The Big C: We Learn More About Cancer From An Institut Kanser Negara Oncologist

A quick lesson on cancer.

  • By: Afiqah
  • Tuesday, 23 June 2020
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The Big C: We Learn More About Cancer From An Institut Kanser Negara Oncologist

All you need to know about the Big C.

COVID-19 may be the C-word of the moment.

However, cancer is the other that has been around for a while now, and it continues to ignite a sense of fear amongst the people.

We decided to find out more about the disease and learn about the treatments available to battle it. 

Meet our oncologist

Dr Tan Chih Kiang, an experienced clinical oncologist.
Rojak Daily met up with Dr Tan Chih Kiang, a clinical oncologist at Institut Kanser Negara (IKN).

He has served in the oncology department, which he described as demanding and interesting, since 2009. 

What is cancer, anyway?

In case you didn't already know, our bodies regenerate.

“All these mechanisms are well-regulated. But of course, as we get older, there are some problems along the line of this regeneration, so cancer cells are actually cells that are not able to regulate properly in the sense that they continue to grow or spread to other parts of the body and cannot be controlled by its normal mechanism.”

Dr Tan made it clear that cancers are NOT contagious.

“Generally, cancers are not something that comes out of the blue or something that happens to you from somewhere else or being spread by somebody else,” he said.

Cancer forms when our cells failed to regenerate.
He further explained that cancer is derived from our own body and could be from any of the cells.

The early stages of cancer may not cause pain. However, as it advances, the potential for it to start causing pain grows with it.

In terms of cancer as a disease, there’s the solid tumour and hematologic malignancies.   

Haematological malignancies also sometimes being referred to as “blood cancer”, such as leukaemia and lymphoma. These are managed by haematologists.

Other cancers besides haematologic malignancies are solid tumour. IKN manages mainly the adult solid tumours, whereas the paediatric oncologists will manage tumour in children.

There are over 100 types of cancer. Some of the more common ones include breast cancer, colorectal cancer and lung cancer.

What causes cancer?

To this question, Dr Tan admitted that it is a bit more difficult to explain. However, one should note that it is multifactorial.

“Of course, there are certain cancers which are related to genetics,” he said. 

Angelina Jolie underwent a preventative mastectomy.
For example, women with the BRCA1 gene have a high risk of developing breast cancer. Hence, Hollywood actress Angelina Jolie’s decision to undergo prophylactic double mastectomy (a preventive procedure which involves the removal of the breasts even though the disease has yet to develop) is understandable.

While some cancers are related to genetics, the majority of them are not.

Lifestyle is one of the main contributing factors, Dr Tan told us. Smoking and alcohol consumption are some of the more common influencing agents.

“But again, as I said, it’s always very difficult to pinpoint one because we do have non-smokers who actually develop cancer,” he clarified.

On any red flags to watch out for, Dr Tan stated: “It’s difficult to pinpoint one. Depending on the type of cancer, location and stage of the diseases, the signs and
symptoms might be very different”.

However, you should go and see the doctor in the event of unexplained constitutional symptoms such as weight loss or loss of appetite. If you have a strong family history of cancer, Dr Tan advises that you consider going for a screening test and early checkup.

All in all, “If you have any symptom, it’s always good to go to the doctor to clarify”.

You shouldn't Google your symptoms.
The doctors would hope to be able to pick up on the occurrence of cancer without the symptoms. The early detection would be possible amongst patients who have gone for their routine medical checkup or early screening program, especially in cases of those who are at high risk.

So, yes, go and get yourself examined, folks!

Unfortunately, according to Dr Tan, “most of our patients are usually presented at a later stage of the disease when they already have the symptoms”. 

However, researchers are making efforts to ascertain the cause for the late presentations.

“I think there are some studies currently ongoing in Malaysia trying to look at several areas to see what the actual causes are – whether it’s behavioural which refers to the patient’s attitude in coming late to see us or whether the delay is due to problems they face in accessing healthcare or if there is a delay in diagnosing them or in initiating treatment.

"And based on those findings, hopefully, we can try to come out with a solution or plan on how to tackle each of the causes,” he stated.

There's just too much at stake for some patients.
His firsthand encounter with a Stage 4 breast cancer patient ten years ago taught him that in treating patients, it is not just about the disease.

“I offered her treatment. The problem is that she was not really concerned about her disease.”

The patient was the mother of a disabled son and she only earns a few Ringgit by selling snacks to schoolchildren at a nearby school.

