Category: Health

Replacing Missing Teeth With Dental Implants

April 27, 2022 Return

WORDS RACHEL SOON

Like many couples, Shahreen Hazaline and Muhamad Shukor are a pair of complementary opposites; one bubbling over with energy and laughter, the other calmer and more soft-spoken. Yet both share similarly warm smiles when they look at each other. It’s hard to imagine that just over 3 years ago, in the middle of Shahreen’s fourth pregnancy, they found themselves facing her diagnosis of stage 3 breast cancer. For this HealthToday issue, they share their story of a road travelled together.

NOVEMBER 2014: SUSPICION

It was in the 12^th week of her pregnancy when Shahreen noticed the lump in her breast that wouldn’t disappear.

“I could feel something inside, like biji-biji (seeds).” She waves a hand over her chest as she recalls. “When people breastfeed, they sometimes get lumps because of mastitis or [blocked] ducts. But those usually go away if you rub repeatedly at them. This didn’t.”

What she found doubly strange was that she wasn’t even breastfeeding anymore by then; her third child had been weaned some weeks ago. Curious, she brought the matter up to her gynaecologist on her next routine check-up. Examining Shahreen, she scheduled an ultrasound that same day.

The lump appeared to be a liquid-filled cyst. Uneasy with the results, the gynaecologist referred her to a breast surgeon, who did a biopsy.

“The surgeon didn’t say ‘cancer’, just ‘something’s wrong’. But I already started to cry a lot. I cried as we walked by people in the hospital, like someone had passed away.” Shahreen mimics a dramatic wail, then laughs. “It was bad enough before with the hormone imbalance from pregnancy. My gynae referred me to a counsellor; I think she was alarmed at how upset I was.”

The surgeon recommended an operation to remove the lump when the baby was 16 weeks old and fully formed, to reduce any risks from anaesthesia. Alternately, they could wait until after the pregnancy, but there was a high risk the cancer—if it really was cancer—would progress rapidly in that time, especially due to Shahreen’s increased oestrogen levels.

Shahreen left the final decision to Shukor. His heart fell.

“I had to make a decision for two lives,” he tells me. “How could I let go of either one?”

In the end, they chose to go ahead with it. They felt that knowing the truth was better than uncertainty. And there was no ignoring the lump itself.

DECEMBER 2014: CONFIRMATION

A month later, they operated. The results indicated stage 2 breast cancer.

Shahreen was advised to start chemotherapy as soon as possible. Her doctors assured the couple that the baby would not be affected, as the drugs would not cross the placental barrier.

It was still frightening. They had never bothered to learn much about the disease. After all, she checked none of the usual boxes of risk factors: she had no family history, she was under 40 years old, she had breastfed all her children, she didn’t smoke or eat much junk food.

December was supposed to be their long-awaited umrah pilgrimage. But treatment couldn’t be postponed, the oncologist said, as the cancer could go far in 2 weeks. Neither could she start treatment before the trip; her immune system would be so weak that the crowds at Mecca would put her at risk of infections.

Instead of boarding a plane, Shahreen found herself entering the hospital’s cancer centre, where she saw a patient being wheeled out from a chemotherapy session. Right before her eyes, the woman abruptly vomited in the hallway. She wondered if that would be her eventually, too.

How did this happen? In her mind, thoughts overcrowded. Day and night, she couldn’t stop crying. Cancer is a taboo in Malaysia. How will people react to the news? What have I done wrong? Was it a sentence by God, a kind of retribution for something I’ve done?

In fact, just 2 weeks before, Shahreen had resigned from her job in the government and joined her husband to work as an independent unit trust agent. She wondered if other people would point fingers at things like that, saying she had brought the cancer on herself. Maybe it was sceptical of her, she says, but it was a real fear.

She asked Shukor to keep her diagnosis a secret. Only their respective parents and Shukor’s older brother were informed, and Shukor always obtained her consent first before telling anyone new.

At one point, she tried sending an email to the National Cancer Council Malaysia (MAKNA), the only cancer society she knew then.

