|HEALTH TRIBUNE||Wednesday, May 30, 2001, Chandigarh, India|
PREGNANCY is a period in a woman's life when she focuses on positive thoughts of the future and thinks about ways in which the new baby will enrich her life. It is hard to imagine the feelings when a pregnant woman receives the diagnosis of cancer. The diagnosis of cancer during pregnancy can precipitate emotions of fear and anxiety for the patient as well as her family. The patient may be forced to choose a compromise between her foetus's well being and her own. These issues are further complicated by the potential for the termination of her reproductive capacity as a result of cancer treatment. A cancer diagnosis may bring anxiety about the impact of cancer treatment on the foetus. The unanticipated nature of the diagnosis adds to the women's emotional distress.
Cancer is the second leading cause of death in women in their reproductive years. pregnancy does not appear to increase the risk for any particular cancer. The simultaneous occurrence of cancer and pregnancy presents a complex ethical and therapeutic dilemma. Numerous difficult issues arise but acceptable alternatives can be devised based on a thorough knowledge of the natural history of cancer, the effects of treatment on the growing foetus and a strong, compassionate doctor-patients relationship.
Treatment decisions must take into consideration not only toxicity to the mother but short and long-term consequences for the foetus as well.The question often arises whether to delay or modify optimal treatment of cancer for the sake of the foetus.Two important principles of treatment include these steps: alleviate maternal suffering and do no harm to the foetus. The need to prolong the mother's life is the most important consideration.
The most commonly diagnosed malignancies during pregnancy are breast cancer, cancer cervix, lymphoma and melanoma. Pregnancy-associated cancers tend to be more advanced at presentation. Diagnosing breast cancer during pregnancy can be challenging. A routine breast examination can be difficult due to engorgement, the proliferation of the breast tissue, and an increase in breast vascularity which results in an approximate doubling of the breast size.
Many of the symptoms of cancer such as nausea, weight loss, breast lumps, vaginal or rectal bleeding are also common during pregnancy.It thus becomes difficult to diagnose cancer as many cancer symptoms may be interpreted as being related to pregnancy.
A pregnant patient can be safely and reasonably staged with imaging. Imaging must be tailored to the clinical question to be answered. CT is not advocated as the radiation dose to the foetus is greater. Magnetic resonance imaging (MRI) is the procedure of choice because it does not involve ionising radiation.
Treatment needs to be individualised with appropriate obstetric care and monitoring to maximise the potential for a favourable outcome.
Surgery: a potential cure for cancers of the breast, ovaries, and melanoma is the best option and presents few risks for the patients or the foetus particularly in the second and third trimesters.
The use of radiotherapy during pregnancy has been associated with a wide variety of congenital anomalies and late toxicities. The severity of these effects range from minimal to severe and possibly lethal. Avoidance of radiation exposure during pregnancy is advised.
Chemotherapeutic agents designed to interfere with cell growth, regulation and division pose potentially catastrophic risk to a developing foetus. A number of studies have described adverse effects including spontaneous abortion, premature birth, low birth weight, intrauterine growth retardation and major malformations.It is difficult to implicate a single cause of foetal abnormalities that result from cancer treatment during pregnancy. Drug therapy has the greatest potential for foetal risk when administered during the first trimester. Various other factors include opportunistic infections that can infect the developing foetus, and nutritional deficiencies secondary to anorexia from cancer. All these in combination can be detrimental to the developing foetus. Patients who require chemotherapy and are in the early stages of pregnancy should be advised to take the option of therapeutic abortion. Abortion is an option for a patient who does not want any risk.
The timing of delivery needs careful consideration. If chemotherapy is to continue after delivery, breast-feeding is inadvisable as drugs can pass through the milk.
Pregnancy-termination is important in allowing the optimal care of the patient presenting with metastatic cancer. Cancer rarely metastasizes from the mother to the foetus.
