Pt. 2 had left cancer DCIS. She is on adjuvant hormone therapy and SERI (selective ER inhibitor). There are two types of estrogen receptors that can be targeted: ER(alpha) and ER(beta). ER(alpha) is found in breast, endometrium, ovarian cells, and the hypothalamus . ER (beta) is found in granulosa cells, kidney, bone, heart, lungs, intestinal mucosa, and endothelial cells. Tamoxifen is an antagonist against ER(alpha) in breast tissue but an ER agonist in the bone (decreasing risk for osteoperosis). However, Tamoxifen is a partial agonist in endometrium, increasing the risk of uterine cancer.
Pt. 4 was a 57 yo female who had right breast cancer IDC with HER 2 overexpression. CEA/CA 153 ratio was within normal limits. This ratio is important in tracking the progress of chemotherapy. While she had no side effects after chemotherapy, her daughter insisted that she under go plastic surgery after her MRM (modified radical mastectomy) and is now experiencing pain and numbness in her right shoulder. These types of plastic surgeries can lead to a deformity. The patient regrets breast reconstruction as it is causing unnecessary complications.
Pt. 5 was a 67 yo female who had extranodal lymphoma and ileus with an ileum mass. After surgery to remove the mass, the pathologist determined it to be a low grade B-cell lymphoma, so Dr. Chen decided not to treat with chemotherapy. She has had complete remission for 2 years. She has pernicious anemia, which is a macrocytic anemia. Pernicious anemia is the most common cause of vit. B12 deficiency: it causes autoimmune destruction of parietal cells that lead to IF (intrinsic factor) deficiency. IF combines with iron to be absorbed in the ileum.
Clinical Pearls:
- PET/CT scan using a radioactive form of glucose can detect malignancies and infections. Cancer and infections will use glucose. However these imaging studies take 2-3 months and the patient may become anxious waiting for results.
- Uncooked foods and yogurt drinks should be avoided before chemotherapy. Chemotherapy causes leukopenia which increases the risk of infection. Uncooked foods are more likely to have bacteria and yogurt drinks include forms of bacteria that would be good for people who are not immunocompromised, but may cause infection for IC patients.
- CEA (a tumor marker) can detect disease status in prostate and ovarian cancers. CEA can be monitored before after chemotherapy to determine if treatment is working.
- dementia due to chronic disease in old age is common
- prophylactic levofloxacin is given to neutropenic patients after chemotherapy
Inpatients:
55yo male with esophageal cancer receiving parenteral nutritional supplement and had a gastrostomy today (an artificial external opening into the stomach for nutritional support). Surgery was initially delayed due to tracheal stenosis that would make it difficult for intubation for general anesthesia. However it was decided he would receive spinal anesthesia for the operation. He now has abdominal pain due to lack of muscle tone from spinal anesthesia. He was given laxatives.
Female patient with colon ca. suffering from malnutrition. Dr. Chen prescribed albumin and explained to the family that they would have to pay out of pocket for each albumin treatment since she does not fall under the criteria (over 70 yrs old or nephrotic syndrome). Today studies show that she has a liver abscess. Dr. Chen says that if infection isn't the cause of death, hepatic encephalopathy will develop in 1-2 months. Dr. Chen said that all doctors have memorized the guidelines for drugs because they could get fined for subscribing it unnecessarily. He also expressed that it is frustrating to consider insurance guidelines which do not always match up with international guidelines. Dr. Chen also thought it was laughable that America wanted to adopt a universal healthcare system similar to Taiwan - he thinks that competition between insurance companies and hospitals will improve care. I thought it was interesting to hear that although Taiwan's healthcare system is based off of studying the best healthcare from all over the world there are still many shortfalls and frustrated physicians.
Dr. Chen also told us that truly top of the line treatment and medicine cannot be found in Taiwan. The insurance company uses the cheapest drugs to keep costs low. In America we think that healthcare should be a right and shouldn't be a product that we buy. Yet, in Taiwan, the low costs of healthcare for patients leads to waste and abuse that negatively affects patient care indirectly. Doctors fear getting sued by the NHI and the patients and practice defensive medicine. The NHI is currently running under a deficit.
Dr. Chen often sites recent studies to determine what kind of chemotherapy to give to his patients. I think oncology is a difficult field because they are still trying many methods to target oncogenes. When I asked what he thinks are the most promising therapies out there, he says that immunological therapies might be a new way to target oncogenes. Simply put, it is the idea of getting B-cells to specifically target cancer cells. There has also been documented studies on introducing p53 genes into cancer cells, but that has been unsuccessful.
Hematology and Oncology rotation was one of the more difficult fields that I have shadowed. Cancer seems to still be relatively misunderstood and individualized treatment is a necessity for each patient. New therapies are constantly coming out and one must be up to date with treatment options all the time.
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