“I told them about my diagnosis. They replied and asked for my phone number; they wanted to advise me.” Shahreen smiles. “But I backed off, because I was afraid.”

JANUARY–FEBRUARY 2015: STRUGGLE

Shukor did his best to support his wife in her isolation. She was scheduled for six cycles of chemotherapy up to April, each lasting 3 weeks.

“It was a very stressful time for her,” he tells me. “So I took her to the hospital whenever she wanted to go, stayed with her when she was admitted to the ward. I let go of a lot of other things to spend more time with her.”

It helped that their self-employment allowed some flexibility. Nevertheless, finances were a struggle. No longer eligible for a government employee’s medical coverage, Shahreen had a private medical card, but with how recently it had been obtained, she and Shukor would still need to pay for the first few hefty bills out of pocket first.

But there was little choice. She was pregnant and needed treatment as soon as possible.

“We had to tighten our belts. It definitely affected the time I had for the business. But if I was working under a company, I wouldn’t have been able to take so much leave.” Shukor’s smile is soft as he looks at his wife. “Because I was working independently, I could take care of her more.”

Was it frustrating for him at any point to be a caregiver? Shukor shakes his head.

“It was more a sadness. Everybody who has a life partner, a spouse … they already have things planned for their lives, right?” He takes her hand. “So when something like this happens, those dreams—you just keep them aside to deal with whatever is happening to her, right now.”

MARCH 2015: COMING TO TERMS

Things changed for Shahreen when she met another cancer survivor for the first time.

Her counsellor had advised her to come for a patient support group meeting at the hospital. But being afraid, she made up her mind to arrive late, hoping it would have finished without her and she wouldn’t have to actually talk to anyone.

“But when I arrived, as it turned out, the meeting had been cancelled.” She laughs. “The counsellor was like—’what a pity, she’s come all this way’ and tried to find something else for me.”

Coincidentally, there was an ongoing art exhibition in the hospital by Elaine Therese Lim, a painter who had survived ovarian cancer. The counsellor introduced Shahreen to her and left them to talk.

“So we chit-chatted … and I told her all the things I was feeling. And she said to me: the fact you got this disease isn’t because God wants to punish you, or that you’ve made a mistake. None of that. If God wants to give it, anyone can have it. There’s no need to think so hard on the reasons.”

It was like a weight lifted from Shahreen’s shoulders.

“After meeting her and being comforted by her, I felt really good. It was the first time I’d met a cancer survivor. And I started to accept the fact that … okay, I’ve got this. Fine. So get through it.”

A few days after that encounter, Shahreen opened her Facebook page and posted, for the first time, a status update acknowledging she had cancer. Dated 15^th March 2015, it begins with: “God always has a better plan.”

“To my surprise, there was no negative feedback,” she says. “All of my friends just gave encouragement and support.”

It emboldened her and removed her doubts. In subsequent posts, she wrote all the details down: about her disease, about the chemotherapy she was going through, about the ‘chemo baby’ she carried.

“After meeting Elaine Therese, I thought: why not share these things?” Shahreen smiles. “I thought it might help someone out there who needed—not the medical details, but the knowledge that it can be done, even during a pregnancy. Maybe one of the reasons God gave me the cancer was so I could do that.”

APRIL 2015: DELIVERY

At the end of April, Shahreen’s fourth child, Zhafran, arrived with no complications. To her relief, she was able to give birth to him naturally as she had her other three children; as her gynaecologist had promised, the chemotherapy had no effect on that.

She shows me a phone photo of a healthy, chubby-cheeked young boy sitting in front of a plate of cake.

“Alhamdullilah, he’s okay. He turned 4 on 28^th April this year.” She beams as she swipes through more photos of her son’s birthday celebration. “In fact, when I gave birth to him, he was around 3.85 kg! That’s normal for our family. My eldest was around 3.95 kg.”

Unlike most pregnant women, Shahreen’s overall weight had remained unchanged for months until her delivery date. Her body had been shrinking while her son’s had been growing.

