SILVER LININGS 2008
September 6
Atlantic Hall, Waterfront Hotel, Lahug, Cebu City
Speaker : Dr. Mark Kho
Topic : Coping With Cancer Treatments
Host  : Twink Macaraig

Twink Macaraig:  Hi good afternoon. I’d like to deviate from my script just a little bit. I basically want to say I’m no longer with Asia Business News. In fact, I’ve been an anchor with the ABS-CBN News Channel for maybe the past 3 years. But also for that time, I remember that while I was still with this Singapore network, covering it as a foreign correspondent for the Channel News Asia news network, I remember covering this same event, Silver Linings back when it was first held I think in Shangri-La, in Ortigas. And I remember then that I covered just this newsworthy event. And since then, which was what maybe… 5, 6 years ago, I subsequently was diagnosed with breast cancer. And so I come to you today as somebody who shares intimately what all of you are going through. And I have since been well, cancer free for the last 2 years. And I consider myself absolutely competent to host or moderate this discussion with you today. So what I’m supposed to talk about is how does one cope with cancer treatment. All of us know that millions of questions run through our heads when it happens. Does chemotherapy hurt? And I think there will be various answers to that. What are the side effects of chemotherapy? How do I manage these? Will I lose my hair?  Can I maintain a normal schedule during chemotherapy? What side effects can I expect from radiation? Why are some given Tamoxifen and others aren’t? I personally am non-Tamoxifen. What are the side effects of Tamoxifen? After my diagnosis, should my diet change? After all my treatments, what follow up routine is required?  Is it normal to be constantly scared of a recurrence? Yes, let me tell you that right off. Be scared of it but then again, don’t be abnormally or maybe… unduly crippled by this fear. What can I expect after a modified radical mastectomy? And to answer all these and other questions, please welcome… ICanServe regular surgical oncologist, Dr. Mark Kho.

Dr. Mark Kho: Good afternoon ladies and gentlemen. Hello! How’s everybody? Fine… you know… first of all I’d like to thank Kara for inviting me, of course, all of you know Kara. And I, I actually asked for a better time slot. What worst time slot is this when everybody has had a good lunch. Did you all have a good lunch?  Yes, what did you have for lunch? Good food? Bad food? Good for breast cancer? Bad for breast cancer? Alright… and well, congratulations for having a good lunch but I hope you share this time with me. And I’ll try to be very brief actually and as, actually Twink was saying she had first hand experience. I can’t claim that. I can’t claim to be a breast cancer survivor like you. But I … I’m very… actually I am your number 1 fan. I’m a strong admirer of the courage of all women who have breast cancer and I think all of you deserve a round of applause. Thank you very much. I’m here as an observer. And somebody who wants to share with you some of my thoughts because of my, I’d say pretty much everyday or daily encounter with patients and with ladies of different sorts who all share a particular experience that of a breast cancer. I actually entitled my talk, now that… now that feels better, coping with cancer treatments. When Kara again actually invited me, I was taken aback of this topic. I said how am I going to talk about this when the subject is too broad and there’s too many experiences that you can talk about. There’s so many ways of coping and different people have different ways of coping. I’m sure you’ve met all sorts of women. And so… however I still want to thank the entire ICanServe Foundation and congratulate you. I was, I am very, very impressed  with how the organization has, has worked, from the moment I stepped into, or I flew, what do you call it? I stepped down from the airplane and looked up at the big tarpaulin all about Silver Linings, all the way to coming here to this hotel and the organization is just amazing. I thought that, I immediately thought I’m not needed here. I mean, everybody is coping too well. They’re organizing this forum too well so there’s no need for a, for a coping session. But I’ll try and hope you’ll bear with me.

Recently there have seen a lot of demonstrations. People are rallying to different causes and I think they… you know on CNN who hasn’t been deluged with the democratic and the republican national conventions but they failed to look at what we all share here. And I wish that they were all been, they’ve all been rallying to this cause of how to beat breast cancer or how to beat cancer.  Because the cancer problem is indeed quite big. If we see a recent Time Magazine issue, there is an inside story says actually 7.6 million people worldwide were killed by cancer back in 2007. That’s what? That’s more than the population of Cebu is it? Or Cebu is about 10 maybe million. And 45% of these 12 million cancer cases worldwide diagnosed in 2007 were in more developed, affluent countries. And that tells us that 55% of patients diagnosed with cancer are actually coming from 3rd world countries like ours. And this is seen to be a big problem and a continuing problem and going to be a bigger problem because as we see the curve of deaths from heart disease coming down from 1950 to about 2002, as this graph shows. We see that the rate from, of cancer deaths has actually been just a steady line. Here, the red line. And this is because in heart disease, we are able to do a lot of things. Now we are able to stop a heart attack even before it happens. While that for cancer is not the same story. We see that as early as 2003 that for men and women, for women under the… men and women under the age of 85, cancer has now out paced or out-ranked the, the deaths from heart disease. And so cancer is now the leading cause of death among men and women in the United States under the age of 85. And now here in the Philippines, the statistics are no different. We see for cancer, it is actually the 2nd leading cause of death after cardiovascular diseases. And if we separate, if we look at the world scene, the Philippine scene, and the United States scene, we see a very similar pattern that breast cancer occupies the number 2 slot in terms of lead cancer cases.  

And in the Time Magazine issue, we see that that breast cancer is said to be spreading around the world and in that cover story, we see that the Philippines is ranked top 10 among  the breast, the countries with the largest breast cancer incidence.  Scary but true.  

Twink:  Dr. Mark?

DrMK: Yes?

Twink:  May I interrupt you at this point, why, why… have you figured it out why the Philippines is so high up there?

