#5 How to be a better patient – How to prepare for your doctor’s appointment

Imagine you have an upcoming doctor’s appointment. You are seated, the doctor ask you to explain your physical complaints. Seven minutes later you are told you probably have this disease and 3 minutes after that you are sent out the door with a doctor’s prescription for a medicine with a weird name. You forgot to tell them some vital information that might have alerted the doctor to think about some other disease. On top of that you forgot what this medicine you are about to pick up is good for. I’ve seen many patients confused about their diagnosis and their treatment. Would you want to prevent this situation? Here are some tips:

  • 1. Write down your main physical complaints in advance (bulletpoints should be fine). This could be either on a piece of paper or on your phone. A piece of paper might be preferable. You could hand the paper over to them and the doctor could scribble some explanation on the paper.
  • 2. Write down your questions in advance.
  • 3. Ask your doctor to summarise the diagnosis and the treatment. Make sure this is clear for you before you walk out of the doctor’s office! You could even ask the doctor to write it down for you on the paper you brought along.

If you manage to stick to these 3 simple rules, you’ll be more informed than most patients. I’ll be writing more about how to maximise the utility of your doctor’s visit in future blog posts, so stay tuned!

Featured image credits: Photo by Nathan Dumlao on Unsplash

#4 How to be a better patient – What to do when you have a complaint?

Imagine you’re a patient with extreme pain and you therefore go to A&E (i.e. emergency room) in the hospital. Here you are sat down and not helped for hours. Or imagine you have had a very bad experience with a healthcare professional (doctor, nurse or whoever else in the hospital). What would you do?

You might hold a grudge against that specific person. It is then recommended that you discuss this issue with the specific healthcare provider. Don’t just keep your feelings to yourself. If unresolved, these experiences could erode your trust in the specific healthcare provider.

I was discussing this issue with a colleague earlier today. He mentioned that doctors should also play their part. Whenever doctors sense a patient is particularly unhappy with the healthcare service, whether it’s about yourself or a colleague, they should invite the patient to discuss this issue. Doctors shouldn’t shy away from having these difficult conversations. In the end the doctor-patient relationship might become damaged beyond repair if left unaddressed. My colleague mentioned that a good doctor invites the patient to discuss their complaint and if it’s a big error, they should even encourage the patient to file an official complaint. In general, this complaint is not intended to punish anyone, rather it will illuminate processes and behaviour that needs improvement. In the end, this will also benefit healthcare for other patients. Obviously both sides should try to stay respectful, we’re all humans and anyone can have a bad day and make a mistake. My colleague also mentioned that usually after having these kind of difficult conversations, these patients feel heard and understood, resulting in a stronger doctor-patient relationship than before.

In short, whenever you as a patient have a complaint about a healthcare service or provider, don’t shy away, try to communicate your feelings!

Featured image credits: Photo by Andre Hunter on Unsplash

#3 How to be a better patient – preventing colorectal cancer

According to UK statistics, 1 in 15 UK males and 1 in 18 UK females will be diagnosed with bowel cancer (i.e. colorectal cancer) in their lifetime. Sources from Cancer Research UK estimate that 54% of bowel cancer cases in the UK are preventable. They break this number down as follows:

  • 13% of bowel cancer cases in the UK are caused by eating processed meat.
  • 11% of bowel cancer cases in the UK are caused by overweight and obesity.
  • 6% of bowel cancer cases in the UK are caused by alcohol drinking.
  • 7% of bowel cancer cases in the UK are caused by smoking.
  • 2% of bowel cancer cases in the UK are caused by ionising radiation.
  • 5% of bowel cancer cases in the UK are caused by too little physical activity.
  • 28% of bowel cancer cases in the UK are caused by eating too little fibre.