Two weeks after Zhafran’s birth, Shahreen left him in the care of a friend while she underwent a positron emission tomography (PET) scan and a second operation on her lymph nodes. Due to the involvement of radioactive particles, she wasn’t allowed to be near her son for some days.

After the operation, based on the number of affected lymph nodes and the size of her tumours, the doctors modified her diagnosis to stage 3 breast cancer, which initially shocked her. Hadn’t she been doing chemotherapy all this time? But it was explained that the initial diagnosis had been incomplete as they couldn’t assess more than the breast lumps while she was pregnant.

Furthermore, many cancer cells in the lymph nodes were dead, which meant the chemo was working. Shahreen would still have to go through another four cycles of chemotherapy on a different medication, with an additional month of radiotherapy, but there was hope.

To her disappointment, unlike with her previous three children, this meant she would not be able to breastfeed her newborn son for his first year. Patients undergoing chemotherapy were generally recommended to wait until 6 months after their final cycle to prevent health risks to the child.

“Even with a pill to suppress the milk, it would just come out, and I would have to let it be.” Shahreen pauses, for once without a smile. “You have to understand … I breastfed my first three children until all of them were 3. When it’s something so natural to you, to have to just wipe or throw it all away … it felt very sad.”

MAY 2015, AND ONWARDS: LIFE GOES ON

When I ask if they had childcare issues, the couple exchange looks and laugh.

“He can cook very well!” Shahreen says proudly. Shukor is more self-deprecating and explains that they had a hired helper to take care of the children. Though yes, he did cook as well.

With her eldest being 8 at the time, the couple aren’t sure the children understood what their mother’s illness meant, even with her weight loss, her falling hair and eventually (with Shukor’s help) her shaved scalp.

“We explained to them that mum was ill. But for them, ‘being ill’ normally meant having a fever for a little while and then getting better, right?” Shukor says. “Something like cancer, that goes on for months … it was a bit harder to understand, I think.”

Shahreen thinks that the sense of normalcy was also helped by the fact that she never had to stay at the hospital for more than 2-3 days at a time, even during her initial cycles. By the third cycle, she was asking the oncologist about going back to work, and got the green light based on her blood count and her physical condition.

“I was bored staying at home and not going anywhere. So I would do chemo, and after 2-3 days I would just go out and work. The children didn’t seem to notice a difference.” Shahreen raises an eyebrow. “Is that a good or a bad thing?”

One of the things Shukor also had to handle was a barrage of well-intended recommendations for alternative treatments from others. He tried to filter through them with the help of Shahreen’s doctors and friends of his own who had medical backgrounds.

One of them, who had done research in the field of alternative medicine, explained to the couple that clinical research was a multi-stage process, and some products labelled as ‘clinically researched’ might have only been tested in animals.

“After learning more about it, I thought it’s better to follow what the doctors said.” Shukor smiles. “Especially because she was pregnant, I didn’t want to take the risk on whether the hospital’s medicines and alternative ones would complement or fight each other.”

DECEMBER 2015: REMISSION

Thirteen months after her diagnosis, the doctors declared Shahreen no longer needed treatment. She was to come in for a follow up every 6 months; in 2018, the oncologist changed it to once a year.

Even though it’s been more than 3 years, they still feel the difference in their lives.

“When you’re healthy,” Shukor says, “you feel like you’re going to live till 60 or 70 years old. But when something happens, you feel like your life will be shorter … everything we planned for the long term needed to be adjusted.”

“Before this, we used to think: okay, we have a lot of time, we can do whatever whenever, next year, or the year after,” Shahreen adds. “Like—when I was in secondary school, I was a hiker. But after getting married, I just stopped, thinking that’s something from the school days, no time for that now.”

In 2017, Shahreen hiked up Mount Kinabalu with a group of fellow survivors. It was one of over 10 mountains and hills she tackled that year. She also launched herself into things she had never considered doing before, like dragon boat racing and bowling with others from the Breast Cancer Welfare Association (BCWA).