There are many unanswered questions about the long-term effects of anticancer drugs on the surviving child. Little information is available on the long-term follow-up of the offspring of patients treated for cancer during pregnancy. However, there are reports of normal physical, neurologic and psychologic development, including normal school performance after in utero exposure. However, further studies are needed to evaluate the long effects of in utero exposure. Efforts should be made to allow the foetus to develop as fully as possible, prior to exposure, provided a delay in treatment would not significantly compromise the mother's health.
Questions regarding pregnancy and cancer are important for surgeons, obstetricians and oncologists. These patients deserve the best we can offer them. Cancer challenges two lives. Better awareness along with an increased readiness to evaluate unusual symptoms may help avoid undue delay in diagnosis. Treatment needs to be instituted as soon as possible to avoid poor maternal outcome. The parents should be advised about the potentially increased risk of early abnormalities and long-term risks to the offspring of the women treated for cancer during pregnancy. Pregnancy is terminated and the treatment of cancer is started when the disease is detected in the first half. It is a reasonable option to wait for foetal maturity when cancer is diagnosed in the second half of the pregnancy.
THE 10th of May, 2001 at midnight CNN stopped its regular telecast to announce a breakthrough in cancer treatment now approved by the US regulators on food and drugs.
This is about an anticancer drug "Gleevec" — a once-a-day pill, which is first in a new class of drugs that strike a specific target believed to cause cancer. The therapeutic effects, being sufficiently dramatic and sustained, are not countered by exaggerated toxicity. The safe and effective use of anticancer drugs in the treatment of leukaemias requires in-depth knowledge of the pharmacology of these agents.
In no other field of medicine is the margin of safety more narrow or the potential for serious, if not fatal, toxicity more real. At the same time, anticancer drugs are capable of curing many of these otherwise aggressive malignancies, and their discovery and development have provided a paradigm for approaches to the improved treatment of the more common solid tumours.
The intelligent use of these drugs begins with an understanding of their mechanism of action. In addition, the disposition of the drug in the human body plays a critical role in determining drug-effectiveness and toxicity.
Because of the potential of these agents for toxicity, it is critical for oncologists to understand the pathway of drug-clearance and to adjust the dose in the presence of compromised organ function. Clinicians must also be alert to the potential for genetically determined differences in drug toxicity and response.
The leukaemias and lymphomas have been the proving ground for chemotherapy. The first evidence for antitumour activity of a chemical agent came from experiments with nitrogen mustard in a patient with Hodgkin Disease in 1942. The even more startling discovery of remission induction by antifolates in acute lymphoblastic leukaemia six years later ushered in the era of chemotherapy in cancer treatment.
Subsequent clinical experiments in these diseases established the basic principles of combination therapies and dose intensification, developed effective strategies for marrow trans-plantation and demonstrated the importance of specific mechanisms of drug resistance. These principles have led to curative regimens for acute leukaemias and lymphomas, effective therapies for chronic leukaemias and they have provided the conceptual basis for the current practice of medical oncology.
Most initial trials of "Gleevec" conducted are in patients of chronic myeloid leukaemia. Chronic myelodid leukaemia (CML) is a frequently observed blood cancer inIndia and in the world over. Around 4500 people in the USAdevelop this leukaemia each year. The disease progresses through three distinct phases, the chronic phase, the accelerated phase and the acute phase (otherwise known as blast crisis). Current therapies for this type of blood cancer include various drug regimens such as hydroxyurea, interferon alpha and cytarbine and bone marrow/stem cell transplantation. Some of these drugs prolong the overall survival (around six years) but have considerable adverse effects. The transplantation of bone marrow or stem cell, considered the only curative treatment for CML, is associated with substantial morbidity and mortality and is limited to patients for whom a suitable donor is available and needs to be done early in the chronic phase.
The first consistent genetic abnormality in (any) cancer was identified in CML. This leukaemia is caused by the abnormal fusion of two bits of genetic code, resulting in a protein (BCR-ABL) which through its tyrosine kinase activity, is believed to induce a potentially lethal proliferation of white blood cells. An inhibitor of this protein activity should be an effective and selective treatment for CML."Gleevec" having the generic name ST1571 and generic formula (4-[C4-methyl-1 piperazinyl) methyl]-N-[4-methyl-3- [4- (3-pyri dinyl) 2-pyrimidinyl] amino] phenyl]benzamide methane sulfonate was synthesised after a similar compound was identified as the inhibitor for tyrosine kinase activity. This drug functions through a high degree of specificity for tyrosine kinase activity of BCR-ABL but does not affect the normal cells.
