“How much time?” A question that some would ask and want to know while others would rather not ask or know. This question is not unusual for those patients with an incurable terminal illness. The most common patient group would be those with incurable cancer. However, this question is also relevant to many patients with non-cancerous conditions such as end-stage lung disease, cardiac failure or neurological conditions such as multiple sclerosis. So how accurate is the doctor’s prognostication / prediction?

A study from University Hospital Dusseldorf, Germany studied aspects of subjective and objective prediction of survival in 216 cancer patients who were referred for palliative radiotherapy (J Clin Oncol 2007; 25: 3313 – 3320). The survival of these patients was estimated according to 3 categories - < 1 month, 1 – 6 months and > 6 months – by two physicians (A & B) and the institutional tumour board (C). After 6 months, the accuracy of these estimates was assessed. The correct progneses were correctly predicted in 61% by A, 55 % by B and 63% by C. In general, statistical examination of the study results showed fair agreement of the estimates which proved to be overly optimistic. In particular the survival of patients who died in < 1 month was over-estimated by 96% by A, 71% by B and 87% by C. Overall, the accuracy of the three estimates did not improve with increasing professional experience.

A 50 – 60 % accuracy rate in predicting an outcome is not much better than flipping a coin. Statistically, if you flip a coin enough times, you will get heads half of the time and tails the other half. Predicting when the final moment will be is a tall order. The only person who could predict accurately is the Almighty up there. Doctors are probably more accurate at predicting if the time is very near – within a few days. Any attempt to predict in terms of weeks or months would be close to pure guess work. There are objective parameters which helps a doctor to be more guarded with his prediction. For example, patients who have colorectal and breast cancer have better prognosis than those with brain metastases. Patients who are too frail and weak to perform daily activities at home tend to do less well. Consequently, these patients have less time on their hand.

When faced with the question “How long?”, a doctor can only come up with an average estimation based on published studies of similar patients. It can act as a guide, albeit not an absolute one. To the patient as well as the family members this piece of information is important. Knowing that it is only months and not years would allow the patient to set his or her own affairs in order.

When I am asked the question, I give a range, rather than a definite number of weeks or months. This is because I know that not only have I no power over such matters and hence cannot be accurate but also to prevent patients having to ask the difficult question “Doctor X told me I only have 3 months to live, can it be longer?”. After all, doctors are human, they do not hold all the answers!

Following breast sparing surgery for cancer or removal of the axilla lymph nodes with microscopic cancer deposits, radiation therapy to the breast and / or the axilla is often recommended. The rationale of radiating the area is to reduce the chance of recurrent disease either in the rest of the breast or in the axilla.

Researchers from the Netherlands recently reported on the 10-year results of the EORTC 22881-10882 trial on 5318 patients with stage I and II breast cancer (J Clin Oncol 2007; 25: 3259 -3265). Following surgery, all patients received the standard 50 Gy irradiation of the operated breast. Then the population was randomized to either receive a boost dose of 16 Gy radiation to the breast (2661 patients) or no boost dose at all (2657 patients). After a median follow-up period of 10.8 years, the cumulative incidence of local recurrence was 10.2% versus 6.2% for the no boost and the boost groups, respectively. Put it another way, patients who had a boost dose were 46% less likely to develop local recurrence. (The treatment for local recurrence is a salvage mastectomy.) Consequently the number of salvage mastectomies was reduced by 41%. However, since the radiation rays do not just stop at the breast, the radiation will also affect the underlying lung tissue. Radiation damage to lung tissue will lead to lung fibrosis. This study showed that severe fibrosis was significantly increased, with a 10-year rate of 4.4% in the boost group versus 1.6% in the no boost group. The survival at 10 years was the same in both groups, 82%.

In another study from the University of Pennsylvania, stage I and II breast cancer patients who received breast radiotherapy (RT) were studied to see if there was a difference in the incidence and distribution of coronary artery disease between patients who had had left-sided and right-sided breast irradiation (J Clin Oncol 2007; 25: 3031 – 3037). In total 82 patients underwent cardiac assessment and were studied. At a median time of 12 years after RT, 59% of left-sided breast cancer patients who had cardiac stress tests showed abnormalities in the stress test. The incidence of abnormalities in right-sided breast cancer patients was significantly less, being seen in 8% of patients. In the left-sided group, the stress test showed 70% of the abnormalities to be in the left anterior descending artery territory. Of those who underwent cardiac catheterization, 92% had coronary stenoses. In about two thirds of these patients, the stenosis was found solely in the left anterior descending artery.

