer for the Mesothelioma Cancer Alliance. Please follow David on Twitter @haasblaag.
My latest in a series of my favorite Khan Academy health related videos is on inflammation. I expected this video to be more scientific, teaching about the process commonly called the inflammatory cascade, a process where once something happens to start the inflammation process how the body responds with a series of chemical reactions leading to the cardinal signs of inflammation: dolor(pain), calor(heat), rubor(redness) and tumor(swelling). Actually the video is an interview with a physician about the long term vs. short term effects of inflammation and methods used to reduce inflammation.
Certainly don’t go out and start using all the drugs mentioned in the interview, but it is fun to watch and get you thinking. Enjoy.
Overdiagnosis was not a term I ever heard in medical school, and I suspect it is one that few or you had heard of much more than a year or two ago. Overdiagnosis is when a condition is diagnosed that is not causing any symptoms for a patient now, nor will it cause symptoms at a later time in their life. I wrote about overdiagnosis earlier after reading the excellent book, “Overdiagnosed: Making People Sick in the Pursuit of Health” by H Gilbert Welch.
This book nicely discusses the issues of overdiagnosis in both chronic disease and in cancers. The long-held assumption that all malignancies left untreated progress, spread and lead to death is simply not true. We are learning that many types of cancer have unpredictable courses. Prostate cancer is the most notorious of these, with good evidence showing that most prostate cancers are ones patients live with asymptomatically whether they know about them or not and die of something else without ever having symptoms of the prostate cancer. This is the primary issue behind the recent USPSTF “D” recommendation against routine PSA screening in asymptomatic men. There is strong evidence that some percentage of renal cell cancers, some types of breast cancer and thyroid cancers not infrequently regress or remain indolent and never lead to symptoms.
The recent evidence suggesting frequent overdiagnosis in breast cancer is very disturbing. An April 3 article in the Annals of Internal Medicine in a large retrospective review in Norway infers a 15-25% incidence of overdiagnosis in women found to have breast cancer on mammographic screening. They used every other year screening, and suggest that for every 2500 women screened 6-10 cases of overdiagnosis occurred, 20 women were diagnosed with breast cancer that was not overdiagnosis, and 1 death related to breast cancer was prevented. We have strongly encouraged women to get annual mammograms for years. Personal anecdotal experience can make us even more confident that we are doing the right thing. I have had many patients diagnosed with early breast cancer by mammogram over the last 20+ years, and until recently had not had any women over age 40 that I can recall diagnosed with advanced stage breast cancer who had been getting their annual mammograms. It was very intuitive and tempting for me to believe that I was saving many lives and preventing much morbidity by aggressively pursuing early breast cancer diagnosis. I know that I have put many women through emotionally stressful and uncomfortable additional testing, biopsies, and breast cancer treatment. It is concerning to think that I may be subjecting some of these women to overdiagnosis and unnecessary treatment, but until we as a society actively address the issue of overdiagnosis and try to find ways to figure out which early cancers found on screening can be managed with active surveillance and which need curative treatment we are left with the inevitable overdiagnosis dilemma. This will involve asking a cohort of women with various very early cancers to be observed for progression prior to intervention. Whether this is going to be acceptable is not clear. We need to do the same thing for men with early prostate cancer. We are following lots of men with prostate cancer, but as far as I know not in a formal study that will give us help in knowing which cancers can be safely followed. For now I’m doing nothing different except keeping my eyes wide open to further research and recommendations.
Much of what we do in medicine today is aimed at early diagnosis of asymptomatic disease, and overdiagnosis is a very valid concern any time we are screening for asymptomatic disease. The recent changes in criterion for hypertension, diabetes and hypercholesterolemia are leading us to the preventative treatment of many diseases that are of themselves asymptomatic. The whole issue of overdiagnosis is going to be fascinating to follow over the next decade or two.
