Author: noorali

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Colon Cancer

Dear Dr. B: I have a strong family history of colon cancer. I would like a blood test done every year for early detection of colon cancer. What about CEA blood test that colon cancer patients get so frequently? Why cannot my family doctor order this test for me to make my life easy? Asks Mr. C.

Dear Mr. C: CEA stands for carcinoembryonic antigen. This test has been available for 35 years. It is currently used for patients who have been diagnosed with colon and rectal cancer. Enthusiasm for this test among surgeons and cancer specialists has fluctuated over the years. Originally, the use of this test was poorly controlled. But now the dust has settled and CEA has emerged as the test of choice for patients with colon and rectal cancer.

This test is not good for early detection as there is 30 percent false positive and false negative results in patients who have had no previous colon cancer. Patients with false positive results end up getting many unnecessary investigations. And patients with false negative results may have a false sense of security that they do not have colon or rectal cancer although they may be harbouring one!

CEA is also elevated in other cancers and benign conditions. Therefore, it is hard to be sure if the high level is due to colon and rectal cancer or due to other cancers or benign conditions.

Therefore, the surgeons order CEA after the diagnosis of colon and rectal cancer has been made but before the cancer is resected. CEA provides some idea to the surgeon about prognosis and whether the tumour has already spread. Lower levels indicate limited spread. In about 50 percent of cases, high CEA and increasing CEA after the cancer has been resected, indicates that the cancer has already spread or recurred.

If CEA is high before surgery then it dramatically drops after surgery if the patient has no spread. Then CEA is tested at frequent intervals to see if the level remains the same.

After 33 years of CEA use, the experts have not been able to agree how often CEA should be ordered after successful resection of the cancer. Some do it every month, others every three months for the first two to three years as most recurrences are expected to occur during this critical period. Then the frequency of the blood test is reduced as longer one survives, better the prognosis.
So what is there for early detection of colon and rectal cancer?

Examination of stool for occult blood on regular basis combined with or without endoscopy (flexible sigmoidoscopy or colonoscopy) are currently the best screening tools. Again, each test has its advantages and disadvantages. The optimal method for early detection remains uncertain and people’s compliance rate very poor, as the tests require certain amount of preparation and time. When it comes to colon and rectum, the tests are not very comfortable.

But screening is very important. It has been shown that screening for colon and rectal cancer has reduced mortality by 15 to 33 percent in those who undergo screening routinely. Colon and rectal cancer is the second leading cause of cancer-related deaths in Canada. Therefore, besides screening, early investigation of symptoms like rectal bleeding and change in bowel habit is very important if we want to improve prognosis and survival.

So, Mr. C, discuss with your doctor other methods of early detection as CEA is not a good test for screening for colon and rectal cancer.

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Prostate Cancer

Dear Dr. B: What is PSA? I believe this a blood test to check for prostate cancer. If this is true then why is my family doctor reluctant to order one for me? Can you please tell me more about this test, who should get it and how often? Yours, worried Mr. P

Dear Mr. P: PSA stands for Prostate-Specific Antigen. Yes, this test is now widely used for early detection of prostate cancer and to follow the progress of patients who have had prostate cancer.

Prostate cancer is now the most commonly diagnosed cancer in Canadian men and second most common cause of death from cancer in men. Prostate gland is present only in men at the junction of the urinary bladder and the urethra. PSA was thought to be produced and secreted solely by the cells of the prostate gland. But this is not true anymore. PSA is also found in breast cancer and other cancers.

Once upon a time, digital rectal examination was the only crude way to pick up early prostate cancer. Then came PSA blood test. PSA was expected to replace the embarrassing and uncomfortable digital rectal examination. And it was promoted as an ideal test for screening and early detection of prostate cancer. But this hope has not materialised. And the controversy continues.

In a recent edition of the Canadian Medical Association Journal, there are two commentaries on this issue. One is written by two family physicians and the other one by a urologist.

The family physicians feel that PSA testing in men over 70 should be avoided. They restrict the use of PSA screening to men between 50 and 70 years of age unless they are at higher risk (e.g. black American men and those with a family history), in which case screening is initiated at 40.

How often the test should be ordered?

According to the family physicians, the literature survey suggests that PSA should be ordered anywhere from every 2 years to every 5 years. Normal value should be less than 4 ng/mL. Another report suggests that men with PSA results of 4ng/mL and below should be tested every 6 months for at least 3 consecutive tests.

Currently, these family physicians recommend PSA every year for eligible patients but feel that screening every 5 years is a reasonable alternative.

The urologist’s commentary agrees that PSA testing for all men between 50 and 70 is a good idea. But PSA screening every 5 years may be inadequate. The urologist feels that yearly testing is reasonable unless the PSA level is below 1 ng/mL, in which case testing every 2 years is acceptable.

In about 20 percent of patients with normal PSA results, diagnoses of prostate cancer will be missed, which supports the idea that digital rectal examination is an important additional diagnostic tool. But digital rectal examination on its own will miss a substantial numbers of prostate cancers.

The urologist feels that the upper limit of normal (4ng/mL) may be too high and it would be prudent for family physicians to refer patients to a urologist if the PSA result is above 2.5-3.0 ng/mL.