These numbers are likely to be population specific, meaning that the exact numbers might be different for the people living in your region. Regardless of the specific regional differences, this list immediately shows what you could do to reduce your chances of getting bowel cancer. A Danish cohort study, suggested that one could reduce the risk of getting bowel cancer by 23% if the study population followed the following 5 lifestyle recommendations:

  • Physical activity: ≥30 minutes of moderate activity
  • Maintaining a limited waist circumference: ≤88 and ≤102 cm for women and men
  • Not smoking
  • Limiting alcohol: ≤7 and ≤14 drinks/week for women and men
  • Diet: eating plenty of fruit, vegetables and fibers, while limiting red and processed meat

The somewhat annoying thing surrounding this issue is that most people are aware of these lifestyle recommendations. However, often it’s too hard to get started or to maintain these healthy habits. Overturning your bad habits and substituting it with good habits doesn’t happen overnight. I’d suggest that you don’t compare yourself to others, simply start small and strive to be 1% better than yesterday. This concept has been popularised by author James Clear, check out his book “Atomic Habits“. It’s never too late to get started.

Image credits: James Clear

Featured image credits: Photo by Dan Gold on Unsplash

#2 How to be a better patient – recognising alarm symptoms

One of the most shocking moments during my first internship in the hospital was when I had to examine an old lady with a suspicion of having bowel cancer (also called colorectal cancer). She has had blood in her stool for the past few months. Lately she had pain during defecation and therefore went to the GP. After rectal examination, it was clear she had bowel cancer. She was referred to the department of internal medicine where I was interning. The bowel cancer grew through her bowel wall into other organs. It was clear that the cancer had been growing for a while, because of the late stage cancer and her frailty, there were no curative treatment options. It’s impossible to exactly know what her chances of survival would have been if she had sounded the alarm earlier, nevertheless it’s almost certain that her chances of curative treatment options would have been larger if the cancer was discovered earlier.

Doctors are trained to pick up alarm symptoms. In medicine these are called “red flags“. These are symptoms that indicate the patient might be having a life-threatening or life-altering disease that needs urgent medical attention. In this post I want to share the alarm symptoms for bowel cancer. According to UK statistics, 1 in 15 UK males and 1 in 18 UK females will be diagnosed with bowel cancer in their lifetime. 54% of bowel cancer cases in the UK are preventable (let’s discuss prevention tomorrow). In short, there’s a large chance you, a friend or a family member will get bowel cancer, so it’s good to be aware of the main alarm symptoms for bowel cancer:

  • Unintended weight loss: it’s hard to say exactly how much weight is worrisome. Usually a few kilograms (around 4 or more kg) weight loss becomes a bit suspicious, but it also depends on your baseline weight.
  • An inexplicable sustained change in your stool, such as regular episodes of constipation, diarrhea, or narrowing of the stool, that lasts for more than a few days
  • Having a constant sensation you need to poo despite recently having done a number two
  • Rectal bleeding: immediately alert your doctor if you have had this, even if it has just been 1 episode. There are several causes of rectal bleeding and let your doctor examine whether it’s cancer, haemorrhoids or something else.
  • Black or very (unusual) dark brown stool: this could be an indication of blood in your stool. Usually blood in the stool is even more smelly than a regular poo…
  • Unusual prolonged cramping or belly pain

Some countries provide a national bowel cancer screening programme. If you’re lucky enough for this taking place in your country, it’s important to participate. In this way you increase your chances of detecting or even preventing cancer at an early stage, increasing chances of getting curative treatments.

Let me know if I’ve missed any important alarm symptoms. I’d love to hear from you.

Credits to image creator: Anatomy vector created by brgfx – www.freepik.com

#1 How to be a better patient – an intro

Whilst being a student in medicine and science for more than a decade, I’ve experienced several remarkable situations. Whenever I see a patient, I can’t help but placing myself in their shoes: how would I behave, what would I do, what would I ask the doctor? Very often I find that patients don’t do the things I would have done. Too often I’ve seen patients confused about treatments or not standing up for their own perspective. Obviously it’s not a fair comparison, since the average patient hasn’t received medical training. Nevertheless, I believe with some basic tips and tricks, patients can be empowered and can be more in control of their experiences in medical settings. In this blog post series “How to be a better patient”, I’ll try to discuss the following things:

  • 1. How to communicate more effectively with healthcare providers
  • 2. Which medical alarm symptoms to be aware off
  • 3. How to reduce your risk of disease
  • 4. The pitfalls of modern medicine
  • And much more…

I want to give you a sneak peak into how a medical doctor thinks. If you know how a doctor thinks and how doctors approach a problem, it should become clear how to navigate the healthcare system.