I am far from an authority on coping with grief, but as a family physician of almost 30 years and having some personal experience with grief I feel that sharing some of my experience may be useful. I’ve had a fairly simplistic approach to grief for a long time, and am not completely sure how I came to this point, but it has worked for me and it seems to be well received and appreciated by patients. At least some of this came from the pastor who was a part of my residency program when my first wife died near the end of my third year. I seem to recall talking about this with Becky Sullivan MD, my residency director and mentor during my early years of practice in Puyallup. Still I think the crystallization of this triad of needs to be met during times of grief is something I came to understand and verbalize by talking to many patients over many years.
I believe a major key to getting through a time of great loss is to find a way to take care of our basic physical and emotional needs. I think of these as, “Eat, sleep and carry on.”
Eat: I too often see patients in acute grief with superimposed upper abdominal pain that I am certain is from gastric hyperacidity and not eating. Simply forcing yourself to eat can go a long way towards getting through a period of grief without complicating peptic ulcers or gastritis. I tell patients that they don’t have to be hungry, don’t have to feel like eating, and don’t even have to eat an extremely healthy diet. They just have to force themselves to chew and swallow a reasonable amount of food three times a day. Tradition in many communities, religions and cultures bears out the importance of eating. It is a nearly universal custom for family, friends and relatives to bring meals to the bereaved.
Sleep: Sleep is very difficult for many people in times of great stress or grief. In my opinion this is one of the most important times for physicians to prescribe sleep aides. It is tough to maintain your sanity and move through the rituals, responsibilities and duties expected when you are reasonably rested. In a sleep deprived state this is nearly impossible. Don’t be afraid to ask your physician for help if sleep is a problem after a major loss.
Carry On: This is my way of saying that forcing yourself to participate in at least some of your usual daily activities is very helpful in regaining some sense of normalcy. If you stay home all day, only see others who are also grieving, and don’t force yourself to carry on with your usual life activities it is too easy to become all-consumed by your grief. If you exercise normally continue to exercise. If you go to church continue to go to church. If you are in a service club, a book club, a bowling league, or other routine activity try to get back into that activity reasonably quickly. It can really help as a distraction and start to lead to a feeling that life can and must go on after the loss.
There is much more to managing grief, and I’m certainly no psychologist. Still, the advice to eat, sleep and carry is a good base on which to base your recovery.
I was reading my American Family Physician at the YMCA this weekend, and found an article “Implementing Advance Directives” that prompted me to come home and write this post. I have to admit that I should need to more often and earlier with many of my patients. I need to have a better plan for helping patients successfully and confidently choose to complete both a living will and a durable power of attorney. A living will outlines you preferences for decisions you want made on your behalf in various circumstances if you are unable to verbalize you own preferences. A durable power of attorney legally authorizes someone to make health care decisions for you in the circumstances where you are unable to make them for yourself. These two documents complement each other. I’ve too often tried to maneuver the minefield of coming to decisions for a patient’s care when they have failed to make their preferences clear and implement a durable power of attorney giving one individual the power to execute those choices. Then an out of town relative shows up to save the day, or a sibling dispute over how to deal with Dad’s terminal illness care happens. This type of thing is all too common, and makes a stressful time for everyone. Making your preferences known, putting it in writing, and designating a legal power of attorney helps your loved ones avoid this unnecessary messy and at times ugly scenerio. Both of these documents are crucial to both you and your family to assure that your wishes for decision making about your health are carried out according to your wishes.
Why don’t I do a better job? I suspect it is a combination of factors. I think the first is that this is rarely high on a patients list of topics they want to discuss at an office visit. It is easy to put off this discussion when seemingly more pressing issues are the patient’s expressed reason for the office visit. Even at physical exam visits, or in the medical coding lingo “preventative care” or “health maintenance” visits, it is alluring to focus on topics that lead to a longer or healthier life rather than a better death experience. Here is the list of the physician-related barriers to completion of an advance directive listed in the AFP article:
Discomfort with the topic.
Lack of institutional support.
Lack of reimbursement.
Lack of time.
