The moment you step out into the sunshine, your body will start to make vitamin D. Vitamin D is important for the normal development of bones, especially in a growing child. Lack of this vitamin in children will lead to the development of bowed legs. This occurs because the bone becomes ‘softer’ in the absence of adequate amounts of vitamin D in the body.

Sometimes called ‘the sunshine vitamin’, vitamin D is also thought to play a role in various types of cancer. A study from Heidelberg (Anticancer Res 2006; 26(4A): 2729 – 2733) looked at the plasma levels of 25-hydroxyvitamin D [25(OH)D] in healthy subjects (n=239), 23 patients with colorectal adenoma (commonly known as polyp) and 98 patients with colorectal cancer. The researchers found that colorectal cancer patients had significantly lower levels of 25(OH)D than normal individuals. For those diagnosed with colorectal adenoma, the 25(OH)D levels were low as well but exclusively in the winters only.

Previous studies on breast cancer patients have shown that the serum levels of 1,25-dihydroxyvitamin D [1,25(OH)2D] were lower in them when compared to normal individuals. A study from Imperial College, London measured the levels of 25(OH)D in 279 Caucasian women with breast cancer (J Clin Pathol 2006 Oct 17, epub). There were 204 patients with early breast cancer and 75 patients with locally advanced or metastatic breast cancer. Patients with early breast cancer had significantly higher circulating levels of 25(OH)D as compared to those with advanced or metastatic breast cancer. Indeed through the years there has been evidence to suggest that vitamin D and calcium may play a role in the development of breast cancer. A recent review on vitamin D, calcium and breast cancer risk (Cancer Epidemiol Biomarkers Prev 2006; 8: 1427 – 1437) summarized the following: (1) there is some epidemiologic evidence for an inverse relationship between vitamin D and calcium intake and breast cancer; (2) some studies have shown that serum or plasma levels of vitamin D metabolites are inversely associated with breast cancer risk; (3) a high level of sunshine exposure has been associated with a reduced risk of breast cancer and (4) calcium has been associated with a reduced risk of benign proliferative epithelial disorders of the breast (which are putative precursors of breast cancer).

“In the body, the metabolism of calcium and vitamin D are intimately linked. The calcium molecule plays a crucial role in the process of cell signaling (a bit like cell to cell talk). Thus it is not difficult to understand why they both could play an integral role in cellular function and dysfunction. What is not known for sure yet is how much vitamin D is enough and how much sunlight exposure is optimum. (Remember, excessive sunlight exposure can lead to skin cancer.)

Until we have the answer, I am afraid you can’t use the vitamin D excuse to get an extra few hours of sun tanning by the beach!

“What are you doing?”  I asked. “Oh, I am scraping my tongue with a tongue scraper” came the answer. “Why?” I asked again. “Part of oral hygiene.” replied my father. That happened many, many moons ago and I never knew there was a scientific explanation to this practice.  In those days the tongue scraper was a thin strip of bronze. It was 1cm wide, tapered at both ends and silver plated. You could only buy it in a silversmith’s shop.  Recently, I started seeing tooth brushes with a small scraping blade attached being sold in retail pharmacies as a combined tooth brush and tongue scraper. Finally, this ‘weird’ morning ritual has gained traction in the modern world.

Our breath, not unlike our looks, is an important attribute which can give a good or bad impression about oneself as a person. Bad breath, also known as oral malodour or halitosis, is common. In the developed world, 8 – 50% of people perceive that they have recurrent episodes of bad breath. It can affect people of all ages and can cause sufferers to lose self-confidence and self-esteem.

Bad breath when you first wake up is common. It disappears quickly and is generally not regarded as halitosis. True, longstanding bad breath is usually caused by problems in the mouth or nasopharynx. The most likely cause of oral malodour is the accumulation of food debris and dental bacterial plaque on the teeth and tongue. This is a result of poor oral hygiene and results in inflammation of the gum (gingivitis) or periodontal inflammation (inflammation of the gum and inflammation around the teeth called periodontitis). Adult periodontitis can cause variable degrees of oral malodour. Aggressive periodontitis, typified by rapid loss of periodontal bone and resultant tooth mobility, can cause intense halitosis. People who suffer from dry mouth can also develop or have worsened oral malodour. Some people with dentures can also develop bad breath because of increased tongue coating. Apart from inflammation in the mouth, respiratory infection can cause oral malodour because of nasal or sinus secretions passing into the oropharynx. People with lung conditions such as bronchiectasis or lung cancer can develop halitosis. Foreign bodies stuck in the nose can produce a striking odour to the breath.

