Does the statement “The will to live” refer to a proven scientific phenomenon or is it an abstract concept without scientific basis? Does “The will to live” refer to an internal switch which an individual can just ‘switch off’ at will and thus ending one’s life? Let me recount a recent event and you can be the judge.

I was recently looking after a very pleasant, elderly gentleman with inoperable hepatocellular carcinoma (primary liver cancer). During the course of his illness, he suffered the complications of ascites (fluid in the abdomen) and oesophageal variceal bleed (bleeding from a vein in the oesophagus). His liver function started to deteriorate and he became jaundiced. Despite all this, he remained cheerful, co-operative and stoic while being nursed at home. On my visits, he was always upbeat and promised to soldier on and ‘do what the doctor has advised’. This went on for about 3 weeks.

One Saturday, out of the blue, the gentleman casually said to his daughter-in-law “I am getting tired of fighting”. The weekend passed as per usual. Sometime on the Monday morning, the gentleman said to his daughter-in-law “I am leaving tomorrow”. By the time the daughter returned from work on the Monday evening, the gentleman was not responding to her speech. Although he was awake, he did not speak or ask for food / water. In the early hours of the Tuesday morning I received a call to say that he had had a brief episode of breathing difficulty but it had settled. As the children were concerned, I arranged for his admission. When I saw him, he was comfortable and breathing normally. His eyes were open but he did not respond to me. I admitted him and kept him comfortable. Early on Tuesday afternoon, several hours after admission, he passed away peacefully.

The children asked “How did he know?”; “Could he just switch off like that?”  I do not have the answers. Have I seen such an incident before? Yes, on many occasions. Do I have a scientific explanation for it? No.

Examples of the will to survive are not uncommon in the animal kingdom. I believe we humans possess the same innate power to want to survive. In the animal kingdom, some animals can sense that their time has come. Perhaps our ‘sense’ is not as developed as in animals.

In a similar vein, I have noticed that a patient’s mental attitude towards illness plays a role in his / her recovery. A patient who goes into an operation with a positive mental attitude tends to have a much smoother post-operative recovery. Patients who have an indifferent or negative attitude somehow have a more choppy recovery. I do not have a scientific explanation for these “abstract phenomena” and I am not perturbed by it. I see these as reminders that there are still things that we, the scientific community, do not understand and cannot explain. That is the wonder of life!

Hepatocellular carcinoma is a common cancer worldwide. The incidence in the East is very much higher due to endemic chronic hepatitis B virus (HBV) infection in the population. The incidence of HCC has been increasing steadily in USA and the major risk factor for HCC in US is chronic hepatitis C virus (HCV) infection. In 1975, the total incidence of HCC was approximately 1.59 per 100,000 person-years. By 2006, this had reached 4.82 per 100,000 person-years and this increase has been attributed to the increasing numbers of Asian immigrants in the United States. However, a presentation at the recent 101^st Annual Meeting of the American Association for Cancer Research (AACR) has come up with a surprising culprit (Abstract 1816, presented Arpil 19, 2010).

Researchers from the National Cancer Institute (NCI) reviewed data from the NCI SEER database. The case population studied consisted of 5607 people diagnosed with HCC. They examined the odds ratio of an individual developing HCC with the risk factors of HCV infection, HBV infection, alcohol-related disease, rare metabolic disease, diabetes and obesity. (Odds ratio tells you how much more likely it is that you are going to develop the condition compared with someone without the risk factor.) HCV infection has the highest odds ratio of 44.26 (ie 44 x more likely than a non HCV infected person). The odds ratios for HBV infection, alcohol-related disease, rare metabolic disorder, diabetes and obesity were 13.37, 4.43, 3.51, 2.37 and 1.53, respectively. However, the researchers found that diabetes was associated with the greatest percentage of cases (33.5%). The other associations were alcohol-related disorders (23.9%), HCV infection (20.7%), HBV infection (5.7%), rare metabolic disorders (3.1%) and obesity (2.7%).

The incidence of obesity and diabetes mellitus is increasing worldwide and the Asian population has not been spared. While chronic HBV infection is the most important risk factor for HCC in Asia, the general population and clinicians need to be aware that diabetes and obesity are also associated with HCC. The above study found that 67.9% of Asians with HCC had one or more of the identified risk factors. Both obesity and diabetes can be helped by adopting a prudent life style - maintaining a healthy body starts with you!

There are 2 types of diabetes mellitus – Type I and Type II. Type I diabetes occurs when the pancreatic islets, which produce insulin, are destroyed by an auto-immune process. It affects young children and they are dependent on insulin injections for life. Type II diabetes occurs when the body tissue becomes less sensitive to the action of insulin, thus, more insulin has to be produced by the body in order to keep the glucose level normal. Type II diabetes usually affects adults who are overweight / obese and older. As one gets fatter, one develops insulin resistance and this leads to an impaired glucose level. Eventually a proportion of overweight / obese people develop persistently elevated glucose levels and the condition is termed Type II diabetes.

Researcher in Umea University, Sweden, studied the association between blood glucose and cancer risk in 274,126 men and 275,818 women from Norway, Austria and Sweden (PLoS Med 2009; 6(12): e1000201). The study found that impaired glucose level was associated with increased incident and fatal cancer risk. In men, the risk per 1 mmol/L glucose increment for incident cancer and fatal cancer was increased by 5% and 15%, respectively. Significant increase in the risk of incident and fatal site-specific cancer was observed for cancer of the liver, gallbladder and the respiratory tract. Incident risk of cancer of the thyroid and multiple myeloma were increased. Men with the highest impaired glucose level also had significant increased risk of fatal colon cancer. In women, the risk for incident cancer and fatal cancer was increased by 11% and 21% respectively. Significant increase in the risk of incident and fatal site-specific cancer was observed for cancer of the pancreas and stomach. Incident risk of urinary bladder cancer was increased. Women with the most amount of impaired glucose level also had significant increased risk of incident endometrial cancer.

The result from this European study corroborates the findings of a Korean study published in 2005. Impaired glucose levels are associated with increased risk of cancer. For those who are overweight, this bit of information is another reason for you to lose weight. Achieving it depends on what you eat, how much exercise you do and how determined you are.