Waiting for the patient to initiate the discussion.
In my case it is certainly not discomfort with the subject, and I am not intentionally waiting for the patient to bring up the subject, but lack of time and reimbursement undoubtedly play a role.
In addition most patients really don’t need my help in working through this decision process if they address the issue before there is a crisis. Although there are cultural, personal and ethnic variables that shape our decision making, most of my patients can really quite quickly and easily work through the process of completion of both a very functional living will and a durable power of attorney without my assistance. So why doesn’t everyone just do it themselves? Here are the barriers listed in the AFP article that are patient related:
Fear of burdening others, i.e. family or friends.
Health Literacy
Lack of interest or knowledge of the subject.
Spiritual, cultural or racial traditions.
Waiting for their physician to initiate the discussion.
So how can you just “Do it yourself?” It’s really easy. Obvoiusly since you are reading this article you have access to the internet, and everything you need is just a few clicks away. I encourage you, if you have not already completed these documents, to DO IT NOW:
Down load your state’s Advance Directives at the caringinfo.org site. This is really easy and you can get everything you need by selecting your state from the list here.
Many states have a form called a POLST form. This stands for physician orders for live sustaining treatment. If you use a search engine like Google, and you type in your state + POLST form you will easily find a form to download if your state has a POLST form. You can get the Washington State form to download easily at WA POLST download. Many physician offices have these available, just ask your doctor.
For some people a form to help you ascertain your values on this subject and to make your values clear to the individual you choose to have your medical power of attorney is helpful. The University of New Mexico Institute for Ethics has published online a non-copyright protected form for you to download. Some patients will find it helpful to attach this to their advance directive as guidance to their proxy in making decisions in line with their values.
There you have it. You have no more valid excuses to keep you from completing your own advance directive and living will. Once you complete it be sure to not keep it a secret. Give a copy to your physician, to the person you choose as your DPA, and keep a copy handy at your home. Don’t be a victim of your own procrastination or discomfort with this topic. If you find it helpful ask questions on the subject up with your personal physician. Be sure to let them know you have these documents completed.
In my best cheer-leading mantra: You can do it! Go – Go – Go!
Of the names we use to describe symptom in medicine the term asthenia is among the most descriptive. Somehow I am enamored by the term. Asthenia is an interesting word, beautiful in some way to me, but asthenia is not a symptom I look forward to using to describe my patient’s condition. Asthenia is almost a synonym for weakness, but implies a more serious connotation. Asthenia is usually used to describe a generalized weakness, as is noted in conditions like chronic wasting diseases like advanced HIV disease, cancer, advanced heart, kidney or liver disease, or some neuromuscular diseases. Asthenia is often associated with other symptoms like malaise, fatigue and dizziness. I usually think of asthenia being associated with weight loss, especially muscle mass loss.
Weakness that I don’t think of as being asthenia on the other hand is usually used to describe a loss of muscle strength that is localized or if generalized is not associated with overall wasting or other symptoms of advanced disease. Weakness can be associated with neuromuscular disease like a nerve root impingement, a stroke or other brain lesion and other causes that lead to true loss of power in one or more muscles, or can be more a perceived weakness where patients feel they need to exert more force than normal, but on testing muscle strength is normal. Disorders like chronic fatigue syndrome and depression can lead to perceived weakness
A specific disorder called myasthenia gravis is a condition where strength at rest is normal, but with repeated use muscle strength decreases. It is due to an autoimmune disorder where antibodies against the post-synaptic acetylcholine receptors at the neuromuscular junction are blocked.
Numerous medications have asthenia as a potential side effect. The HIV drug Ritonavir which functions as a protease inhibitor has been associated with asthenia. This has to be somewhat of a dilemma as progression of HIV itself is a potential cause of asthenia. Chronic opioid use for pain management has been linked to asthenia in some individuals. Alcoholism is a common cause of asthenia, as are other types of drug abuse. The list of potential medication causes of asthenia is long, and medication use always needs to be considered in a patient presenting with undiagnosed asthenia.