DrMK: That’s an enigma, Twink. We don’t know. It’s a mystery. It’s an observation though. It’s a… it’s a… if you wonder why the Philippines has it and we don’t have studies to show why we get it, why we get it. Well, look at the United States. The United States has the number 1 or is the leading country with the highest incidence of breast cancer. And in such a rich country with all the resources behind them, with all the studies behind them, they were not able to figure out also why they have the largest incidence. So… and that’s why breast cancer sometimes is such a menace because we are not, we are not yet, we are not yet ready or we don’t know what the cause is.

Twink: Are there theories?

DrMK: Lots of theories and lots of risk factors and I’m sure Dr. Salvador may have introduced to you. We don’t know the exact cause but the risk factors are number 1 being female, and number 2 aging. The problem with these 2, we can’t prevent it. We can’t make women men and we can’t make the … you… we can’t make you become younger. We can, we can only become older. So that’s the problem. The first, the biggest, the major risk factors that have been identified in breast cancer are being… gender and ageing. So when we look at the statistics of the United States, and divide the cancer cases into men and women, we see that breast cancer is indeed the lead cancer. And we’re no different here in the Philippines. We see that in our latest facts, Philippine cancer facts and incidence, we see that which is dated 2005, we see that breast cancer is again the lead site of cancer among women here in the Philippines. And it leads the number 2 site which is that of cervical cancer by at least 50%. But cancer is said to be the most treatable of all chronic diseases. Chronic diseases like hypertension, like diabetes which do not have any cure. Cancer is actually very treatable. And from the 20th century moving on to the 21st century, we are proud to be able to have better therapies as we go along. From what we have as cytotoxic radiotherapy or anti-hormonal therapy and surgery, we are now moving towards what we call Hodgkins-based diagnosis, targeted therapy and patient specific therapy. This is because our knowledge of the cell, of the cancer cell has evolved. From what we know of the cancer before, the cancer cell before used to be just a cell wall and a nucleus. Right now, it’s a dizzying …. World within just the cell alone. There are so many molecules, there are so many things happening inside a cell that has been identified that can be related to the cancer, carcinogenesis or cancer causing. And so these have now served as approaches to block the activity of a cancer cell. And we now have new targets in cancer therapy. So again cancer therapy has been evolving. And we are trying to go into an ideal situation where we can be very specific. As you know breast cancer patients are all very different. And within the foundation, you will see that women indeed you may have breast cancer, but you too may have breast cancer but the people are also different. And so we are moving into what we call patient specific or tailored therapy. But it requires of course, a team effort by the … all the disciplines that is involved in medicine as well as in the psycho-social support of the patient.

Now let me move on to some things that I have thought of. And which will, hopefully, be general statements regarding coping with any cancer treatment.  

The first is to confront your fears. I say that very easily but I’m sure if I was a patient stricken with cancer, this maybe a little more difficult. But this is very normal. Patients… cancer truly evokes powerful negative emotions. There’s a fear of losing control, there’s anger, there’s depression, etc. But again very normal. But we… up to a point we have to accept this and be able to confront this squarely. And rather than being fearful, the courage that comes out should be focused on education. Meaning, know the problem, understand the disease. Try to understand, there are so many ways. Now I’m sure the foundation is into a lot education, has come up with booklets, videos which make patients more aware of their, of the disease itself. Because it’s in knowing the disease that you are empowered.

Understanding. Understanding the whole aspect. Cancer actually is not a death sentence as you know, and there are treatments out there, and you can be cured. It’s just up to you to seek that treatment. Faith, I say faith in everything. Faith in a greater being, faith in your self especially, faith in your doctor, faith and trust in a lot of things. Because that sometimes is what we need. We really sometimes cannot just use understanding because I myself cannot understand why a Stage 1 patient after all the treatment are given can have a recurrence.  While a Stage 3C patient can be treated the same way yet not have a recurrence. It’s very hard to understand and sometimes we just have to have some faith in it. There should be positive visualization and also relaxation techniques. ‘Yan very important. There probably are nearby spas out here which can be helpful in getting that relaxation feeling as we go through treatments.  

The second point is or step 2 is take charge ok? There should be no substitution. You can’t say: Ok, my husband or my sister, ok you can have the cancer. Can I just take a by or can I take a rest, can I  take a break?” There is no such thing.  You are the leader of your treatment team and therefore you also have the right to a second opinion. You should, when you go on a consultation with the doctor, always or preferably take a close friend or a relative along to the consultation.  There are many things you might not be able to grasp while going through the, the overwhelming feeling of just having cancer. And then think in advance of questions to ask. It’s very important that if you can take notes or even go through a discussion of a specific treatment. Again this can be very overwhelming and so sometimes you need to take notes and… be prepared when you go for a... an opinion or a consultation.

Step 3 is know your options. There are a lot. In fact surgical oncologists like me when I go through a talk for a patient, a new patient that comes with a fresh diagnosis of breast cancer, we go through at least a 30 minute to about an hour just talking about the options. There are a lot of options and you have to learn as much about the disease and you will become an expert. This is not a problem for you becoming an expert and to find out the latest and most effective treatment prior to commitment, to treatment. We want to think out of the box and therefore, we want to try to get support. Where as we … maybe have been very independent before, let’s try to get support from our family. All in the financial aspect, as well as the spiritual aspect. I always tell my patients that you know this is the time not to… maybe lower your pride, be humble enough that you need, we all need somebody that no man is an island.

And there are many tools that you can use. Of course, there’s internet now. There are a lot of books and support groups like your group who can help.  

Step 4 and the last step is to fight back after knowing what the disease is. After taking charge, accepting it and knowing your options, we then have to fight back. And so during treatment, we need to keep asking questions to understand the disease more and be able to fight back. Make sure you have the following. You feel confident in you. You have confidence in your doctor, in a good hospital, in a good treatment plan so that it will carry you through the treatment. And don’t worry about being a pest, hindi kayo pest. Hindi kayo peste, huwag kayong mag-alala. Hindi, as long as you ask questions, go ahead and ask questions.  Don’t worry that they’re silly questions or whatever questions. Just ask them so that you know, you can, you’ll be able to cope again better.