“Her concern was if she were to get admitted for the chemotherapy treatment, there would be no one to take care of her son,” he recalled.

It was then that he began to realise that in performing his duty to treat patients, he must take into consideration many other aspects including their problems.

The diagnosis phase

To diagnose cancer, there are a few steps that need to be taken first, according to Dr Tan.

“Generally, the doctor will start off by getting (to know) more history from the patient to find out what is actually happening, what the symptoms are and when it started.”

A physical examination would also be conducted to check for lumps.

IKN’s magnetic resonance imaging (MRI) machine.
The patient may have to undergo tissue diagnosis too. Should this be required, a sample of the tissue would be sent to the lab for further testing. In most cases, the
patient would have to undergo a medical imaging procedure “to see whether the disease is mainly just localised or has actually spread to other parts of the body”.
Based on the results gathered, the doctor should be able to determine the type of cancer and its seriousness. The next course of action would then be tailored accordingly, Dr Tan explained.

The cancer situation in Malaysia

According to the Malaysian National Cancer Registry 2012-2016 edition, within five years, over 100,000 cases were recorded.

“What they have found out is that in terms of risk to develop cancer, I think it was one in nine in female and one in ten in male,” stated Dr Tan.

Institut Kanser Negara is a specialist centre committed to providing treatment for cancer cases. It is one of the six centres under the Ministry of Health Malaysia.

“Besides just doing our usual clinical service – which means seeing patients, and treating patients – IKN is also involved in educating the patients, the public and the carers,” explained Dr Tan. 
Institut Kanser Negara, est 2013.
IKN also plays an important role in the research area, which includes finding better ways to care for the patients. This includes finding ways to make drugs more accessible and continuously looking for solutions to improve in every aspect possible with the interest of the patients as the top priority.  

When discussing the topic of cancer treatments, radiotherapy and chemotherapy would always be part of the conversation.

"However, the treatment of cancer is actually more than that. It very much depends on the type of cancer and stage”.

Hence, it should not come as a surprise that besides the two, the clinical services offered at IKN also include nuclear medicine, palliative care, surgical oncology, gynaecological oncology, oromaxillofacial oncology, anesthesiology, intensive care, pathology and acute cancer treatment.

Dr Tan also explained that these days, instead of simply calling it ‘chemotherapy’, the term you might actually be looking for is ‘systemic treatment’.

Why is that, we asked?

“Because chemotherapy essentially means using a cytotoxic drug. Of course, we’re still using it nowadays but there are a lot of treatments that have come in under this systemic treatment such as targeted therapy, hormonal therapy, immunotherapy and others as well.” 

Visiting the lab

The CT simulator at IKN.
We were granted a brief tour to check out several of IKN’s treatment facilities.

Our first stop was the daycare area where patients come in for treatment for the intravenous drugs. The treatments here are those that can be administered and completed within the office hours or within a day. Should a patient require a treatment that would take longer, he/she will have to be admitted to the ward.

Do not be mistaken though. The duration of the treatment is not an indicator of the severity of the disease. Different types of cancer call for different types of drugs and regimens for there is no one drug that treats all cancers.

“Certain regimens are administered every two weeks, some three weeks while others four weeks. Some injections could be for two days, some just one day. It’s just like a recipe rather than the severity of the disease,” Dr Tan said.

We also learnt that the dosage of the drug differs based on the patient’s weight.

The treatment is tailored for specific patients.
We also checked out the radiotherapy area, which is located on the ground floor. It is common for a radiotherapy area to be based at or below ground level of a hospital due to the radiation involved. It would require a lead-shielded room.

If it were not at the basement-level, the flooring would have to be shielded with lead too.

Besides the impracticality, it is also not cost-efficient. 

Before the actual radiotherapy session is started, patients are required to go through the simulation process. Not only would this step allow a sense of familiarity to the treatment for the patients, but it also enables an accurate setup, which is essential, as the treatment may need to be conducted repeatedly over days or weeks. 

“We do not want to irradiate on different areas. We want accuracy. So, what we do is we use markings and measurements of the patient. We also use certain things to help immobilise the patient so that when they come for treatment later, we can treat at the same area accurately every single day,” elaborated Dr Tan.

With the information obtained, the patient could go to the next room and still be set up the same way.

The plastic sheet takes on the patient’s specific shape.
“Of course we use other devices to help. These are some of the things you try to lock onto the patient. They come in (the form of) a flat plastic sheet. We’d soak it in warm water and it will become soft. We then mould it on the patient.