Still in my practice, admittedly a suburban practice where neglected disease is relatively uncommon and HIV is not a major part of my practice, advanced age, end stages of serious illnesses, and cancer are the most common causes of asthenia. As patients become very old it is common for them to lose strength and body mass and whether this is asthenia or not may be up for debate. Asthenia associated with weight loss is a fairly common presentation of undiagnosed cancer. Asthenia is fairly common with end stage cirrhosis and liver failure, with very severe congestive heart failure and with COPD as respiratory failure approaches. In most cases unless a diagnosis can be made with good treatment options asthenia is a serious if not ominous symptom.
I have to say I rarely describe a patient as having asthenia, but when I do it is with the intent of trying really hard to find an underlying cause that can be treated or at least discovered, because asthenia in my mind is usually something that needs to be figured out.
It is largely anecdotal, but is a really an interesting perspective on how at least some physicians choose to forgo futile end-of-life treatments because they know the limits of modern medicine first hand.
Add Some Red to Black Friday and I’ll give some Green to the American Cancer Society
Millions of Americans shop for Christmas gift bargains on Black Friday every year. I encourage you to give a gift on Black Friday that costs you nothing more that a little time, and which can help you feel you have truly given life and hope during this holiday season.
My readers will know that I’m a big proponent of regular blood donations. Kay, my wife has ovarian cancer and has been a recipient of donated blood when her blood counts get low from chemotherapy. Cancer patients are among the highest users of donated blood products from red blood cells to platelets. I’m donating regularly to be sure our family puts more blood into the blood banking system than we take out. I want you to join with me on the Friday after Thanksgiving this year by paying a visit to your local blood donation center. There are even potential blood donation health benefits.
I’m putting out a challenge to readers, your friends and anyone else you can contact. Black Friday is a day when many of us are out and about shopping and getting ready for the holidays. The holiday season is also a time when blood donations tend to fall behind need. Here is the challenge:
I’ll donate $1. (up to $1000) for every comment to this post or tweet me @DoctorPullen telling me that you have or intend to go to your local blood donation center on Black Friday and donate blood. $1. may sound like chump change, but I want to get 1000+ people who would otherwise not donate blood to do so this Friday. We are in a world of easy communication, and I bet everyone who reads this knows 10 people who are in a position to get to their blood donation center this black Friday and donate. Just do it!
Take a break from shopping, get off your feet, and relax while you give one special holiday gift. Use the twitter or facebook links to send this off to your friends, tell your coworkers, shout from the roof tops, whatever but let’s make this Black Friday blood red with our generosity.
My daughter, son and I plan to go to the local Cascade Regional Blood Bank center in Puyallup Friday. I checked and they are open 7:30 AM – 5:00PM. I’ll try to keep a counter going on the site to let you all know how we are doing.
They Turned Me Away Today
Egg on my face. I went today to donate, but was turned away because I went to Belize on vacation a couple of months age, an area with malaria exposure potential. I’m now ineligible for a year, joining a majority of the rest of Americans. If you are among the 37% who are eligible donors get to your blood donation center and give. Keep our blood supply safe and plentiful. Happy Thanksgiving.