Now there are too many cancers, there are too many side effects and side good, whatever effects of cancer treatments and there are so many treatments as you know. And they’re all different for different people. I’ve just listed down some of the most common which I cannot go through in this brief session with you. But I encourage you again to talk to your, to talk to your doctors or to talk to your caregivers to be able to cope with these. But in general we go through, again to understand that side effects are treatable, and you need to talk with your doctor or nurse. I hope you don’t get a nurse such as this, the one on the left. Medyo mataray, medyo masungit but again don’t worry nurses are there to help you and if they’re like that again, go to another nurse. Or just pest, be a pest and talk to a, talk to the nurse or your doctor.  

Fatigue is a common problem but it’s treatable. Pain is also very treatable. We now have non-narcotic or even narcotic pain relievers which can be used to alleviate your pain. The number one thing that you, that you should alleviate and that you should get out of your system is pain. Hindi puwedeng tiisin. Palagi kong sinasabi sa aking mga pasyente, puwedeng tiisin ng mga asawa ninyo pero yung pain huwag niyong tiisin, yung kirot huwag ‘no? And anti-emetic drugs are also there to reduce your nausea and vomiting.

Now a common… Kara actually asked me to talk about lymphedema. You know lymphedema is not a very common thing. I bet you if we go across the breast cancer survivors here, we will only see only a very few, few of you, a minority of you having lymphedema. It’s actually after surgery we only, lymphedema is only about less than 5%. And it may have to do also with the technique of surgery.  But once you get lymphedema, then the first thing you have to do is try to prevent complications. And the thing to do is to protect your skin, to look after your skin.  Use saunas, steam bath and hot tubs with some care. You want to travel with are, exercise or elevate your arms and maintain an ideal body weight. Palaging sexy katulad ni Twink dito. Tama ba? Alright.  The problem with lymph edema is that the only evidence based treatment, the one that has been proven to work are compression garments. Which are like those stockings that you wear on your arm. Those are the ones that can work. And they’re not even 100% what? Fool proof. So or effective. So that’s the problem. There are pneumatic compression pumps and massages and other therapies that have been used but again they’re no better than the compression garments that can be used. So again, it depends on what the degree of lymphedema is and the best person to go to is your nurse or your doctor to go through some of the options with you.

Now, just a word about complementary and alternative approaches. There are so many things out there that are being told us that can, can help in coping with cancer treatments. So these complementary and alternative approaches are actually based on evidence, just more effective in relieving the cancer related symptoms than slowing the disease itself. So you have to be very clear about that idea that it doesn’t affect your prognosis or your cancer but may help you in relieving the symptoms. And these alternative approaches should be discouraged or avoided if it will delay conventional treatment, has not been scientifically proven, is provided by unlicensed practitioner and requires the intake of substances that have not been approved by the FDA or the BFAD. So there have been a lot of researches that have come up. Some of them because of these research and study, some of them, some of these complementary and alternative approaches have been recommended while some of course, have been discouraged like the use of anti-oxidants and restrictive diets and supplements with anti-coagulation properties especially during surgery, etc.  There are ethical issues involved as well and these should involve a discussion with patients and caregivers. I’m trying to be pro-active, I’m not waiting for the question to be asked about these supplements and about these approaches and I’m telling you that these, there are, there maybe some short and long term consequences in terms of end of life care. That has to be brought up also when we talk about ethical issues and we should recognize ethical responsibility among caregivers when recommending or allowing or guiding patients, and the risk to benefit ratio also has to be weighed.

Now what about dietary factors? Ang dami diyan ‘no? Si Newsweek and Time Magazine have just put up cover stories regarding supplements and cancer and diets. So are these really good in terms of coping with cancer treatments? Even our dailies, our local dailies and everywhere you, everywhere you go around, you go around Cebu I’m sure you’ll see these types of advertisements telling you that these supplements can help. But first thing I’d like to say, you have to be very careful. In a consumer report that came out, in the report that came out, we see that some supplements can indeed be dangerous and can cause death. And because they have been very good in the art of labeling ‘no, or more properly – mislabeling. And so we have to be very discerning in terms of taking these supplements, and then answer these questions: Are these really, is this really quackery? Or is this alternative medicine? But what we have to understand is that these methods, these supplements are being accepted more and more. And there’s a lot of interest in them. Why? Because there is frustration over your standard treatments. The side effects what like I’m saying. There’s lack of complementary treatment and these alternative practitioners actually have not much to give up. Unlike us, we have a license to give up. Sometimes, we have to tell you, “You know what?  When you go through chemotherapy, you’ll lose your hair, you’ll grow mouth sores, you’ll feel bad, you’ll be…parang namamatay ka na, parang, parang naglilihi ka na hindi mo alam.” I’m sure that’s what you felt Twink, when you went through chemotherapy. And you’ll just, overall you’ll just feel all these bad things. But we have to tell you that. Whereas, the alternative practitioner will say “You know what? We will put you in a room, nice music, aromatherapy, beautiful, beautiful music, beautiful people around you. You will take capsules that won’t cause any side effect ‘no? Once a day lang, sarap pa and wala kang mararamdaman. And most of all, you will get well.” Di ba? That’s such a nice approach and unfortunately some of these alternative practitioners do it that way. And they’re viewed with a better approach as you see. Now I don’t want to give you the impression that all of these are bad. Because we have been guilty, we in the conventional medicine field have been guilty actually and because one of our biggest names in the medicine world, one who discovered penicillin by the name of Dr. Alexander Fleming. He said penicillin sat on his shelf for 12 years while he was called a quack. “I can only think of the thousands who died needlessly because my peers would not use my discovery.” And so we don’t want to label everybody as a quack. Remember that. And… but the road to proving that these alternative medicine can be useful maybe long and tedious as well. One of our wonder drugs in breast cancer is paclitaxel. It was discovered in 1964. And back at that time it was only coming from the bark of a tree. And if we thought like that then we would have thought “Ah this is one of those herbal medications again.” It entered phase 1 trial since…’70 or ‘83 and was only licensed for use in breast cancer in ’94. So it took what 30 long years for a drug to be developed. But this should be, how it should be approached and I’m sure millions of dollars were spent in terms of research. But this is just so all of us and all of us can have the benefit of knowing that a drug really works and not just being just advertised for personal gain. And so we’re glad that some of these, the… some countries, some rich countries have put their money where their mouths are and have for example, in the United States there is an Office for Alternative Medicine and cancer treatments, which is a congress budgeted office as  well. And the goal is to facilitate the evaluation of all these alternative treatments so that we will then, once we know and we have the proof that these work, these can become integrated and we can be, we can be, we can all benefit from it.