“At university, I used to work part-time at a bowling alley. We had free games, but I never played, always thinking ‘oh no, what if my ball goes in the drain and people laugh at me?’” Shahreen grins. “But now I’m more open to whatever happens. ‘Just do it!’ Us survivors, we feel like we have a second chance. There’s so many more things we want to try.”

I ask if the two of them have advice for those starting their own cancer journeys, or with loved ones doing so.

“Don’t wait,” they both say.

Shahreen tells me about stories from her support groups; people would delay their treatment, looking for alternatives, only to come back when the cancer had progressed even further. It was ironic, she says, that people were willing to entrust hospitals with a credible diagnosis of their condition, but not with credible treatment.

To friends and family of patients, the couple also advises that they not add too much stress to the patient, and instead try to find means of emotional support.

“When someone has cancer, they’re already weighed down by heavy thoughts,” says Shukor. “Things like how easily the cancer can spread, or when they’re going to die.”

“The easiest thing you can do is to find them a support group, whether on Facebook or elsewhere. Those groups have survivors, even doctors,” Shahreen adds. “A patient can sometimes be afraid of taking that step. Help take them there.”

“Also? Don’t Google everything.” They laugh together. HT

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STOP! For goodness sake

April 25, 2022 Return

WORDS PANK JIT SIN

If you’re wondering what it is I’m asking you to stop, well, it’s smoking. I recently had a friend pass away from lung cancer. He had stopped smoking for 8 years by then and picked up healthy exercise habits. It wasn’t enough and after 3 years of battling the disease, he succumbed on 2^nd August this year. Smoking is very much a man’s disease as many more men smoke compared to women. The World Health Organization (WHO) puts the number of smokers at 1 billion—800 million are men and 200 million are women. As November is Men’s Health Awareness month, let’s see what we can do to help smokers quit. HealthToday speaks to reader Keo Chia who managed to kick the addiction some years back. Smoking cessation comes with many benefits, among which are improvements in lung function, reduction of cardiovascular disease risk and reduction of cancer risk.¹

Keo during his interview.

It’s not you, it’s me

We asked Keo what his main driver was behind the decision to quit. Was it his children? Was it his wife? Or was it his health? He says, “I tried quitting cigarettes a few times before finally succeeding. Before that, I couldn’t last more than 1 or 2 days before the overwhelming urge to smoke took over.”

Things stayed the same with Keo trying to quit smoking once every few months due to nagging from his family or urging from friends. This constant trial-and-failure cycle is a typical trait of those looking to quit smoking. According to the US Centers for Disease Control and Prevention (CDC), a smoker tries to quit between eight and 10 times before succeeding. However, a 2016 Canadian study says it could take a smoker almost 30 trial-and-failure cycles before finally winning the fight against smoking.²

Things remained pretty much the same until one day, Keo got fed up of failing and told himself, “I WILL quit this time.” Instead of going cold turkey or cutting down on cigarettes like he did previously, Keo decided to use a nicotine patch. He approached a pharmacist near his home and received some counselling on how to use them.

The first time he put the patch on, Keo discovered he was feeling nauseous and dizzy. “I thought I was sick,” he says. However, the patch worked, and he didn’t feel the urge to smoke at all. The symptoms went away gradually over the next few days and he used the patch for 2 weeks.

After 2 weeks, Keo cut the patch into two, effectively halving his dose. This is not recommended, as suddenly halving the nicotine dose could trigger an urge to smoke. Ideally, he should have purchased the patch with a slightly lower dose to reduce the risk of smoking relapse. Luckily, Keo did not face this problem. Again, he wore the patch, this time closer to 3 weeks. When he felt he was ready, he again reduced the dose by half. At the end of 2 months, he could go without cigarettes and even without the patch!

It was the happiest he had been for a long time. There was a sense of achievement and overwhelming pride that he no longer needed to subject his new family (he had just settled down and had a baby by then) to secondhand smoke exposure. He says, “Remember, the decision to quit must come from yourself. Until you make that decision, the urging and nagging by others won’t work.”