Running a marathon for cancer research!

My mission is to improve care for cancer patients. Cancer research is a corner stone to making this possible. Over the years I myself have been doing research on different types of cancer, such as brain cancer, breast cancer, lung cancer and now liver cancer. However, I haven’t properly participated in raising money for charity and this needed to change. I believe in challenging yourself and voluntarily making yourself suffer, so I came up with an activity that involved something I truly detest… that is running.

The Dutch Cancer Society (called KWF) has a charity run in Rotterdam in April 2022. Of course, I had to sign up for this marathon in my hometown. Unfortunately, that means I’ll need to train in the cold and rain this winter in order to be prepared…

Over the past 2 years many charity events had to be cancelled during the COVID-19 pandemic. As a consequence, funding towards cancer research has taken a hit. That is why your donations will matter even more in the coming months and years. I hope you will be able to support patients in their fight against cancer! Please consider sponsoring me, just visit https://acties.kwf.nl/fundraisers/subramanianvenkatesan/rtm-41 and donate.  

Resistance #1: Senescence as a mechanism to resistance?

Discovery of senescence

This first blog post will be about senescence. Senescence is considered the state in which a cell has permanently stopped to divide. It is a stress response that is distinct from quiescence (= reversible cell cycle arrest), terminal differentiation and contact-inhibition. In 1961 Hayflick and Moorhead discovered that fibroblasts divide around 50 times before they stop to proliferate (1). This so-called “Hayflick limit” was later linked to shortening of telomeres with every cell cycle (2, 3). It was found that not only fibroblasts, but that non-cancerous cells in general across species and tissue origins, have a limited number of divisions after which replicative senescence is initiated (4). This was a groundbreaking discovery, because this means cells can’t divide forever!

Senescence as a barrier, preventing cancer development

Surprisingly, senescence does not only occur when the Hayflick limit is reached and replicative senescence is initiated.  In 1997 the team of Scott Lowe discovered that overactivation of growth signals provided by so-called oncogenes, such as RAS can stop cells from dividing permanently  (5). Their discovery suggested that senescence is not merely activated after a number of cell divisions, but is a protective program, triggered by abnormal levels of cellular growth signals. Around 2005 several labs found that in the stage before transforming into full-blown cancer, many cells are senescent (6, 7). This suggested that our bodies are trying to prevent cancer from developing by catching them into a non-dividing cell state, before it actually develops into full-blown cancer. Unfortunately, this isn’t always successful, and a cancer cell is still able to escape/bypass this mechanism of senescence leading to the development of cancer. Indeed, senescence is highly prevalent in the pre-stages of cancer. Once a cell has become cancerous, it is considered to have unlimited potential to divide, essentially becoming immortal.

Senescence in cancer

Even though cancer cells are considered to have an unlimited capacity for cell division, apparently, some cancers still have the capability to senesce! It appears that some cancers are better in suppressing senescence than other cancers. The question whether cancer cells can escape senescence after becoming senescent is still somewhat controversial, since there’s an ongoing debate about whether senescence is reversible. There is accumulating data that senescence is potentially reversible (8-12).

Senescence as resistance mechanism?

So how does all of this tie into resistance to therapies? It’s been shown that certain cancer treatments can damage cancer cells so much that they stop dividing and senesce, we call this therapy-induced senescence. A whole list of cancer treatments are known to induce senescence. Check out this splendid review by the Gerwitz’s lab for the long list of treatments (13). Recent evidence suggests that senescent cancer cells can make their non-senescent neighbouring cancer cells more aggressive and potentially resistant to cancer therapies (14, 15).

In short, senescence isn’t just a boring state of cells that aren’t dividing. Even the non-dividing cancer cells seem functionally relevant and can’t be ignored. It seems plausible that senescence itself can be a way to generate resistance in cancer cells. The mechanisms through which senescence can drive resistance needs more investigation.