So the next few slides, or the next, just a few slides will talk, will tell about what has now been the evidence regarding these, these approaches so that we can use them to cope with the cancer treatments. The American Cancer Society has come up with the guidelines, for example. The first one is to eat a variety of healthy foods, with an emphasis of, on plant sources that means eating 5 servings of vegetables and fruits everyday can help. Adopting a physically active lifestyle that means not go, you don’t really, necessarily have to go to the gym everyday, but you just have to do like 30 minutes to 45 minutes of brisk walking.  And then the third is to maintain a healthful weight throughout life. And the 4th is if you have to take alcohol, try to limit it. Now there are many drugs now that have been proven to be useful in terms of coping with the side effects and depending on the degree of your side effects then we can use this, these medications. And there are many medications right now, I’m not going to run through all of them. I’m going to give maybe some practical tips that you can use in terms of trying to cope with certain, more common side effects of treatments like nausea, vomiting. The usual tip that I tell my patients is first to take small, frequent meals. The 2nd is to choose cold or non-odorous foods. When you eat cold food that you like then you will have less nausea and vomiting because the problem with hot food is that they steam and they have smell. And so just the smell alone will make you vomit. And so, and then save favorite foods in the ref, and sit up after eating. The idea is to slow down when you’re eating, ride it out because the nausea vomiting is going to go away after some time.  

For mucositis or mouth sores, there are many things you can take. Again, cold bland foods, moisten the dry foods. Cut the foods into small pieces, sometimes use a straw and coordinate eating and use of pain relievers. There are many other practical aspects or tips that can be used depending on what symptom you have or what side effect like constipation, for diarrhea, for low white cell counts. This, in the interest of time I shall make this the responsibility of your individual caregivers. And as well as for loss of appetite, dry mouth, fatigue and drinking.

For drinking, it’s very important that we drink a lot during any therapy whether it’s surgery or chemotherapy. Because drinking is a lot easier than chewing as you know. It, you would have less energy, less saliva, it’s using less gagging and it speeds up gastric emptying. So this is a very important thing that you may take home in terms of coping with cancer treatment.  

Now, this Dyspepsia ‘no.  This sounds very, very high faluting but this is very simple and it is one of the most common challenges in patients on chemotherapy. This is the loss of that wood taste. You lost, you lose that taste acuity and there’s a distortion of your taste. Sometimes it’s a metallic taste after chemotherapy. And there are many mechanisms that are involved. And the worst are the big guns, the use of the big guns who are bigger weapons against breast cancer. There are many things that we can do to help alleviate this or help minimize this side effect. The trick here is I guess to do what is best for you. It can be different that’s why it’s a trial and error thing. You find foods that are best consumed with the least alteration of taste. And really it’s a trial and error thing. Very hard to say that one works, one technique works for the others. There can be some nutrition… nutrition counseling that can be used also but the problems are what are ok foods now, today maybe revolting tomorrow. So it can change too. So this is, this probably has to be more individualized in terms of this side effect.

So I’d like to conclude by, or summarizing… I probably have given you some tips and tricks in coping with cancer treatments. And hopefully in the spirit of Halloween which is coming up, I have given you some treats as well. And I’d like to end by sharing with you a philosophy that I, aside from being very grateful for this opportunity, I’d like to share with you or leave with you a philosophy which I hope will help you cope in your cancer treatments. And this is what, this philosophy I gained through my stay or my 5 year stay at the City of Hope National Cancer Center. This is a center, the biggest center actually in California which is nestled on St. Gabriel mountains and this is the… the cancer center is called the City of Hope which was in… which made news quite recently because of its pioneering work in stem cell research. Recently we had a reunion of my co-fellows back in the… when I was a fellow back in the early ‘90s, and it’s very heart warming to be able to return to your alma mater from time to time and gain some more knowledge so that we can treat our patients here as well. And the cancer center, the campus is strewn with gardens like this, a Japanese garden with a small waterfall which aims to create a healing environment for patients. And this is maybe what we should try to seek sometimes when we go through bad times with our treatments. And it caters to all kinds of denominations and there is also a rose garden where behind it there is a grotto of the Virgin Mary. So it caters to the, those who adore the Virgin Mary. And behind the grotto, there is a metal sculpture which embodies the philosophy or the message that I’d like to share with you and that is… there is no profit in curing the body if in the process we destroy the soul. Again very important to remind yourself that it’s not just the cancer that you’re treating, it’s also the person or the soul behind it. And always give yourself hope as there is always hope. And you should all actually congratulate yourself for being given a great gift that of breast cancer and being able to understand and realize yourselves more.

Thank you very much and I hope I’ve made you feel better. Thank you.

Twink:  Thank you Dr. Mark Kho. So we open our floor for questions but maybe I’d like to start out Dr. Mark. I don’t know what would you consider to be the most significant breakthrough in the treatment of cancer, say in the last 10 years. Something that is available to us now that perhaps wasn’t available to our mothers.

