“Cancer: shock breakthrough” was the headline on the 20^th June of The Independent newspaper in England. It was referring to a news release by Mayo Clinic researchers on 2 patients with advanced prostate cancer who had been given the human antibody called ipilimumab. (Ipilimumab binds to the cytotoxic T lymphocyte-associated antigen 4, a molecule on T cells that plays a critical role in regulating immune responses.)

These 2 patients had been participating in a clinical trial of over a hundred patients with advanced prostate cancer. In addition to receiving androgen-ablative therapy (treatment to remove testosterone availability in the body), these two patients were randomized to receive a single dose of ipilimumab intravenously. Their advanced prostate cancer responded dramatically to the treatment and went from an inoperable stage to a stage where surgery could be considered. In the end,  both patients underwent surgery and when the prostate tissue was submitted for pathological examination, the pathologist had a tough time finding cancerous cells in the prostate tissue.

Ipilimumab has been used in clinical trials for patients with advanced prostate cancer before. At the recent 2009 annual meeting of the American Society of Clinical Oncologists (ASCO), a poster presentation from the Memorial Sloan-Kettering Cancer Center in New York City, reported their experience with ipilimumab in 45 patients with metastatic castration-resistant prostate cancer. Ten of the patients had ≥ 50% reduction in the PSA level. In one patient the PSA level normalized and his metastatic lesions showed complete response.

In the medical world, occasional exceptional response to a new drug can happen during preliminary study. However, with further clinical trials, the new drug may turn out to be less effective than existing drugs or to have unacceptable side-effects. Ipilimumab may turn out to be a very effective drug for prostate cancer; however, we must wait for further bigger clinical trials before we can pass final judgement.

New promising drugs for treating advanced cancers are always welcome news for patients, their families and doctors. However, sensational headlines can sometimes lead to unrealistic expectations. When the drug fails to deliver the sensational response, the patient and his family members feel let down and ‘cheated’. Sensational headlines sell newspapers while premature sensational medical headlines cause disappointment.

Last week President Barrack Obama urged doctors to work with the government to rein in health care costs before they cripple the government and its health care system. The US government spends 15% of its GDP on health care provision yet some of its citizens are still not able to afford health care. The hospitals have the most up to date equipment and patients attending the emergency room are often over-investigated because doctors are afraid of being sued in case they miss something. Patients undergo CT and MRI scans at the drop of a hat; the doctors are practising defensive medicine.

Contrast that to my experience in a foreign land last weekend. During my trip to Cambodia to donate stationary and personal hygiene products to primary and middle school children, I took the opportunity to visit one of the 3 big government hospitals in Phnom Penh. It is a 300 bed hospital providing emergency and routine care to the people living in Phnom Penh and the surrounding districts. Its intensive care unit was not air-conditioned and had bare tiled walls. There wasn’t even a fan on the ceiling. The patients were lying in basic metal framed beds. Some of the patients’ nursing needs were provided by the relatives camped next to the patients. Oxygen is delivered from a large cylinder rather than piped oxygen through wall outlets. Neurosurgical patients do not have the luxury of intra-cranial pressure monitoring after their surgery for traumatic head injury. The ventilator machine looked like it was in need of major maintenance. The state of the operating theatres was just as grim. The operating rooms had 1960s operating tables. Every room was really bare and gloomy. If you have a brain tumour and require surgery, you can forget it as they do not have the equipment to do it. If you need a total hip replacement, you have to go overseas. If you have a 1 cm stone stuck in your ureter and you want minimally invasive surgery to remove it, you have to go overseas. If you cannot afford it, then you can have it treated locally but you will end up with a large incision in your flank. In the hospital, imaging is limited to standard x-ray and ultrasound scanning - no CT and certainly no MRI.

Patients in the United States expect their doctors to be able to discover all the ailments in their body because they have the technology. Even with the best facilities, sometimes doctors are still unable to diagnose everything. In the United States, this could be construed as making a mistake and the doctors and hospital get sued. If only the hospitals in Phnom Penh were to have 10% of what is available in a typical American hospital, the Cambodian people would be overjoyed. Sue the doctor if he inadvertently misses a small tumour or a rare condition? Not likely.

Recently at the delicatessen counter of a supermarket, I heard a mother asked her teenage son “Would you like some salami for lunch?”. After receiving an affirmative reply the mother promptly asked for 20 slices of salami. The teenage boy was shorter than me but he was 3 times as broad and deep as me! In other words, he was overweight, if not obese, with a sizeable belly.

Obesity has reached an epidemic proportion worldwide and the incidence of metabolic syndrome (MetS) seems to be paralleling obesity. Metabolic syndrome is strongly linked to insulin resistance, abdominal obesity, diabetes mellitus and dyslipidaemia. The adipose tissue (or more commonly known as fat) in the body can be divided into subcutaneous adipose tissue and visceral adipose tissue (VAT). Overweight and obese people have increased amount of VAT. One of the many sites for VAT accumulation is the liver and this can give rise to a condition called nonalcoholic fatty liver disease (NAFLD). When inflammation sets in, the condition is called nonalcoholic steatohepatits (NASH). If left unchecked, NASH can lead to progressive liver fibrosis and eventual liver cirrhosis. There is increasing evidence that people with visceral fat accumulation have an increased risk of developing primary liver cancer or hepatocellular carcinoma (HCC). Will visceral fat accumulation cause increased risk of HCC recurrence after curative treatment in patients with suspected NASH?

Researchers from the University of Tokyo studied 62 patients with HCC on a background of suspected NASH (Gut 2009; 58: 839 – 844). The visceral fat area (VFA) was determined by CT images at the time of HCC diagnosis. The patients were divided into two groups based on the VFA:- high VFA group (VFA > 130 sq. cm in males, > 90 sq. cm in females) and control group (VFA < 130 sq. cm in males and < 90 sq. cm in females). Using percutaneous radiofrequency ablation, all patients were treated with a curative intent between 1999 and 2006. These patients were followed up until HCC recurrence. The cumulative recurrence rates at 1, 2 and 3 years in the VFA group were 15.9%, 56.5% and 75.1% , respectively. These are significantly higher values than those found in the controls, being 9.7%, 31.1% and 43.1%, respectively.  The researchers concluded that visceral fat accumulation is an independent risk factor for HCC recurrence after curative treatment in patients with suspected NASH.

While I applaud the mother who wanted to look after her child well, perhaps she has been looking after him far too well for his own good. Saddling an adolescent with excess / excessive weight is equivalent to storing up future health problems for the child. When he / she attains adulthood and starts developing diabetes mellitus, arthritis in the hips and knees, he / she might think differently about the excessive amount of food you have been feeding him / her.