New approach gives hope to lung cancer patients



University Malaya Specialist Centre consultant cardiothoracic surgeon Dr Sivakumar Krishnasamy sheds light on lung cancer, the symptoms and options of treatments for patients in an interview at UMSC, recently. Photo: Bernama


Leen was six when her grandfather was diagnosed with stage four lung cancer.

“I was so worried that ‘Atuk’ (grandfather) would die soon, even though I did not know what cancer was back then,” said the 43-year-old freelance editor who only wanted to be known as Leen.

She remembered how resolute her grandfather was in fighting the disease and that he was able to accept the tragic fate that had befallen him. However, in his last days, the pain was too unbearable and Atuk could not smile anymore, she said.

When Leen grew older, her youngest aunt was diagnosed with the same cancer.

“My aunt wanted to get better but the disease worried her too much. She succumbed to the disease two years after diagnosis,” she said.

The word cancer naturally scares everyone and sadly the common perception is that “Your life may stop the day you are diagnosed”.

Fortunately, in spite of the rapid increase in the number of cancer cases, developments in medical technology have made it possible for doctors to diagnose cancer early, thus improving the chances for recovery.

Even when the cancer is at an advanced stage, there is still hope for treatment and a favourable outcome.

UM Specialist Centre (UMSC) consultant cardiothoracic surgeon Dr Sivakumar Krishnasamy said there was hope for cancer patients.

“We don’t give up on our patients easily without a thorough diagnosis and assessment. Thereafter, appropriate treatments are planned accordingly,” he said.

Citing a 42-year-old patient with stage four lung cancer who was referred to him, he said the man initially presented to the neurosurgeon with headaches and was found to have a growth in the brain.

A computed tomography (CT) scan subsequently also detected a growth in his right lung.

According to Dr Sivakumar, a multidisciplinary team consisting of the neurosurgeon, respiratory physician and oncologist was applied in his management and it was decided that the best treatment for him would be the removal of the lung tumour and radiotherapy for the single brain lesion.

“I went ahead and removed the lung tumour in January 2017, and today the patient is still alive and having a good life with his children. This tells you that even at stage four, there is still hope for (cancer) patients,” he told Bernama in an interview recently.

UMSC’s multidisciplinary team approach

UMSC prides itself in embracing a “multidisciplinary team (MDT) approach” in treating its patients. For lung cancer, the MDT consists of respiratory physicians, cardiothoracic surgeons, oncologists, radiologists and pathologists. The team convenes fortnightly to discuss cases that require attention and to find the best treatment solutions for the patients concerned.

“We think it is a crime if only one doctor takes it upon himself to manage the patient as different specialists may have a different view and approach to the disease.

“We come together, discuss and then decide on the best treatment options for the patient. We then present these options to the patient who ultimately decides which treatment he/she prefers,” explained Dr Sivakumar.

“Some patients may only need one modality of treatment, while others may require a combination of treatment modalities such as surgery, radiotherapy, chemotherapy, immunotherapy and targeted therapy,” said UMSC clinical oncologist Dr Adlinda Alip.

Being a university-based hospital, UMSC also offers options of numerous clinical trials investigating new treatments that may potentially benefit patients.

Explaining the journey of patients presenting themselves to UMSC, its consultant respiratory physician Dr Ernest Poh Mau Ern said patients with symptoms such as persistent cough would typically see a respiratory physician upfront.

After a thorough physical examination and checking the patient’s history, he will be sent for a basic chest radiograph. If an abnormality is detected on the chest radiograph, the patient may need to undergo a computed tomography (CT) scan or a positron emission tomography (PET)-CT scan.

For an accurate diagnosis of lung cancer to be made, a tissue biopsy will be arranged.

This can be done via a CT-guided percutaneous biopsy where a biopsy needle will be passed externally to reach the tumour (if it is located at the periphery of the lung) or via a bronchoscopy, where a scope will be passed through either the nose or the mouth into the airway to obtain a biopsy (if the tumour is located centrally).