"It follows the patient’s contour. Hence, it is not reusable for others.” 

This is mainly used for the treatment of head and neck region.

Not meant to be used by anyone else but the patient himself/herself.
IKN has several different types of radiotherapy machines. Think of them as different car models, said Dr Tan.

Dr Tan’s easy explanation to how the radiotherapy process goes down is simply:

“Patient lies down here, the machine moves and it delivers a radiation beam”.

The Linac Elekta radiotherapy machine.

Malaysia compared to the world

Dr Tan stated that the cancer treatments we have here “are quite comparable with most of the developed countries”.

“Treatments that are being approved by world authorities like the United States Food and Drug Administration or European Medicines Agency may be available in Malaysia later,” he said. 

Drugs that have yet to be listed in Malaysia may be accessible under early access programmes, compassionate programmes or under research. 

The misconceptions of the Big C

According to Dr Tan, “some patients still think that cancer is just like an infection. They also sometimes have this misconception that cancer can just spread like
sharing utensils when you eat together or live in the same house”.

Well, folks, it doesn't work that way at all. Apparently, some have the perception that the treatment given could cure the disease like your usual flu and cold.

Another more common misconception is that cancer equates to a death sentence. With the rapid advancements that continue to progress, that is not necessarily true.

Dr Tan also brought up some points on the misconceptions about cancer treatments.

“There’s hearsay about someone who has gone through one dose of chemotherapy and passed away. The problem accelerates faster through the power of social media," he lamented. 

With that, he stressed that patient education is very important.

“I think it’s good for a patient to come and see us and find out more on their own so that we can explain. Give us a chance to explain to them,” he stated.

And by the way, not all chemotherapy drugs cause hair loss. #NowYouKnowLah

The 40-year-old also noted that we should be wary against alternative medicine – even if it claims to be plant-based.

“Even though the actual form is actually based on plant or leaves, the active chemical component might be toxic. The fact is some of the chemotherapy actually is derived from plant extract.”

This goes to show that even plant-based products come with their own side effects.

"It could be harmful, especially when patients have ongoing conventional treatment with us and they take alternative medicine outside because it could potentially interact with the treatment they're having here; this could potentially affect the effectiveness of the treatment we're giving and may increase the side effects of the treatments".

Consoling cancer patients

We all have the good intention to help those in need. However, when it comes to dealing with cancer patients, “the most important thing that I’ve noticed and observed over the years in this profession is that you should just give them time.

"Just be by their side when they need us,” said Dr Tan.

Just be there for them.
He added: “Bombarding them with a lot of information or trying to help them out by giving them suggestions can be overwhelming to the patients, especially those who just knew about their diagnosis and even more so if it’s at a more advanced stage.

"They need a lot more time to let it sink in because they’re going through a lot of emotional struggle within. Give them enough time. When they are ready, they will come and ask for help.”

Dr Tan also reminded about the importance of verifying information before spreading it to others.

“When we recommend treatment to a patient, it is based on strong evidence. People have spent years conducting controlled research to prove that certain treatments work better than others. Based on all this, we make a recommendation.

"Not just based on testimonials – which in terms of under the eyes of science are one of the lowest levels of evidence, IF it is considered evidence”.

Remember, that sometimes, "good intentions could go bad,” Dr Tan shared.

Advice to cancer patients

Dr Tan advises you to have faith.
His advice to cancer patients out there is: “Stay strong and be hopeful. There are new advancements ongoing every single day and month.”

"In fact, years ago, when diagnosed with advanced lung cancer, you’re looking at about a year or so of survival. The majority passes away within one year – which was exactly what happened to my grandfather.

"But over the last decade or so with a lot more new advancements, there are some Stage 4 lung cancer patients who are now still living beyond five years,” he elaborated.

“We hope in the future with more new advancements, we can at least control stage 4 cancer patients just like chronic diseases right now such as hypertension or
diabetes. Although we’re not able to cure such patients, we’d be able to work towards a longer control of symptoms of the disease.

"I think that's what we hope for – at least for those patients with advanced cancer”.

Dr Tan also strongly advises patients to NOT listen to hearsay. He once again asked that doctors be given a chance to do what they do best.

“Come to us to find out more about your condition as well as treatments and we can always talk about the pros and cons and then we can see how we can go about treating the disease itself.”

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