Staying in Check

An interview with doctors from Mount Elizabeth Hospital, Singapore.

DR. FOO KIAN FONG
Senior Consultant,
Medical Oncology

You specialize in gastrointestinal cancer. What patients are the most susceptible to this form of cancer?
Gastro-Intestinal (GI) cancer is the term for the group of cancer that affects the digestive system. This cancer includes the esophagus, gallbladder & biliary tract, liver, pancreas, stomach, small intestine, bowel (large intestine or colon and rectum), and anus. It is safe to say that GI cancer is one of the most common forms of cancer. In Asia, the most common form of GI cancer has been noticed in the large intestine/colon. If we were to map the incidence rate for colon cancer against age, we would see that there is a sharp jump in the numbers of patients suffering from colon cancer after the age of 50 for both sexes. Moreover, other factors such as genetics, a strong family history of cancer and tendency to polyps all increase the chances of colon cancer. Polyps are small growths in the lining of the colon and are harmless but over time they will become cancerous., Hence they are best removed if they are discovered.

However, there are certain factors which will increase the chances of a person contracting cancer. These include a diet high in fat and low in fiber, smoking, higher than recommended daily ingestion of alcohol. Other factors such as lack of physical activity and even inadequate sleep can cause polyps eventually leading to colon cancer. A study has shown that a person enjoying less than 6 hours of sleep a day will have a 50% higher chance of developing polyps.

Since we have a magic figure of 50 years of age, I would highly recommend patients to get regular checkups once they reach that age. It is important to mention that for people who have an unhealthy lifestyle, the screening should begin when they are 45 years of age. In the screening process, we take stool samples where we check for blood and also perform a colonoscopy. Any polyps that have been spotted during the colonoscopy can be removed thus removing the probabilities of it becoming cancerous.

What would you say is the most effective way to treat a patient suffering from any Gastro-Intestinal (GI) cancer?
There are four stages of cancer. The chances of curing the patient and giving them a clean health bill is much higher in the first three stages. Once a patient hits stage four, the chances of a cure are next to impossible. We would always want our patients to be in the first three stages and to guarantee that we suggest screening.
The earlier stages of GI cancer require operations while for the fourth stage we can only use chemotherapy to control cancer as a cure is not a possibility here.

If you had one piece of advice as an oncologist, what would it be?
My suggestion as an oncologist to my patients is always to make lifestyle changes. Simple steps such as cutting down alcohol intake and watching what you eat will lead a person to live a long and disease free life. It is important to eat a balanced meal where a person is eating plenty of fiber and a limited amount of fat. It is also important to couple this with some form of activity where the individual is engaging in at least 5 hours of moderate activity in a week. Finally, I request patients to stop smoking and get a minimum of six hours of sleep each night.

What is the most challenging and rewarding part of working as an oncologist?
The most challenging part of being an oncologist is when my patients are at the fourth and last stage of cancer. As I have already mentioned, there is very little chance of cure in this stage. Thus ensuring my patients are comfortable in the remaining years of their lives has to be the biggest challenge for me as a doctor.

The rewarding part of my job is when I can see the operation has been a success and the patient has been cured of the disease. It is really fulfilling to see my patients go back to living their normal lives and knowing that I played an important part.

What are your thoughts on using alternative and complementary medicine to combat cancer?
I believe in Bangladesh, there are not many alternatives and complementary medicines sources as there are in my part of the world. A good example of alternative medicines includes Traditional Chinese medicine. While I do not condemn the use of alternative or complementary medicine, but when they are administered with chemotherapy, they may interact with the chemotherapy to cause liver or other problems. Hence I usually request my patients to inform me if they are using any alternative medicine. There was a study in the National Cancer Center in Singapore, where they discovered that about 56% of the patients use alternative medicine and 46% of these patients felt there was no need to inform their doctors about the use of these medicines. And it is only when the blood tests show abnormal results that the patients are willing to divulge this information.

Another big question mark regarding these alternative and complementary medicines is the authenticity of effectiveness. Not much is known about the herbs or its effect on cancer. And more often than not people start using these medicines based solely on word of mouth.

However, I must reiterate that I am not against these medicines because I occasionally see some effect. Especially on liver cancer patients.

Dr. Ling Khoon Lin
Gastroenterologist

One of your clinical interests is in IBD. The incidence of IBD has been historically low in Asia when compared to the western world. What is your take on this phenomenon?
Inflammatory Bowel Disease (IBD) has been historically low in Asia but its incidence has been increasing over the last few decades. Crohn’s Disease and Ulcerative Colitis are the two main forms of Inflammatory Bowel Disease.