The biopsy sample will then be handed over to the pathologist for processing and interpretation. Once the diagnosis and type of lung cancer are confirmed, the patient will be staged appropriately based on the scans and the case will be discussed at the MDT meetings.

Dr Poh stressed that these procedures are carried out rather quickly so that the best treatment options can be offered to the patient without any unwarranted delay.

Lung cancer statistics

Health Minister Datuk Seri Dr Dzulkefly Ahmad has been quoted by the media as saying that the three most common cancers among men in Malaysia were colorectal (16.4 per cent), lung (15.8 per cent) and nasopharynx (8.1 per cent).

The three most common cancers among women were breast (32.1 per cent), colorectal (10.7 per cent) and cervix (7.7 per cent). Lung cancer was the fifth most common cancer among women.

In 2014, the National Cancer Registry data indicated that over 4,000 cases of lung cancer were reported every year.

According to the latest World Health Organisation data published in 2017, deaths due to lung cancers had reached 4,644 in Malaysia, or 3.36 per cent of total deaths.

Explaining how cancer grows in the body, Dr Sivakumar said there has to be a stimulant or failure to suppress the cancerous gene.

This stimulant, according to him, can come from the external environment while the failure to suppress the gene can happen internally or originate from the external environment.

He confirmed that 85 to 90 percent of patients with lung cancer have been a smoker at some point of their life or have been exposed to people who smoke.

“There are many factors associated with lung cancer and many studies are still ongoing globally to investigate the causes,” he added.

Risk factors

Asked if genetics play a part, he cautioned that the risk for another member of the family to contract the disease is always imminent and the whole family has to take precautions and not take symptoms lightly.

“What’s more important here is the awareness of the symptoms and the mindfulness that (they) are at risk. That’s why we are trying to educate the people that there is always a risk for anyone else to get it in the family line,” said Dr Sivakumar.

National Cancer Registry and UMSC data also showed that the highest number of lung cancer cases were among the Chinese, followed by the Malays, Indians and other races.

Explaining this, Dr Adlinda said not all genetic mutations are hereditary in nature. For example, the epidermal growth factor receptor (EGFR) mutation has been seen in a sporadic manner amongst Asian patients.

This means that lung cancer can happen to anyone, even among non-smokers who have no family history of the disease.

Dr Poh pointed out that while smoking definitely increases one’s chances of getting lung cancer, other factors also contribute to increased risk.

These include a family history of cancer, genetics and exposure to second-hand smoke and asbestos. Lung cancer due to exposure to asbestos was seen in people who were doing roofing and tile works in the past when asbestos was widely used for insulation purposes.

Said Dr Poh: “We have to be careful not to make an assumption that just because one does not smoke, they are not at risk of getting lung cancer.

“Environmental factors such as air pollution, both outdoors and indoors, have long been a concern, with more research linking exposure to lung cancer. The crucial question is which pollutants may be responsible that can potentially inform regulatory action to improve air quality and public health.”

Symptoms and late detection

Dr Poh said symptoms may not be present in the early stages of lung cancer which explains why most patients usually present rather late in the disease.

Nevertheless, symptoms such as a prolonged cough, appetite loss, unintentional weight loss, coughing out blood, unexplained shortness of breath, back or joint pain, weakness of upper or lower limbs, headaches and visual disturbances should not be taken lightly.

“When you have a symptom that doesn’t seem to be going away, for example, a cough that has persisted for two weeks despite a visit to your family doctor, you should get specialist input on the matter. An early referral to a specialist may make all the difference in the world when it comes to respiratory diseases such as lung cancer,” he said.

Dr Sivakumar, meanwhile, said lung cancer is the most aggressive type of cancer where “it grows by the day” and most cases in Malaysia present at an advanced stage.

Dr Adlinda said early detection would definitely increase the odds for successful treatment, which in turn would increase the patient’s chances of survival.

“If they present late, treatment will be geared towards prolonging life and improving quality of life,” she added.

  • This is the first of a two-part article on lung cancer.