DrMK: We can’t give it one, there’s not one weapon that I can say is the, is the best weapon or the best thing that we have. I think it’s a combination of the efforts of so many scientists, so many dedicated people. These are people who are more intelligent than us, who have dedicated their lives to work in the lab. There are people who just work in the lab the whole day and night. And then they die working in the lab trying to find a good treatment. But the efforts I think we should all appreciate because truly in the past 10 years, there have been a lot of great developments.  We now have treatments that have, that are not only more effective but also have less side effects. When we talk about for example, the big, the big, the major ways of treating cancer. Let’s go through for example, surgery. We now have ways to conserve the breast. With not only can do mastectomy which is of course still standard but there are now options. In fact we can do a lot of reconstruction now. For those of you who feel you want to have your breast back after a mastectomy, we can make it, we can make it… we can have you make, have a new breast, and a bigger breast if you like. And in fact, we can take out your…

Twnk:  Huwag naman just one breast, both of them siguro..

DrMK:  Of course, we can also reconstruct the other breast para pantay naman ano?  Eh free pa yung tummy tuck diyan, oo. Kasi we can move the bilbil and they keep the new breast. Oh. Isn’t that ano… so that’s one ano for surgery for example. For anti- hormonal therapy, Twink mentioned about Tamoxifen. There are now better, more powerful drugs than Tamoxifen namely, the Aromatase Inhibitors and the other area…

Twink:  Dr. Mark are you saying laos na yung Tamoxifen ko?

DrMK:  Well, hindi ko sinasabing laos. It still works. It’s like the standard treatment but fortunately for everybody, unfortunately kasi Tamoxifen does not, it’s not everybody. Meaning, there are still, we still get recurrences from Tamoxifen. And now, and in the past decade, there have been drugs which have been compared to Tamoxifen and have been shown to be, to have less, create less recurrences. And improve the survival of patients. And another aspect in that which have been compared to Tamoxifen is that of ovarian oblation or ovarian suppression. Suppressing your hormones.  And that I think is also a big development. The 3rd one is radiotherapy. Well, radiotherapy we have a lot of new techniques as well. We now have what we call a linear accelerator, which is more, which aims to the particular side much better than the cobalt treatment that we used to have. In fact cobalt, yan ang laos. Yung cobalt medyo laos na yun. Sa States wala na, outlawed na ang tawag.

Twink:  Actually it’s illegal na…

DrMK: Hindi naman, well, environmentally kasi yung cobalt kasi may source and it’s hard to get rid of it and you know, the environment advocates are the Green Peace people ganun, are very, they don’t like these radioactive materials.  Whereas the linear accelerator, wala nang ganun. That has been eliminated.  And lastly, the… as I have mentioned targeted therapy. There are now treatments that are not like chemotherapy that have not much side effects that for selected patients can improve your chances and can improve your survival. One of these, of course is Herceptin. I’m sure some of you have been on it and Herceptin is now a proven drug which can help lower the chance of recurrence. In chemotherapy, the bad… kalaban palagi natin yung chemotherapy. But in chemotherapy there have been a lot of strides as well. In fact the targeted therapy that I’ve just spoke about is a form of chemotherapy. And now this is the type of chemotherapy that we’re going to have and we look forward to the future.  Less side effects, more powerful, hopefully cheaper… hindi pa, pero hopefully as years go it becomes cheaper and more available to everybody. And as well as…again, more powerful. Even the chemotherapy drugs themselves are actually much better now. My dad who used to give chemotherapy as well used to tell me “Naku, they…”  yung doctor mismo has, has to be on a mask, tapos talagang parang space suit bago mag-administer ng chemotherapy. Because they are really highly toxic, may fumes pa eh. As you give chemotherapy, you’ll see fumes coming, yung mga nitrogen mustard and all that. But now it’s not, it’s not that case anymore. We can, as you know everybody is getting, many of you have been getting chemotherapy in… some in clinics, some in the hospital. But it’s not in the way that we used to do it. So again, we are very grateful and we should be very happy that we are living in exciting times and we are looking more and more…. There are so many drugs and so many approaches now. There are therapies, new therapies that are upcoming, and that are in the pipeline that we should all look forward to.  

Twink: Thank you.  Any questions from the audience?  And perhaps while you are thinking of a few questions… yes ma’am?

Q1:  Good afternoon po. I’m Sylvia Canete from Davao. Breast cancer survivor. I was diagnosed 2003, nag 5 years na ho ako nuong … February. I was taking Tamoxifen for 3 years, shi-nift ho ng oncology doctor to Arimidex. Ok lang ho ba yun doc kahit na 2 years Arimidex instead of having it for 5 years?

DrMK:  Very good question, Twink you want to answer that?

Twink:  No. Who am I to answer that?  I know lang mine Tamoxifen…

DrMK: No? Akala ko you know your options also. Just kidding, just kidding.  Indeed this is one of the things that I’ve been saying. That there are now… Arimidex is one of the aromatase inhibitors so with the Femara and Aromasin.  These are the new aromathase inhibitors that we have which depending on the case we can use now to either shift you to … or move you to, or even start you to, on pala….  And that’s why…

Twink:  Doctor, what factors would these be? That would determine whether it’s one drug Tamoxifen or the other?

DrMK: There are too many factors to mention and I think they should be on an individual basis. If I make generalizations now, I think I would create more confusion. Just to tell you though that there are these options. It’s like going to, going to Jollibee di ba? There is now a menu, dati wala e. Dati that’s why the doctors before are more powerful.  We only, there’s only one drug – Tamoxifen to give you and that’s it. So no choice for the doctor nor the patient. So tapos. End of discussion. Whereas now it’s a menu. It’s like going again to Jollibee, there’s spaghetti, there’s palabok, there’s…. is Jollibee our sponsor? Or is McDonalds?  Sorry, sorry… neither, whichever in a what’s… fast food chain. So you have menu, you have a menu now. And that’s what I, that’s the message I want to impart.  