References

(This is not a comprehensive review, simply for education and entertainment, so forgive me if I didn’t refer to your seminal discoveries)

1.         Hayflick L, Moorhead PS. The serial cultivation of human diploid cell strains. Exp Cell Res. 1961;25:585-621. 2.         Harley CB, Futcher AB, Greider CW. Telomeres shorten during ageing of human fibroblasts. Nature. 1990;345(6274):458-60. 3.         Bodnar AG, Ouellette M, Frolkis M, Holt SE, Chiu CP, Morin GB, et al. Extension of life-span by introduction of telomerase into normal human cells. Science. 1998;279(5349):349-52. 4.         Röhme D. Evidence for a relationship between longevity of mammalian species and life spans of normal fibroblasts in vitro and erythrocytes in vivo. Proc Natl Acad Sci U S A. 1981;78(8):5009-13. 5.         Serrano M, Lin AW, McCurrach ME, Beach D, Lowe SW. Oncogenic ras provokes premature cell senescence associated with accumulation of p53 and p16INK4a. Cell. 1997;88(5):593-602. 6.         Bartkova J, Rezaei N, Liontos M, Karakaidos P, Kletsas D, Issaeva N, et al. Oncogene-induced senescence is part of the tumorigenesis barrier imposed by DNA damage checkpoints. Nature. 2006;444(7119):633-7. 7.         Collado M, Gil J, Efeyan A, Guerra C, Schuhmacher AJ, Barradas M, et al. Senescence in premalignant tumours. Nature. 2005;436(7051):642-. 8.         Sage J, Miller AL, Perez-Mancera PA, Wysocki JM, Jacks T. Acute mutation of retinoblastoma gene function is sufficient for cell cycle re-entry. Nature. 2003;424(6945):223-8. 9.         Martinez-Zamudio RI, Roux PF, de Freitas J, Robinson L, Dore G, Sun B, et al. AP-1 imprints a reversible transcriptional programme of senescent cells. Nat Cell Biol. 2020;22(7):842-55. 10.       Beausejour CM, Krtolica A, Galimi F, Narita M, Lowe SW, Yaswen P, et al. Reversal of human cellular senescence: roles of the p53 and p16 pathways. EMBO J. 2003;22(16):4212-22. 11.       Yu Y, Schleich K, Yue B, Ji S, Lohneis P, Kemper K, et al. Targeting the Senescence-Overriding Cooperative Activity of Structurally Unrelated H3K9 Demethylases in Melanoma. Cancer Cell. 2018;33(2):322-36 e8. 12.       Saleh T, Tyutyunyk-Massey L, Gewirtz DA. Tumor Cell Escape from Therapy-Induced Senescence as a Model of Disease Recurrence after Dormancy. Cancer Res. 2019;79(6):1044-6. 13.       Saleh T, Bloukh S, Carpenter VJ, Alwohoush E, Bakeer J, Darwish S, et al. Therapy-Induced Senescence: An “Old” Friend Becomes the Enemy. Cancers (Basel). 2020;12(4). 14.       Demaria M, O’Leary MN, Chang J, Shao L, Liu S, Alimirah F, et al. Cellular Senescence Promotes Adverse Effects of Chemotherapy and Cancer Relapse. Cancer Discov. 2017;7(2):165-76. 15.       Milanovic M, Fan DNY, Belenki D, Dabritz JHM, Zhao Z, Yu Y, et al. Senescence-associated reprogramming promotes cancer stemness. Nature. 2018;553(7686):96-100.

Fear not, plan, adapt, execute and don’t overthink

I made this figure to remind myself what to do whenever anxiety creeps up. Use fear as a cue to regroup through planning and then executing.

My first week as a medical student in the hospital

I wrote this post a long time back (February 2021), but resisted uploading it (grrr the resistance…). That said, I want to write a bit more about my journey in the hospital. Every week I end up in the craziest situations, so writing about it will be a good way to process what happened.