Ulcerative Colitis (UC) is a condition that causes inflammation and ulceration of the inner lining of the rectum and colon. In UC, ulcers develop on the surface of the lining and these may bleed and produce mucus.

Crohn’s Disease is a condition that causes inflammation of the digestive system or gut. Crohn’s can affect any part of the gut, though the most common area affected is the last part of the small intestine or the colon.

Both UC and Crohn’s Disease are a chronic condition. This means that it is ongoing and lifelong, although you may have long periods of good health, there will be periods of relapses when your symptoms are more active.

While I do not have the data for India or Bangladesh, the figures from Singapore shows that since the late 1970’s to the first half of 1980’s we hardly have any incidence of UC. In fact, the figure is pretty flat. From the late 1980’s there seems to be a surge in the rate of UC and it goes to reach a plateau in the early 2000’s. But the plateau is still at a much higher level compared to the number of 1970’s. If we were to look at Crohn’s disease, it also follows a similar pattern but I would say that it is still 10 years behind. We chalk up the huge surge in IBD to the massive lifestyle change Singapore underwent during the 70’s and 80’s.

This is a very interesting phenomenon which we still have to figure out. We are increasingly seeing younger patients, especially in their late teens who are reporting both UC and Crohn’s disease. Even though we are talking about this increase in incidence in Singapore, when we compare with the incidence rate of white population, in this case, I am referring to Australia the rates are surprisingly lower in Singapore. A multicenter study was conducted, where countries such as Singapore, Malaysia, Hongkong, China, and Australia were chosen to be the centers. When we compared the results from the Asian countries to that of Australia, we noticed that Australians were 20 times more likely to report IBD. In comparison, Singapore and Malaysia had incidence rates of about 1 per 100,000. Sri Lanka was the only center from the Indian subcontinent, and even they had a reporting rate of 1 per 100,000.

And if we try to identify the why behind the higher incidence rate in Australia, I would say genes have a huge role in it. That is Caucasian gene has historically been more susceptible to IBD.

What kind of patients will be more susceptible to IBD?
Unfortunately, we are yet to discover what patients are more susceptible to IBD. The current theory behind IBD is that it is prevalent behind genetically susceptible patients. An infection in the gut triggers the immune system, which causes inflammation in the gut. If the person has a particular gene which is susceptible to IBD, the immune system does not switch off even after the infection has gone.

Researchers have found 100 plus genes in the Caucasian population which makes them more vulnerable to IBD, whereas for the Asian population we have only identified one gene. This lends credibility to the idea that Caucasians are 20 times more likely to have IBD.

Another factor can be a lifestyle choice. People choosing to adopt a modern form of lifestyle where they eat more processed food and have higher alcohol intake will be more exposed to IBD. This also explains the higher IBD rate in the late 90’s in Singapore.

As a gastroenterologist, what is that one piece of advice that you always give to your patients?
To all IBD patients, I suggest that you listen to your doctor. This is simply because IBD is a chronic, long term illness which requires stringent monitoring from the doctors. Just like any other disease if the patient is strict about taking his medication, then it is highly likely that I will not be seeing any ulcers when I perform a colonoscopy on them.

Since the disease is so rare in Bangladesh, a diagnosis of IBD is more fearful to them than if they had been diagnosed with diabetes. I want to remind these patients that IBD is not a death sentence and with proper treatment patients live a long and fulfilled life. I like to give examples of the two US presidents, John F. Kennedy who had UC and Dwight D. Eisenhower who suffered from Crohn’s disease. I want to highlight that IBD is a terrible disease but it should not limit your lifestyle if you take care of yourself.

You are involved in research related to the immunology of gastric and colorectal cancer. What drew you to this topic?
My primary interest has always been immunology, but the diseases that I am interested in, such as IBD, causes chronic inflammation in the intestines. This inflammation, in turn, causes cancer. The other organ that I treat is liver and at one point it was believed that a person suffering from Hepatitis B and C can cause liver cancer due to chronic inflammation. It is this inflammation which leads to cancer, that sparked my interest in immunology.

My research has been trying to solve the puzzle of how cancer bypasses the immune system. In the context of chronic inflammation, there are plenty of immune cells which should be able to stop cancer. Thus the newest form of therapy when treating cancer is immunotherapy which tries to strengthen the immune system.

What would you say is the most challenging and rewarding part of being a gastroenterologist?
The most rewarding part of my job, not just as a gastroenterologist but as a doctor, would be to see my patients improve.
The most challenging part of being a doctor is to make the right diagnosis and to pursue patients to listen to my course of treatment.