In a landmark multicentre trial of this drug, the results of which were published in New England Journal of Medicine in April 2001, patients of CMLfrom Haematology and Oncology Centres inOregon, Texas, and Los Angeles in whom other drug treatments had failed or who could not tolerate other drugs, ST 1571 (Gleevec) was given orally. This was well tolerated and had substantial activity against the cancer cells. The rate of complete haematologic responses increased to 98 per cent as the daily dose was increased and reached higher doses. During treatment with ST 1571, the alarmingly elevated (in millions) blood counts gradually returned to normal during the first month. This suggested that the inhibition of tyrosine kinase activity of the BCR-ABLrestores normal regulatory behaviour to the leukaemia cells which get displaced either by normal blood cells that had regained a proliferative advantage or by differentiation of the primitive leukaemia cells, which leads to its elimination.
The side-effects of the drug were found to be mostly mild like naussea, oedema, muscle pain and diarrhoea. Bone marrow suppression, which occurred in up to a quarter of the patients, could be easily managed by the temporary interruption of treatment.
Gleevec inhibits other proteins linked to the gastrointestinal and lung cancers. The drug is also active in some kinds of brain, prostate and soft tissue cancers. Trials are underway in such cancer patients.
The global pharmaceutical company, Novarttis, has got the rights to market this drug.
RESEARCHERS in the United Kingdom have developed artificial havens for nitrogen-hungry bacteria that will treat noxious liquid leachate from landfill sites.
Prof Andrew Wheatley and his team at Loughborough University, English Midlands, have created "bug hotels" providing the bacteria with a comfortable habitat, warmth and food, that will encourage the indigenous microbes to achieve maximum efficiency when dealing with landfill leachate.
This is pumped through the "hotels", enabling the microbes to remove the main pollutant — ammonia — turning it into harmless nitrogen gas.
The best use of bacteria is accomplished by fastening them to a surface or immobilising them in pores. Many types of adherent surfaces in the bioreactor are under test to see what are the stickiest for example, substances such as polysaccharides.
A balance has to be achieved and one which sufficiently binds the microbes without impairing their activity. In landfill sites the refuse is mostly carbon-based and it can be broken down by microbial action into carbon dioxide and methane. The methane can be drawn off and burned to generate electricity.
The next most abundant component is nitrogen which gets converted into ammonia, a substance which is soluble in water and can be toxic to invertebrates in the environment at relatively low concentrations.
The contaminating leachate is usually diverted into the municipal sewer system or treated onsite, an inefficient process due to the unusual characteristics of leachate.
Loughborough researchers have
harnessed specific populations of bacteria to detoxify the ammonia.
Two groups of bacteria - nitrobacter and nitrosomonas - can oxidise
ammonia into nitrate which can then be passed to another group -
pseudomonas - that converts it into nitrogen gas.
WITH escalating healthcare costs and more and more people opting out of overcrowded and impersonal medical services, at government-run hospitals, there is an overwhelming need for a cost-effective and good healthcare delivery system. Moreover, the health sector in India needs thoughtful revamping, especially with all the paper work and money involved in patients getting admitted to a hospital, not to mention the time lost in getting reliable advice about their illness.
Mediclaim policies have very strict rules which seriously limit their applicability, thereby leaving a large number of people without any medical cover of any sort. This is where "managed care" comes in. Managed care is an established and successful health plan in developed countries whereby health insurance companies, health maintenance organisations (HMO) and preferred healthcare providers (PHP) come together to control healthcare costs by reducing unnecessary medical services and limiting access to medical care, while focusing on quality and preventive medicine.