It is an addiction

More evidence is emerging that a lot of our vices is the result of an imbalance in our brain’s chemicals. Cigarettes contain nicotine and many other chemical compounds. While we tend to think nicotine is the only addictive substance found in cigarettes, a 2007 study discovered that many additives in cigarettes enhance the addictive nature of nicotine and some mask the side effects, thus making it more pleasurable to the smoker.⁶In the study, the scientists arrived at the conclusion that “documented cigarette additives have pharmacological actions that camouflage the odour of environmental tobacco smoke from cigarettes, enhance or maintain nicotine delivery, could increase addictiveness of cigarettes, and mask symptoms and illnesses associated with smoking behaviours.”

It is, therefore, no wonder that smoking is so hard to quit once a person begins. Of course, one could say that smokers shouldn’t have started smoking in the first place, but we all make mistakes. The most important thing to do now is to focus on what can be done to help a smoker should they decide to stop.

While the nicotine patch is a commonly used smoking cessation tool, there are other options out there. Another example is the nicotine chewing gum. For some smokers, the action of putting cigarette into the mouth is a harder habit to break than the actual act of smoking. The act of chewing gum can help to attenuate this condition and also prevent the weight gain associated with this behaviour.

If both the patch and gum are not helping, there’s also the option of taking a pill known as varenicline. This is a prescription medicine and may affect the mood of the person. This is because it affects the reward pathways of the brain, preventing one from getting any pleasure from smoking. One should seek a doctor’s advice before embarking on this option.

Smoking and cancer are definitely linked

When a cigarette burns, it releases 5,000 to 7,000 chemicals, of which about 60 are known cancer-causing agents. Apart from nicotine, these include tar, ammonia, acetone, methanol, butane, and hexamine.^3,4

We often think about lung cancer when talking about smoking. However, there are many other cancers which are linked to cigarette smoke. These include cancers of the mouth and throat; oesophagus, colon and rectum; bladder, kidney, stomach, and cervix. If we think about it, the chemicals from cigarette smoke stay in our mouth and as we swallow, they pass through the throat, into the stomach and come into contact with every part of our digestive system. Those of us who don’t smoke can always tell if the person using the toilet before us is a smoker based on the smell left behind after they urinate.⁵

Relapse

Just like any other addiction, a person who has quit smoking can relapse and pick up cigarettes again. Some people ‘slip’ during their journey to smoking cessation. This means the person sneaks a cigarette or a puff. This isn’t considered a relapse. Relapse refers to a return to regular smoking.⁷

It is important not to be judgmental about smokers who relapse. If you’re a smoker, remind yourself that this is a temporary setback and don’t look at yourself in a negative light. Remember that it is a battle with addiction and many battles will have to be fought before the war can be won. Even before a person starts his or her smoking cessation journey, it is helpful to know what happens should a ‘slip’ or relapse occur.

Did you know?

The nicotine patch does come with its own set of problems. Some side effects users often face include skin irritation, nausea, headache, vomiting, and diarrhoea. These symptoms are usually manageable and can be acceptable if the user is mentally prepared and properly counselled.

Did you know?

Lung cancer is the most common cancer occurring in men and the third most common in women. Approximately 2 million people were diagnosed with the disease in 2018.

Did you know?

Your risk of developing lung cancer takes many years to return to normal after stopping smoking? In total, it takes about 15 years before the risk of developing lung cancer drops to that of a person who has never smoked.⁸HT

References:
1.https://www.who.int/tobacco/quitting/benefits/en/

2. Chaiton, M., et al. (2016). Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open;6:e011045.

3. Cancer Research UK. What’s in a cigarette? Retrieved from https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/smoking-and-cancer/whats-in-a-cigarette-0.

4. Irish Cancer Society. What’s in a cigarette? Retrieved from https://www.cancer.ie/reduce-your-risk/smoking/health-risks/whats-in-cigarettes#sthash.zAwkOexD.dpbs.