So, Mr. P, have I confused you? If yes, then you are now on par with other doctors! The last word on this subject is yet to come. But I hope this information will help you put your doctor’s advice in proper perspective.

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Father’s Day

Recently, my neighbour died. It was unexpected. We were shocked. When I gave the tragic news to my son, his first reaction was: Dad, what will we do without Mr. Link?

On this Father’s day, my thoughts are with Waldemar Link. Waldemar was not only a good neighbour but he was like a father to us and grandpa to our children. When we moved into his neighbourhood 15 years ago, Waldemar and his wife Herta showed us the selfless true spirit of good neighbourhood. Whether it was to mend a fence, check a leaking roof, build a deck, take care of the dying cedar trees or check the mail and look after the house during our holidays, they were always there.

Just a week before he died, Waldemar was there helping my son, Hussein, get a CB radio antenna cable into his room through a tiny hole in a window. If we had a problem in the house or the backyard, our first reaction was: Let us check with Mr. Link!

On Father’s Day, we usually pay tribute to our real fathers. My father died nine years ago. My wife’s father died one year ago. Both had long and happy life except at the end when they suffered from painful illnesses that made their life uncomfortable. Both were lucky to live long enough to see their large families grow and settle down in life. Both were quite satisfied before their death that they had fulfilled their role in life as good fathers. They were always there when we needed them. And they gave us the security and education to be independent in life.

We were lucky to have our fathers when we were growing. But what about those young children whose fathers have been taken away from them by accident or illness? And there are fathers who have chosen to abandon their children due to reasons, which are difficult to understand by third parties. Then there are fathers who have committed or continue to commit acts of terror on their children. These young children are being raised in one parent family. Do we really understand how they feel on this day or rest of the year?

What about single parent fathers who struggle to be good mothers as well? Does society understand and appreciate these fathers?

Most fathers try very hard to be good role models for their children. But not all fathers are paragons of virtue. We, as fathers, make mistakes like other humans. But the important thing is to learn from these mistakes. Father’s day should be that day of reflection to see where we failed and where we can make a difference. What counts is the learning process of self-improvement. There are no schools for fathers to train except what our own fathers taught us. Are we true to those teachings?

Sonora Smart Dodd started Father’s Day on June 19th, 1910. Sonora was raised by her father after her mother’s death. Sonora’s father was born in June. So, for 90 years, third Sunday of the month has been celebrated as Father’s Day. On June 18th, 2000 let us reflect on our past and plan a future for our children so that they can carry our message to their children.

Happy Father’s Day!

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Physician Errors

What is the difference between god and a doctor? God does not think he is a doctor!

You have heard this joke before. But it is not funny when you are a patient and your doctor thinks he is god, he knows it all and he can do no wrong. Well, do doctors make mistakes?

Errors in medicine is a touchy subject. It is a hot potato. Not many people want to touch it or swallow it. But recently, medical journals in Canada, USA and Britain have started to discuss the subject in the open.

In health care, doctors are not the only ones who make mistakes. All humans who work in the system make mistakes: nurses, pharmacists, physiotherapists etc. Even machines make mistakes.

And as we rely more on the machines to make diagnoses for us, the mistakes are increasing. False negative and false positive results from the multitude of tests we order are putting patients at risk every day. That is the price we pay for modern technology.

A report released in US last year says that medical errors kill about 100,000 Americans each year. The chairman of the 19-member panel that issued the report says, “These stunningly high rates of medical errors resulting in deaths, permanent disability, and unnecessary suffering are simply unacceptable in a medical system that promises first to ‘do no harm’.”

An editorial in the British Medical Journal says that studies in Australia, Israel, the United Kingdom and elsewhere, suggest levels of error and hazard in patient care that are no lower than in America. Canada is not immune to the problem. Death of infant Trevor Landry from a narcotic overdose in a Toronto-area hospital is one example of medical errors in Canada. Currently, in Canada, no mechanism exists to track medication or other errors to develop strategies to prevent their occurrence.

Are health care professionals superhuman?

No. But they are highly trained individuals. Each one comes with certain weaknesses and strengths. They are not all born or trained to do everything.

John Hubbard, in a book called “Measuring Medical Education”, says that two types of physicians make mistakes – a shotgunner, who prescribes and does procedures without adequate information and indications; and a timid soul, who makes diagnoses without adequate information.

But there are other reasons for errors as well which people fail to appreciate. Over worked and underpaid workers, inadequate resources, manpower shortages, political interference and personal and family stress does not provide a healthy environment for error free practice.

Is there a mechanism to prevent errors in medicine?

Yes. But the American report condemns the current fragmented system of handling medical mistakes, which relies on a combination of peer review, federal and sates regulation, malpractice lawsuits, and evaluations by professional bodies. The panel suggests mandatory reporting and public disclosure of serious medical errors.

In my view, there are only 5 ways to prevent errors in life: 1. Give your hundred percent to the task at hand, that is, be thorough 2. Do not do anything you are not comfortable with 3. Do everything neatly and clearly 4. Know your strengths and weaknesses and 5. Learn to say ‘I don’t know’.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!