Breast irradiation forms an integral part of the treatment options for patients with breast cancer. While irradiation helps to reduce the recurrence of cancer in the operated breast, it is not possible to completely shield the underlying organs (lungs and heart in this instance) from the side effects of RT. With newer RT machines, it might be possible to reduce the risk of inducing lung and heart damage. Until we can develop medicine or techniques that can totally protect the underlying organs from the RT side effects, we, as patients, can only rely on ourselves to try to ameliorate the ill effects of lung and heart radiation injury. Maintaining a healthy life-style by not smoking, having a healthy diet, exercising regularly and keeping a normal body weight will certainly help to ameliorate the side-effects of radiotherapy.

During a recent question and answer session at a public lecture, I was asked “What supplements or herbs should I consume to protect my liver?”. Milk thistle (Silybum marianum), Chinese herbs and cutting out all meat products were just a few suggested by the audience.

Extract of milk thistle has been used as a traditional herbal remedy for almost 2000 years. Nowadays, many people take it as a ‘liver tonic’ – protection against liver toxins and amelioration of the deleterious effects of chronic liver diseases. The commercial milk thistle product is termed silymarin. It is not a single pure substance but a complex of at least 7 flavonolignans and 1 flavonoid that comprises 65 – 80% of milk thistle extract. From silymarin, a semipurified fraction of silibinin is obtained. Once thought to be a single compound, it is now recognized as a 1:1 mixture of 2 diasteroisomers, silybin A and silybin B. In the last 5 – 10 years, experimental and clinical studies have looked at the effects of milk thistle in liver disease, hepatitis C, diabetes, hypercholesterolaemia and HIV. Some interesting and potentially positive effects have been observed but a definite beneficial effect has yet to be proven. The fact that milk thistle extract is not a single compound but a complex mixture of compounds makes it more difficult for the scientists to tease out which is the truly active ingredient. Perhaps it might be a combination of the components in specific proportions that confers a protective effect. Until we know for sure it is difficult to give concrete advice on its use.

Taking milk thistle and other natural health products (NHPs) [garlic, vitamin C, milk Echinacea species, goldenseal and fish oil are a few examples] is almost second nature to most individuals. Perhaps their use is more so in individuals with chronic illnesses as an attempt to improve their general health or a means to help stave off the unrelenting assault of the underlying disease process. Taking NHPs can interfere with the availability of other medicines in your body. For those with a chronic illness, the NHPs circulating in your body can increase or decrease the availability / concentration of the medicine circulating in your body. For example, concurrent use of NHPs with anti-retroviral (ARV) drugs is common among HIV infected individuals. Limited studies have found that intake of garlic and vitamin C results in reductions in ARV concentrations. The intake of milk thistle, Echinacea species and goldenseal causes an increase in the ARV concentrations (but by a non-clinically important amount). The reason why NHPs can potentially be problematic is because they can induce or inhibit the cytochrome P450 enzymes in the liver. The cytochrome P 450 enzyme system is involved in the regulation of the amount of drugs available in the body.

Most people feel that taking a supplement is being proactive in looking after their health. If the health supplement, like milk thistle, does not have significant side-effects, then consuming it for its potential health effects may have no deleterious consequences and, just maybe, may be of some benefit. However, if we have poor lifestyle habits, such as eating too much,  not exercising regularly, or drinking significant  amounts of alcohol, it is unlikely that any amount of milk thistle, Chinese herbs, sushi or NHPs will stop our health from deteriorating.

Your body is not unlike a motorcar. Every weekend, it is not uncommon to see a proud car owner spending several hours washing and polishing his car. The intention is to keep it gleaming and by so doing maintain its market value. The same applies to your body. If you eat the right food, exercise regularly and maintain a normal body weight, your body will ‘run’ in tip top condition and maintain its ‘value’ – with or without NHPs. I guess popping an NHP pill daily takes less effort. Indeed, it is human nature that we will always choose the easiest option but remember the saying – there is no such thing as a free lunch in life. If you want a healthy body, look after it. Start with a healthy lifestyle!