5. Siegel, R.L., et al. (2015). Deaths Due to Cigarette Smoking for 12 Smoking-Related Cancers in the United States. JAMA Intern Med;175(9):1574–1576.

6. Rabinoff, M., et al. (2007). Pharmacological and chemical effects of cigarette additives. Am J Public Health;97(11):1981–1991.

7. Smokefree.gov. Slips & Relapses. Retrieved from https://smokefree.gov/stay-smokefree-good/stick-with-it/slips-relapses.

8. World Cancer Research Fund. Lung cancer statistics. Retrieved from https://www.wcrf.org/dietandcancer/cancer-trends/lung-cancer-statistics.

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A Cancer Among Men

April 25, 2022 Return

WORDS HANNAH MAY-LEE WONG

Dr Hemanth Kumar Ramasamy

Consultant Urologist & Laparoscopic Surgeon

Following this month’s theme and focus on men’s health, Dr Hemanth delves deep into the topic of prostate cancer, one of the most common types of cancer in men.

The prostate, an organ found exclusively in men, is roughly the size of a walnut. It is a gland that produces seminal fluid, which protects, nourishes and helps transport sperm. “The prostate makes 30% of semen. These fluids are essential for the sperm to survive when it is being sent to the female vagina. It’s got lots a minerals and nutrients for the health and wellbeing of the sperm,” Dr Hemanth explains.

Although the prostate plays a vital role in male reproductive process, prostate cancer rates have been on the rise, and this is certainly an issue men should take note of. Dr Hemanth tells us more in detail.

How common is prostate cancer among men in Malaysia?

From a global perspective, prostate cancer rates are the lowest in South East Asia compared to the rest of the world. Prostate cancer is quite common in the UK, and very common in the US. It is also seen more frequently among the African and American black population.

“Prostate cancer has risen to become the 3rd most common cancer among men.”

In Malaysia, data from the 2007-2011 Malaysian National Cancer Registry Report showed that only six in 100,000 people developed prostate cancer, making it the 5th most common cancer among men at the time. It’s worth noting that in the past, there were fewer urologists, screening tools and overall less awareness on the disease. A recent study conducted by the Malaysian Prostate Cancer Study Group (M-CaP) in 2018, found that prostate cancer has risen to become the 3rd most common cancer among men, occurring in every 12 per 100,000. The breakdown of demographics showed that prostate cancer is most common among the Chinese population, followed by Malays.

Urologists deduce that some of the reasons for the rising numbers could be attributed to: men in Malaysia living longer lives, our shifting diets towards a more western palette (the exact reason for this is still unknown, however studies have shown that a western or meaty diet increases the risk of developing prostate cancer). For example, Japan is a country where prostate cancer incidences are very low. But when we look at the Japanese that have migrated to the US (especially those who are 2nd generation migrants), we notice that their incidences are higher than the Japanese men living in Japan. Therefore, prostate cancer risk could have lots to do with environmental factors.

What are the risk factors of prostate cancer?

The most common risk factor is age. 80% of prostate cancers are picked up after the age of 60, and prostate cancer in men below the age of 45 is rare.

Genetics could be a factor. Prostate cancer is more common in African Americans and Caucasians, and less common in the Asian population.

Family history is very important. If a man has a 1st degree relative who has prostate cancer (like dad or brother), his risk of developing prostate cancer may be higher, and familial prostate cancer tend to appear earlier.

What are the signs and symptoms of prostate cancer?

This depends on which stage of prostate cancer a man is in. In the early stages, there could be no signs and symptoms. Some cases of prostate cancers are accidentally picked up during routine screening tests.

Some men may get symptoms of the lower urinary tract such as: difficulty in passing urine, having a burning sensation during urination, going to the toilet more often, dribbling after urination and so on. These could be the early indications of prostate cancer, but most of the time, these symptoms are associated with benign prostate hyperplasia (BPH)—an enlarged prostate, which is much more common in Malaysia.