“Morning halitosis” is the mild transient oral malodour which often arises after sleep. This may be more likely in people sleeping in a hot dry atmosphere or in those with nasal obstruction (for example due to an upper respiratory tract infection). You can also develop mild but transient bad breath after eating volatile foods such as garlic, onions, spices and durian. (For those who have had experience with the durian fruit, it not only gives you malodourous breath but also makes your other bodily discharge take on a distinct aroma!) Fortunately, these episodes only last for hours. Tobacco and alcohol can also give rise to distinct oral odours.

Oral malodour can be part of the symptoms of an underlying disease process (so called systemic causes). People with conditions such as liver failure, kidney failure, undiagnosed type I diabetes, leukaemias and acute appendicitis have distinctive oral malodour which can be picked up at the time of physical examination. Indeed, sniffing the patient’s breath forms part of the critical training of every medical student during their early formative years.

The clinical assessment for and diagnosis of halitosis is quite crude and subjective. This consists of smelling the air expelled from the nose and mouth and comparing the two (termed organoleptic assessment). If the smell is only detectable from the mouth then the problem lies within the mouth or pharynx (back of the mouth). If it is detectable only from the nose then the problem resides within the nose or the sinuses. If the odour is detected from both the mouth and nose then one has to consider a systemic cause.

The treatment of most cases of bad breath is relatively straight forward but is really dependent on the individual. Improving oral hygiene by meticulous tooth cleaning, use of dental floss and regular atraumatic tongue cleaning are important first steps. It may be necessary to have professional dental care to treat the underlying gingivitis or periodontal inflammation. Regular use of antibacterial toothpaste and mouth washes may help.

The age-old practice of tongue scraping has a scientific basis after all. It scrapes away the desquamated cells, leucocytes and micro-organisms coating the surface of the tongue which gave rise to the oral malodour. As for those who just can’t do without the mandatory daily dose of garlic, I am afraid no amount of tongue scraping is going to help. At least you can sleep soundly, as Count Dracula would not dare come close to you!

On 12th October, the large and successful pharmaceutical company Genentech, which manufactures the drug Avastin (bevacizumab), announced that the FDA has approved its use for patients with inoperable lung cancer. In a trial involving 878 patients, one group of patients received standard chemotherapy and the other group of patients received standard chemotherapy plus Avastin. Fifty one percent of those receiving Avastin and chemotherapy were still alive after one year. For those who received chemotherapy only 44% of them were still alive after one year. The median survival rate was 2 months longer for patients treated with Avastin. About two weeks earlier, on 27th September,  the FDA also approved the use of Vectibix (panitumumab), manufactured by Amgen, for use in patients with colorectal cancer who have progression of their disease while on oxaliplatin- and irinotecan-containing chemotherapy regimens. Avastin and Vectibix are monoclonal antibodies which are the new class of therapeutics targeting cancers.

Drugs like Avastin, Erbitux (certuximab) and Vectibix have certainly given more hope to patients suffering from cancers. The indications for these drugs will probably increase with time. Yet more new and powerful agents are on the horizon and will become available over the next 3 to 5 years. Thus bringing more hope to cancer patients.

Genentech has announced that it will cap the price of Avastin at US$55,000 per year for lung cancer patients. Without the cap, it would cost US$8,800 per month or US$ 105,600 per year! Avastin is also being used for treating patients with colon cancer. As the dosage required is less, the average monthly cost is less than US$4,400. (Avastin is also used for patients with breast cancer.)  However, this is still quite a lot of money if you have to pay for it yourself.

The issue of payment for these new agents has been a vexatious one. Even in the United Kingdom, where there is an extensive social health system, the payment issue has got into the headlines recently. The National Health Service (NHS) was taken to court by a patient, who had had her breast cancer treated, but felt that she should receive an expensive cancer drug to reduce her chances of getting a relapse. The NHS did not think that there was sufficient evidence to support its use in such a situation and so refused. In Asia, and for that matter a large part of the world, most patients would not be able to shoulder such cost without the help of a generous health insurance policy or a truly comprehensive social health care system.

For the doctor looking after such patients, he (or she) is caught right in the middle. On the one hand he knows there is a drug which could potentially help but on the other hand he knows the patient is unable to afford it. What do you do? For me, I still find myself being caught between the devil and the deep blue sea. I certainly do not have the answer. Perhaps we may see a replay of the situation surrounding the drug cost for treating HIV in under-developed and developing countries here.