Twink:  But can I… then I mean, can I assume from what you’re saying that if… since you’re touting these newer drugs as perhaps more powerful, then I can say “Ay ayoko ng Tamoxifen.”  Even though that’s what my doctor might have prescribed and say “No, I want this other one.”  

DrMK: Twink, you have to discuss this with your doctor. You may be eligible. If you’re on Tamoxifen, you may be eligible and you may benefit from switching. I’m not sure, I have to look back and look at the factors that you have…

Twink:  But you’re saying there is the possibility that I will not benefit from…

DrMK: Yes, exactly. That you may not benefit from switching and that’s why we will… that’s why a discussion is needed. So it’s an individual case. Not all breast cancer patients should be switched, not all breast cancer patients should not be switched. I think it’s a case to case basis and there are a lot of factors involved.  

Twink: I think our…the person who asked was talking about….

Q1: I have another question, kasi ang family namin… kasi my mother died of cancer. Ang mga kapatid ko bang lalaki, risk, may risk din ba silang magkaroon ng breast cancer?

DrMK: Very interesting question. And that’s why in my talk I also gave a particular statement. I said that the male… the number… we don’t know the cause of breast cancer but we know that the major risk factor is being a female. Why so? Because if you look, if you put us males in one, not trying to be very sexist here ha? I’m sorry… being a male, if you put us males in one group and then women in another group, you will see that for every one male breast cancer patient, or one male who develops breast cancer, there will be a 100 to a 120. That means, right 120 females. That means that… the females are … as soon as you become a female, you are now 100 to 120 times at risk for developing breast cancer. And that’s the, that’s the factor that has that high risk. Age is 10 times, meaning if you have a younger women, older women, oh sorry sinong may gusto? Older women, younger women here. For every one young woman who has breast cancer, there’ll be 10 older women. So the risk factor there is 10 times. Right? That means the older you are, the higher your risk and your risk is as much, can go as high as 10 times risk than your, your young counterpart. And that’s why if the, if you have a family history of breast cancer that risk is usually only passed on to the female. Women… to the female in the group, the women are at slightly higher risk and the risk there is 2 times. Meaning again, this group does not have a family history of a first degree relative with breast cancer. First degree is your mother, your sister or your? Who’s your first degree relative? Your mother, your sister or your daughter. See?  Any of these 3.  Kasi yung iba, “Ay yung lola ko, yung, yung kapitbahay ng lola ng pamangkin ng hipag ko may breast cancer eh. Baka ako mag breast cancer din.” Hindi ganun yun. You only get that risk only if you’re first degree – your mother, your sister or your daughter has breast cancer then you can have as high as 2 times, 2 times lang because again one group with family history, the other group without. This one with family history of the first degree relative with breast cancer has, for every one here there’ll be 2 here. So the answer to that question, the short answer, sorry to that question is that the males usually do not have to be very worried about getting breast cancer. Although, although there are and I have seen and I had a family with the males and the females all getting breast cancer as well. So but in general, if you have, if a male has a sister, a mother or a daughter with breast cancer, then he may, he may not be too worried about getting breast cancer.  Fortunately for us…

Twink:  So there’s a … maybe very, very slightly elevated risks. Very, very….Not even…

DrMK: May be not. Not even because what you have to divide that by 100 times eh. 100 times less eh so the risk becomes little. Even if it’s 2 times increased which is what it is for the female counterpart, the male is 2 over what 100 of it, so mababa… 0.002 or something like that so mababa. Yun. Did I answer your question? And for that I … you were the one who asked about the Arrimidex as well. I think again, have a good discussion with your doctor on exactly why you have been switched. What’s the data behind it? And does it really benefit you?  

Eh kasi naiinggit si Twink eh… gusto rin niya mag-switch pero hindi niya sigurado.

Twink:  Well, itong lymphedema I’m wondering doctor, why… how come no one has been able… given that in all this time there has, there seems to be no…. yeah, progress as far as determining what exactly causes it. Why it happens in some cases and not in many others.

DrMK: No, actually for lymphedema we are quite clear with the cause. The cause is very simple. Remember that in our axilla here in our kili-kili which is where we remove the nodes from. If the nodes are extensively removed or the channels, the lymph channels are extensively removed, it is like making the south express highway from a 12 lane before here where water and blood flows back from your arm, from your hand and arm to the heart, you transform that 12-lane express way to maybe a 1 or 2 lane. There’s traffic here once you extensively remove it. So the cause is definitely surgery or radiation. When you give radiation to that axilla, you then kill or you make that highway much narrower and that’s where lymphedema arises. Now how do you treat that? We cannot widen. It’s not like the highway in that sense that you can widen the road again. So that’s the problem. It becomes a narrow, a bottle neck here right in the axilla, your lymph channels have been removed, those lanes have been removed. It’s like the SLEX now. If you’ve gone through the SLEX, it’s terrible. The lanes have been narrowed because of the construction but here it’s not construction. It’s really just taken away so you now become a one lane highway here or one lane street. And you cannot expand it. So that’s the problem and so while blood can, blood and lymph and water can flow into your arm, can go to your arm because your blood, your heart is your pump. So there’s higher pressure going through. So your blood can flow into it but takes a while to flow back and that’s why it dams back so that’s why you have edema or swelling of your arm. The problem there is not easy to solve because again you cannot increase, widen the channel. And so what we do as I’ve said, is the first is to just try to prevent complications. And then the use of compression garments, that’s just about it. Some have used massage, etc. And compared to compression garments it’s about the same. Yet the effectiveness is not really complete cure. You cannot cure lymphedema. Again because of the permanent damage that has happened. So the key is really prevention. To see if this can really be prevented. Meaning if we don’t have to give radiation, eh di huwag. Or we don’t have to do that much of an axillary node dissection, we should not. That’s what surgeons are quite aware of.

Twink: I see. So it’s not a matter of being a botched surgery because I had, an aunt too had it, and I’m wondering whether actually I had the same number of nodes removed myself as she did.  But for some reason she had lymphedema and I did not.  