For those with late stage prostate cancer where metastasis has occurred, they may get symptoms mainly associated with the bones, as the bones are commonly where the prostate cancer first spreads to. Prostate cancer lesions in the bone are very typical—they’re called sclerotic lesions and can be picked up relatively easily.

How often should men get their prostate checked? What are the tests available?

With the rising awareness of prostate cancer, screening is becoming more common. Usually, screening can be done in men who are above 50. Patients who have relatives with prostate cancer can opt to do screenings from as young as 45.

Screening is done via a prostate- specific antigen (PSA) test and rectal examination. When a screening programme is carried out, a couple of other tests are usually included, namely: the urine test, ultrasound and uroflow (to test urine flow for possible obstructions). Urologists also would take a detailed clinical history and may ask the patient to complete the International Prostate Symptom Score (IPSS) questionnaire.

What are the treatment options for prostate cancer?

A patient’s treatment plan would depend on several different factors including the patient’s age, the aggressiveness of his cancer and whether the cancer has spread. A trans-rectal ultrasound biopsy is usually done if the possibility of prostate cancer is picked up by a PSA test or rectal examination. It involves using a specialized probe which is put through the rectum, and biopsy samples may be taken through a needle. Small cuts of samples are taken from 12 different areas of the prostate, and these are sent to a pathologist for determining the aggressiveness (grade) of the cancer cells. Several other scans, such as bone scans, MRI or CT scans may be used to determine if the cancer has spread beyond the prostate.

Surveillance

For low-risk patients, doctors can offer patients active surveillance. Treating too early may result in complications of treatment such as erectile dysfunction, incontinence, issues with passing urine, blood in the urine, etc. That’s why for patients in this category, doctors may try to delay treatment as much as possible. During active surveillance, the patient sees his doctors every 3 months for follow-up rectal examinations and blood tests. Every 1 year to 18 months, a urologist may perform another biopsy to monitor the cancer’s progress. If signs show that the cancer is progressing, the patient may opt for treatment.

Watchful waiting is another option, for patients with a less aggressive cancer or for those who are advanced in age.

Radiotherapy & Surgery

For intermediate and high-risk patients, definitive treatment options such as radiotherapy or surgery are available. Radiotherapy can be divided into external beam radiation and brachytherapy. With external beam radiation, radiation comes from outside the body and is directed to the prostate cancer. With brachytherapy (there’s a certain criteria for patients who are suited for it), radioactive seeds are placed into the prostate, and these seeds deliver low doses of radiation over time to kill cancer cells. The surgical option is called a radical prostatectomy. It can be done as open surgery or via robotic prostatic surgery.

Hormonal Therapy

For patients who have locally invasive and metastatic disease, they can consider hormonal therapy. Prostate cancer is fuelled by testosterone, and hormonal therapy is used to cut down testosterone levels in the body—in doing so, cancer cells may die off. Sometimes, hormonal therapy may be given to those with locally invasive disease, to shrink the tumour first, before going for radical surgery. If the newer hormonal therapies don’t work for patients with metastatic disease, they can choose to go for chemotherapy.

In summary, patients should work with their doctors to choose a treatment plan most suited to their condition. HT

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Venom From A Deadly Spider: A Solution For Erectile Dysfunction?

8 Supplements That May Be Helpful In Dealing With Pain Due To Nerve Damage

April 25, 2022 Return

WORDS LIM TECK CHOON

The Brazilian Wandering Spider (Phoneutria nigriventer) is known as one of the world’s most venomous spiders for a good reason. Its venom can cause its victims to experience paralysis, shutdown of the nervous system, irregular heartbeats, and often, death. It also causes painful, prolonged erections in men. Yes, you read that correctly.

Always the type to look at silver linings, a team of researchers in Brazil recently managed to create a substance similar to PnTx2-6, a component of the venom, in hopes of developing a medication for erectile dysfunction that can be used safely by men with diabetes and high blood pressure.

You see, erectile dysfunction is commonly seen among men with those two health conditions, but currently available medications may not be an option for them. Tadalafil, for example, should not be taken alongside nitrate medications for heart problems, as this may lead to sudden and serious drops in blood pressure.