The concept of this is that when a person purchases a medical policy, he or she agrees to frequent only those hospitals and clinics mentioned in the policy. In return, he does not have to pay the medical bills himself. The bills are claimed directly by the third party administrators from the insurance company. This is no small advantage when one considers the hassle that is involved in getting the reimbursement cleared from the insurance agency after first having paid the bill.
Family Health Plan (FHP) and Sedgwick Parekh both act as third party administrators on behalf of General Insurance Company of India. They have a network of over 125 healthcare providers including hospitals, nursing homes, diagnostic centres etc which are made available to the members of the service.
Advantages for corporates
* Assurance of qualitative healthcare nationwide
* Affordable and fixed cost
* No advance payment and no reimbursement of bills
* Restraint to fraudulent bills
Advantages for employees
* Emergency care, nationwide ( 24 hrs x 7 days ). A boon to touring members.
* Convenience to patients — no payment to be made in advance or towards hospitalisation.
* Broadbased coverage from primary care to specialy service.
"Managed Care" is ideal for small to large enterprises and the public and private sectors. It is offered by Sedgwick Parekh as well as FHP. INSCOL in Chandigarh is a preferred healthcare provider for both these HMOs, along with other leading hospitals such as P.D.Hinduja, Jaslok, Indraprastha, Apollo and Escorts.
* The HMO brokers a deal between the client and the insurance company
* The client pays the premium — directly to the insurance company.
* The client avails himself of the services from Preferred Healthcare Providers without making any payment.
* The PHP forwards the bill to the HMO/ insurance company
* The HMO gets the bill reimbursed from the insurance company and pays to the PHP within the stipulated period.
Dr O.P. Jaggi. puts down the OATH thus:
If thou desirest success, wealth and fame as a physician and heaven after death, thou shalt pray for the welfare of all creatures beginning with the cows and Brahmins.
What about character?
Day and night, however thou mayest be engaged, thou shalt endeavour for the relief of the patient with all the heart and soul. Thou shalt not desert or injure thy patient even for the sake of thy life or thy living. Thou shalt not commit adultery even in thought. Even so, thou shalt not covet others’ possessions. Thou should not be a drunkard or a sinful man, nor shouldst thou associate with the abettors of crimes. Thou shouldst speak words that are gentle, pure and righteous, pleasing, worthy, true, wholesome and moderate. Thy behaviour must be in consideration of time and place and heedful of past experience. Thou shalt act always with a view to acquisition of knowledge and the fullness of equipment.
No persons who are hated of the king or who are haters of the king or who are hated by the public or who are haters of the public, shall receive treatment; similarly those that are of very unnatural, wicked and miserable character and conduct those who have not vindicated their honour and those that are on the point of death, and similarly women who are unattended by their husbands or guardians shall not receive treatment.
No offering of meat by a woman without the knowledge of her husband or guardian shall be accepted by thee.
How should be break sad news?
While entering the patient’s house, thou shalt be accompanied by a man who is known to the patient and who has his permission to enter, and thou shalt be well-clad and bent of head, self-possessed, and conduct thyself after repeated consideration. Thou shalt thus properly make thy entry. Having entered, thy speech, mind, intellect and senses shall be entirely devoted to no other thought than that of being helpful to the patient and of things concerning him only. The peculiar customs of the patient’s household shall not be made public. Even knowing that the patient’s span of life has to come to its close, it shall not be mentioned by thee there, where if so done, it would cause shock to patients or to others.
Though possessed of knowledge, one should not boast very much of one’s knowledge. Most people are offended by the boastfulness of even those who are otherwise good and authoritative.
How to look at the world?
There is no limit at all to which knowledge of Ayurveda can be acquired; so thou shouldst apply thyself to it with diligence. This is how thou shouldst act. Again thou shouldst learn the skill of practice from another without carping. The entire world is the teacher to the intelligence and the foe to the unintelligent. Hence knowing this well, thou shouldst listen and act according to the words of instruction of even an unfriendly person, when they are worthy and such as bring fame to you, and long life, and are capable of giving you strength and prosperity.
Before a qualified physician could start
practice, he had to have the permission of the king. This was to
safeguard the people from the nuisance of the quacks.