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mindyourbodyStraits Time 08 Oct 2009
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Dr Ang Peng Tiam for Mind Your Body
The medical director of Parkway Cancer Centre has been treating cancer patients for nearly 20 years.
In 1996, he was awarded Singapore's National Science Award for his outstanding contributions to the medical research.
He also recently published a book on patient stories, Doctor, I Have Cancer. Can You Help Me?, which has been translated into four languages.
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HIV and cancer
Telling someone he has cancer is no easy task for most doctors, but I have done it so often and for so long that I have my script well worked out for most possible scenarios. However, to tell a patient that he not only has cancer but also Acquired Immune Deficiency Syndrome (Aids) is a different ball game.
My first encounter was when I was still at Singapore General Hospital. The patient was a Chinese-speaking young man in his early 30s – well-groomed, polite and affable. He had stage four malignant lymphoma or cancer of the lymphoid tissue. He was treated with chemotherapy and had responded well.
At the time, we were considering a stem cell transplant for him. As part of the routine investigations, we tested him for antibodies to the human immunodeficiency virus (HIV).
It came as a complete shock to me when the laboratory called to notify me that he tested positive. “How could it be possible? There must be some terrible laboratory mistake. Maybe, he had a blood transfusion some time in the past that I didn’t know about.” I thought to myself as I steeled myself to call him into my office to get another blood sample.
“I’m so sorry but there seems to be some mistake in your recent blood test. The test for HIV was positive so we need another sample to clarify the matter.” I said.
His response was most unexpected. I assumed he would be shocked, angry or confused but he simply smiled and said, “Okay!”
Knowing that he was single, I asked if he had casual or commercial sex. He nodded and told me that he had been sexually active since his army days. He frequently visited a border town in Thailand. Over the years, he had engaged the services of about 50 prostitutes.
It is now a routine for every patient with malignant lymphoma to be tested for HIV. In the hundreds of lymphoma patients I have looked after, I can recall fewer than 10 who have tested positive.
Any lymphoma patient who tests positive for HIV is considered as having Aids. This is different from an asymptomatic patient who happens to be tested positive, as he would only be an HIV carrier and not necessarily have full-blown Aids yet.
Aids patient have an impairment of their immune system. This means that their immune system cannot keep the body’s well-being under surveillance, which makes them more prone to developing cancer.
The two commonest cancers in Aids patients are malignant lymphoma and Kaposi’s sarcoma. Other cancers that appear to be associated with AIDS include Hodgkin’s Disease (also a type of cancer of lymph nodes), and cancers of the mouth, lungs, cervix and digestive system.
The treatment of cancer patients with Aids poses special problems. These patients are prone to infections, which only strike those who are already weakened by their underlying illnesses. We also have to be careful not to be too aggressive with the treatment program.
HIV poses not only medical, but also policy challenges. An interesting problem, which used to frustrate me, was that foreign patients were barred from entering Singapore for treatment of their cancers once they are known to carry the virus.
Each time a patient is diagnosed with HIV in Singapore, the doctor is required by law to notify the Ministry of Health. In due course, the patient is blacklisted by the immigration authorities and prevented from re-entering Singapore.
I managed to convince the authorities that this did not make sense. We have millions of visitors to Singapore each year and there is no requirement for them to declare their HIV status at entry into Singapore. Some of these HIV carriers may indeed engage in illicit sex with locals and spread the disease. On the other hand, the cancer patients with HIV that do come have a genuine desire to seek medical care. To me, they pose a lower public health risk than tourists with HIV.
Thankfully, the Ministry has worked out a waiver on a case-by-case basis to allow foreign patients with HIV to come to Singapore for treatment. These patients are fighting two diseases, one of which is highly infectious. But for the patient, HIV is no different from cancer or any other disease – it too bears a crying need for treatment. Giving patients the same sort of choice appears to be the right thing to do.
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