This post is in appreciation of the 35th anniversary of the first “Smokeout”, actually the November 18, 1976 “Don’t Smoke Day” (D-Day) in San Francisco sponsored by the California Division of the American Cancer Society which received national (all 3 major national networks at the time ) and became a national event thereafter. The third Thursday of November each year, just one week prior to Thanksgiving is the Great American Smokeout. About 45.8 million Americans still smoke and most studies show more American smokers would like to quit smoking than those who don’t want to quit. Here are some great reasons to quit: 1. Retire Early(or take a nice vacation every year) on the Savings: If you smoke 1 pack of cigarettes a day for a year, at an average cost in Washington State where I live and work at the average cost in WA of $9.89/ pack you spend $3609.85 a year on cigarettes alone. If saved the 3609.85 annually and invested it at only 4% you would have $111,794.17 in 20 years. It would be more if you invested daily or monthly. Quit smoking now and you can be a long way towards a retirement fund. You may also live to retire. (I admit Washington is the second most expensive state to buy cigarettes in the U.S.) 2. It Stinks: Any non-smoker can tell you that they can smell the odor of cigarettes on your clothing, hair and body from several feet away. By quitting smoking you will avoid smelling repulsive to the majority of others in society. 3. Live Longer and Better: The average smoker dies 7 years earlier than the average non-smoker, and estimates of the time lost per cigarette smoked is 7-10 minutes per cigarette. The whole issue is really much more complex that this, but without doubt quitting smoking can add significant time to the average person’s lifespan. 4. Better Sex for Longer: Smokers have a much higher incidence of peripheral vascular disease, and erectile dysfunction is often the result of vascular disease. Quitting smoking can lead to a better sex life for many smokers. 5. Dying of COPD is Among the Worst Ways to Die: This is my personal opinion, but I’ve taken care of people who have died nearly every common cause of death. Respiratory failure has to be among the least desirable way to die. Being essentially immobile, gasping for air while on oxygen for months or years, and finally dying of a respiratory infection that leads to inability to breath is not among the ways I hope to die. 6. Get Your Kids/Grandkids/Spouse/…. Off Your Case: Nearly every smoker I see in the office comments that their loved ones are hoping the get them to quit, and often annoying them with encouragement and pestering. Why not change all that to congratulations and positive reinforcement after you quit? 7. Feel Proud that You Quit: Most smokers would like to quit smoking. Most who do tell me that they are happy and proud that they were able to quit. Join the ranks of proud ex-smokers.
Please leave comment with more and better reasons to quit. I’d love to have this post be a place for smokers to find the right reason for them and quit themselves. There is no time like today!
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Add Some Red to Black Friday and I’ll give some Green to the American Cancer Society
Exercise -The Unknown Warrior In The Battle Against Cancer
Cancer touches every soul in one-way or another. There are many treatments available for both the mind and the body when living with this disease but the most important treatment option can often be overlooked. With chemotherapy, radiation, surgery, medications and rehabilitation, it is easy to forget that exercise can be a cancer patient’s greatest ally.
Extreme Fatigue is one of the most common complaints heard from patients during chemotherapy treatments but there are ways to help alleviate this uncomfortable side effect without adding additional medications into their day. Numerous studies have shown the merits of exercising throughout treatment to help maintain a normal level of activity. These studies have also shown that continuing to follow an exercise program after treatment may help cancer survivors maintain a quality of life similar to that found before diagnosis.
Exercise can do more than just help reduce fatigue. It can also help many patients address the emotional issues that come with a cancer diagnosis and treatment. Issues such as weight gain, muscle loss, and postoperative healing can create a distorted body image, which may lead to depression. It is widely known that exercise can aid in weight loss and that weight bearing exercises can increase muscle mass but during exercise, the body also releases endorphins that create an elevated mood. This elevated mood could help patients see their situation in a more positive light and aid in their recovery.
Although some form of activity is recommended daily, each patient will require a different exercise program dependent on his or her disease and current treatments or if they are currently in a survivorship plan. For example, a patient receiving Mesothelioma treatment must be more cautious of activities that apply a greater strain on the heart or lungs while a patient being treated for Bone Cancer would avoid any high impact exercises that could lead to a fracture.
Because of these risks, many people choose to have a trainer help them design an appropriate exercise routine. This is a wonderful idea but it is important to remember that the trainer must understand the specific requirements of cancer patients. According to an article published on the National Cancer Institute’s website, the American Cancer Society has developed a certification program for trainers wishing to help cancer patients and survivors. This program ensures that cancer patients and survivors are receiving the best care possible.
by David Haas. David is a writer for the Mesothelioma Cancer Alliance. Please follow David on Twitter @haasblaag.