Witnessing a poor lady getting the diagnosis incurable pancreatic cancer, getting shouted at by a delirious patient, and performing a rectal examination were amongst the many adventures during the first week as a medical student in the hospital. As a medical student at Erasmus Medical Center in Rotterdam in The Netherlands, I’ve received 3 years of training on how the human body works. As a medical student you are taught which symptoms are linked to specific diseases, how to extract relevant information from a patient and how to perform physical examination. Nevertheless, when the time finally came to enter the hospital in my 4th year as a medical student, fear and doubt entered my mind.

I was sent to a faraway hospital in the south of The Netherlands. Since it’s a 1.5-hour drive from Rotterdam, I fortunately got allocated a room next to the hospital for 10 weeks. My first clinical rotation is in the internal medicine department. Every week I’m linked to a different doctor and tag along with them. Whenever a new patient is referred by their respective GP, I am allowed to first see them. I question them about the problem, perform the physical examination, discuss my findings with the specialist in the absence of the patient and finally the patient is called in to get the specialist’s opinion. One of the most intense consultations of the week included telling a patient in her 60s that she has got incurable pancreatic cancer (just to be clear, I simply sat beside the medical oncologist who gave the news). Seeing all the frail people in their 60s, 70s and 80s approaching the end of their lives is a strong reminder that time is limited. Even though I easily get carried away by all the minutia, this is a good moment to take some time to look back at my journey and acknowledge no one lives forever. Whether you’re 80 years old, 50 years old, 29 years old (like me) or just born, I’m sorry to say but time is running out. One-third of our lives is gone because of sleeping, what you do with the remaining two-thirds is up to you. We’ve got to spend our time consciously, because we don’t know what tomorrow will bring us. For the most us (including me), the problem isn’t that we don’t have enough, the problem is too often we don’t spend it well…

FAQs about cancer: What is it and why is it so hard to cure?

There’s currently an overload of information online and it’s difficult to figure out what’s true and what’s not. After discussing this topic with friends, family and patients, I thought it would be helpful in this blog to clarify some frequently asked questions surrounding cancer and while I’m at it, I might also debunk a few myths. To bring you up to speed, I will avoid going into too much scientific detail in this first cancer-related blog post. I have to add that as a cancer researcher I always tend to err on the side of caution and don’t like making sweeping statements or conclusions. Let me know if you think this was helpful or whether you’d rather want a different question answered.

What is cancer?

Our body is made out of billions of cells. Usually, these cells are working for us and operate on a ‘biological programme’ that makes them obey certain rules. This biological programme makes sure that cells with too many mistakes stop growing, are flagged up in the body and are cleaned up by our immune system. As we age there’s more time to accumulate mistakes. Normally this isn’t worrying since an excess of mistakes usually triggers the ‘stop growing programme’, preventing a future cancer from ever developing. However, when the perfect combination of mistakes occurs in 1 particular cell, this can damage the ‘stop growing programme’, allowing the cell to keep on growing without a brake. In other words, cancer originates from your own body and (generally) stems from a single cell gone wild that disobeys the checks and balances encoded in its biological programme.

That said, when we talk about cancer, we are actually referring to the whole collection of known cancers that can arise from the many different tissues that are present in a human body. For example, lung cancer has very different properties compared to brain cancer. You can therefore imagine that the different types of cancers arise through different ways (mechanisms) and are therefore often treated differently by medical doctors.

I have to admit this is a very crude explanation, but if it’s helpful, another post can go over this in more detail.

If we can put a man on the moon, why can we still not cure cancer?

The challenge of tackling cancer is to kill the cancer cells without killing the patient. Unfortunately, cancer cells are in many ways, highly similar to our other healthy cells in our body. An additional difficulty is that a cancer exists out of millions of cells that each can be slightly different from each other, creating groups of cancer cells with different properties and sensitivities to cancer treatments. A particular treatment might eradicate a large proportion of the cancer, but that minority of cancer cells resistant to the treatment can grow back and kill the patient. In other words, the cancer evolves according to the treatment, essentially creating a moving target.

There are many specific ways through which a cancer might defy (resist) a particular cancer therapy. Over the decades, cancer researchers have uncovered several hundreds of these different routes to resistance. I’m thinking of writing a bit more about how cancer can become resistant to therapies in several upcoming posts. Stay tuned if that might interest you!  

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