DrMK: Sometimes it is not, sometimes it is. Sometimes it can be well, unfortunately sometimes it can really be the fault of the surgeon. Some surgeons are a little bit too eager and trying to be aggressive correct.

Twink:  Aggressive maybe…

DrMK:  Because that was, we got lymphedema back in the ‘70s, in the ‘60s. The rate was much higher when axillary node dissection was indeed that more extensive. Right now with the better techniques, with perhaps better antibiotics, better preparation, better skill of the surgeons, we are now able to reduce the rate of lymphedema from surgery, from our standard surgery by as low as about 5% or less.  

Twink: Just 5% there. Thank you doctor. Any other questions? Yes?

Q: Doctor, hi. On the issue of lymphedema.  I’m a survivor for the last 7 years.  I understand that lymphedema occurs after surgery as an effect. The last 6 years, I didn’t have it. Only this year I noticed that my left arm is bigger and have consulted my doctors and said can’t do anything about it.  So I’m bothered.  

DrMK: Exactly what I’ve been saying. Lymphedema is a complication that may not occur right after, as an immediate thing. It can be delayed. So you can still have it as, as our… audience had. You had the same problem. Or you went through… you had 6 years of lymphedema free or swelling free and now you have it. And again as I said that’s not very good, there’s no cure to it unfortunately.  

Twink: But could you… is there… could you have as a guess as to why it would be that delayed after 6 years.

DrMK: Right. Well, the trick is to… if we then have a discussion then maybe, maybe we’ll be able to identify why. Some reasons maybe you got an infection somewhere during the, during that period. Whereas you did not have that infection before. Or sometimes you … you may have other, other associated things that maybe affecting that area. Or … probably you were exposed to some things or you … the activity maybe a little bit different or more or extraordinary than your other patients. Or it may really just be what we call idiopathic, meaning ayan eh, ganun eh. Sometimes it may be just like that. So it’s something that we, we should just try to understand, just try to cope. That’s the purpose of all this, of this session and but don’t worry it’s not life threatening. It may be a little bit discomforting.  Be proud that I have a slightly larger left arm than a, than the right arm. If you think of it like that, like what I’ve said positive visualization, everything positive then you should be alright.  

Twink:  You have a question from a lady over there.

Q: Doris, hi Mark.  Yeah, if there’s no cure, is there a preventive? Kasi di ba…

DrMK:   Hi… of what?

Doris:  Of lymphedema… because I’m into this dragon boat thing and they said daw, you know to improve the circulation is that, is there a preventive?

DrMK: Oo. There’s some, there’s … there’s no cure when you get it. So the prevention is really in the treatment and that’s why we said, the prevention there is not to get radiation therapy when you don’t have to. And the surgery maybe improved depends on the, depending on the case. And sometimes it’s the disease as well. You know, if you have lots of nodes that have to be removed, initially let’s say you get 23 nodes out of… 23 nodes that are positive right?  Versus the one who had zero out of 23 nodes. The one with 23 positive nodes has a higher chance of getting lymphedema. So it may be in the disease itself or in the stage of the disease. But prevention may, so clearly prevention may not… there may be no other better prevention than actually looking at or preventing it through the treatments. But and then, but the answer to your question on how exercise may help or not or cause lymph edema, there’s no clear answer to that.  In fact I will cite a study that showed that increased activity of that arm lessens lymphedema. So actuality may prevent but we don’t have enough evidence or sufficient evidence to say that. But I encourage you then to use in the proper way. Si Doris kasi pasaway yan sometimes eh. So use properly Doris, perhaps it may actually be good. The thing is if you think that dragon boat racing for you is a good activity, is a worthwhile activity, oh I.. by all means, do it, be careful and go.

Twink: Go Doris. Final question here because we have just a few minutes left in our forum. Dr. Mark, if the patient is indigent, cannot afford the chemotherapy and afraid of body mutilation, how can we help her? I guess what this question poses maybe is that … so if one refuses to have a mastectomy then chemotherapy is… I mean…is that the only…

DrMK: Right. You see Twink I was a bit taken, I was a bit hesitant. This is actually the type of patient that I see almost everyday. I work at, also at PGH. We see, we try to see, in fact we limit 100 new cases a day or 100 cases a day at least of breast cancer, breast cancer that we see in our out-patient (clinic) a day. And all of them will go to PGH for one reason, they’re indigent and cannot afford treatment. And so there’s many of our sisters who do not, who cannot afford treatments. That poses a big challenge to us doctors because we cannot say that one treatment maybe equal to another treatment. We know for example for early stage breast cancer, if your clinical stage is between Stage 1 to 3A, then the best treatment would involve surgery, followed perhaps by one of the 4 adjuvant treatments. That’s radiotherapy, chemotherapy, anti-hormonal therapy and targeted therapy. And that will provide you your best chance. If you reverse the order or give chemotherapy ahead or just give chemotherapy only, or just take Tamoxifen only, then you’re not gonna get the same results obviously. For example, if you’re gonna go through surgery and the adjuvant treatments, then you have as high chance of cure, you can go over 90%. Whereas if you just take Tamoxifen, your chance of cure maybe be 30, maybe 20%. So you’re not giving yourself the best chance of getting better. You’re only getting something that’s below par. So what we then try to do at PGH are to, is to be the equalizer. So we provide our service for free. For example, for surgery we provide our service for free. We don’t charge patients for going through surgery at the Philippine General Hospital. Unfortunately, we cannot give everything for free. And therefore, chemotherapy and the other medications are truly not free. But when we get it, when we can get it through donations, through the help of friends like you, through the pharmaceutical industry, through anybody who wants to donate, this is a pitch for the donations… then we are able to become better equalizers for our, for these indigent patients. And I think that’s the way to go, and that I know is what the foundation is all about as well – to help your sisters not only in the knowledge as what we are doing, Twink but also in the material things. Some of them need treatments, chemotherapy, Tamoxifen costs as well even though it may be cheap for some people but it costs for some people. People who cannot afford 3 meals a day may need the … the medication and cannot afford it. So I congratulate everybody for being so aware and so helpful and so generous of both your time and your resources.

Twink: Doctor, does that… well, I remember when I was first diagnosed, I was made, I was under the impression that if I had a radical mastectomy then I wouldn’t have to do chemotherapy anymore. And so I was begging my doctor, “Hey take it off.” You know because I was so afraid of chemotherapy and my doctor well just put his foot down and said no. But would have I been right if I had insisted on it? Would I have been able to avoid chemotherapy?

DrMK: That depends. The… your need or the benefit that you may get from chemotherapy does not depend on the surgery that you got. It is actually dependent on the stage of your disease. After your surgery, your stage can be better determined. And then once you have that, you’ll now see whether chemotherapy can benefit that particular stage of disease. In general, for node positive disease, if you have nodes, if your nodes are positive then chemotherapy will definitely benefit you. Will give you a better chance. It’s not to say it’s a requirement right?  But it may give you a better chance. Whereas if you’re node negative, that is where the issue and the controversy can come. So whether or not you had radical surgery, or whether  you had a breast conservation surgery or other types of surgeries that you have gone through, the need for chemotherapy or the benefit of chemotherapy does not depend on the surgery.  

Twink:  Thank you Dr. Kho.  I believe there was a question from that lady over there. Yes. One last.

Q: Alright. My… I am a health care provider. And with regards to lymphedema, by the way I’m also a breast cancer survivor. Now when I had my surgery, I’ve learned that we need to exercise our arms, the pendulum or climbing our arms towards in the wall as a way of reducing lymphedema.  On the other hand, a year later there was an issue of not exercising the arm because of the problem of the… so which is which now, which one can we advocate at the bed side?

DrMK: The arm exercises are generally advocated but not to reduce the chance of lymphedema. It is actually to reduce the risk of frozen shoulder. Correct. So almost always, we encourage to do arm exercises, the wall climbing, etc. or the hair brushing etc. these are  the exercises that you do for your arm right after a surgery, mastectomy or lumpectomy. Because we want to prevent a frozen shoulder. Having said that, the wound dehiscence on the hand does not, should not be affected by the … timing of arm exercises. We generally tell the patients “O as soon as you can, dapat in the next day.”  The next day or the day after, in the next, within the next few days or when you go home after 2 to 4 days, you should start doing your exercises. With the aim that by 2 weeks after surgery, you should be able to raise your arm. So you should do that. You should not be afraid of wound dehiscence. Wound dehiscence actually does not depend on whether you mobilize your arm. Wound dehiscence has more to do with the technique of surgery, with the infection, if you get a wound infection, if you get complications from surgery then that’s where the wound dehiscence will depend on. Which means that whether or not you do the arm mobilization, if you’re going to get, if you’re destined to get a wound dehiscence you will get it.

Twink: Or a lymphedema for that matter. It seems ok..oh one more question, yes pahabol.

Q: This is the case of my wife. My wife had undergone chemotherapy, the mastectomy, then radiation and because she was also diagnosed with her2neu…. So she had Herceptin treatment, but…. A few months later, a few months after her Herceptin treatment, nagpa-ultrasound siya and CT Scan, it reveals a… there is a cyst sa liver niya. But cyst then nagka metastasis. But prior to that lahat ng mga major organs niya normal. So we are puzzled, why it did so happen very early. Why it is so quick. Just a few months later after the Herceptin treatment.

Twnk:  Would you consider that a recurrence doctor?

DrMK: Well, that depends. So that’s why…If you just say a plain liver cyst, cysts are usually not, not recurrences. However, ok, however there are masses.  There are masses, kasi when you say cyst, a cyst has water within the fluid, within the mass, it’s water filled that’s what we call a cyst. So technically most liver cysts are benign. And so are cysts anywhere else in the body, usually benign.  However, if it’s a solid mass and let’s say it was determined to be a metastasis or a recurrence or a spread then this does not, this does not amaze us too much.  Again, this is what really hurts us with regards breast cancer. We don’t fully understand this enemy of ours. As Twink said, you always have to be wary of a recurrence because again it can happen, any time. Whether you’re still on therapy, whether you’re off therapy, you just had treatment, you just had surgery, you just had Herceptin, you just had all kinds of treatment including virgin coconut oil or whatever, you can still have a recurrence. Even if you’re a stage 1.  you see, it’s just  the chances that may differ. Yet you can have it but does not to say as Twink said, does not to say that you will always be pre-occupied na lang with saying “Naku kawawa naman ako, magkaka-recurrence na ako, paano yan, araw-araw na lang iniisip ko, may recurrence ako ba o wala?”  Puwede na akong actor? And what you then, what you have to realize is life goes on. And it’s like if you do that then I should be as a doctor, I should be worried also that “Naku bukas pwede ako mamamatay. Mamaya pag fly ko sa …. Ano bang flight natin?  Philippine Airlines, naku baka may mangyari pag umuwi sa…pag nag landing kami sa Philippines, sa Manila.” Things can happen right? Things, things like that happen but we can’t dwell on those things. I talk to…. Melissa Lara de Leon  just when I just came in and told her how are you doing? I saw her before she got all her treatments and she said, you know she is happier that she got this. I said good you have considered, you have now considered breast, having breast cancer as a gift. And as something that has enriched your life and has made you more powerful. You now, you all now realize the how important or how, how valuable life is, how everyday, how everyday waking up in the morning feels like. While me? I am trying to struggle with my daily things and I’m pre-occupied with that and I don’t appreciate life as much. So that, actually this can make you a better person if you want it.

Twink: So should I wish breast cancer upon you doctor. Well, on that note we would like to thank Dr. Mark Kho for a wonderful, informative, insightful discussion that we had. Thank you very much for having us and we turn you over to our next forum.