So far, research on mice with induced diabetes and high blood pressure found that the synthesized substance, called PnPP-19, does work to restore the ability to have an erection. This effect is seen when PnPP-19 is applied topically (on the skin) as well as injected directly into the mice.

More research is needed to support this finding and to determine whether the same effect will be seen in humans. Still, it’s a testament to the marvel of nature that a deadly toxin may end up providing a solution for the happiness of human beings! HT

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Reference: Nunes da Silva, C., et al. (2019). PnPP-19 peptide restores erectile function in hypertensive and diabetic animals through intravenous and topical administration. J Sex Med;16:365–374

Watch Out For Fake Dentistry

April 25, 2022 Return

Dr Andrew Chan Kieng Hock

Consultant Oral Surgeon

Private Dental Practice Klang, Selangor

Fake braces done by a bogus practitioner. (Photo by Dr Andrew Chan Kieng Hock)

The issue of fake or illegal dentistry is a current phenomenon which is becoming more rampant in Malaysia. Its emergence can be attributed in large part due to the advent of social media platforms such as Facebook, Instagram, WhatsApp, and YouTube. The problem is more real and pressing than it would appear at first glance. One notable and memorable incident happened in 2017 where an individual who reportedly learned to carry out orthodontic treatment (dental braces) by watching YouTube videos was arrested, fined RM70,000, and subsequently released after the fine was paid through a crowdfunding exercise initiated by a non-governmental organization.^1,2 This is not an isolated case, as there have been numerous cases of other convictions as highlighted by the mainstream media. In this article, Dr Andrew Chan Kieng Hock discusses what constitutes fake dentistry, how to spot fake dentists, and the adverse effects related to fake dentistry.

What Is Fake Dentistry?

Fake or illegal dentistry is a broad term which may include providing dental procedures or services by an unlicensed, unqualified or uncertified individual in a premise that may or may not be licensed. The definition can also include using unlicensed products sold by unregistered dental dealers locally or overseas, on the patients or customers.

Under the newly amended Dental Act 2018, every practicing dentist— whether working in the public or private sector—must be registrable with the Malaysian Dental Council (MDC) and must possess a valid Annual Practicing Certificate (APC). The APC is subject to annual renewal when the practitioner has accumulated sufficient Continuous Professional Development (CPD) merits, which are regulated by MDC.

In addition, all dental treatment must be carried out in a clinical or healthcare environment that is registered under the Private Healthcare Facilities and Services Act (PHFSA) 1998.³ Under this Act, anyone convicted of practicing illegal dentistry can be fined up to a maximum of RM300,000 and/or face imprisonment for up to 6 years.

How to spot fake dentists?

The modus operandi of most fake dentists includes:

Enticing victims by offering services with fees very much below the market prices charged by professional dentists. They usually advertise their services via social media platforms, flyers, posters, business card, or by word of mouth.
Operating in secretive or dodgy premises such as hotel rooms, homes, shop lots, markets, or even inside beauty salons. They frequently change the locations in order to avoid detection by enforcement officers.
Using dirty or rusty instruments which demonstrate the unhygienic conditions of the workplace or the low quality of the products, which are often purchased from e-commerce websites.
Not displaying or revealing their qualifications when probed.

The adverse effects of fake dentistry:

The treatment provided is substandard and often result in harmful and adverse side-effects.
Monetary losses as patients have to pay extra fees to seek retreatment from a legal dentist to rectify the damage inflicted.
Increased health risks including death due to the unhygienic instruments used. Infection control is often compromised, thus subjecting patients to the risk of serious infection, including HIV/AIDS, hepatitis B and hepatitis C.

The prime motivator of fake dentistry is money. Numerous people have been victimized by fake dentists due to pure ignorance and attraction to the huge discounts offered. The Ministry of Health Malaysia together with several dental bodies and stakeholders have been doing active roadshows and forums to warn the public regarding this issue.

Our enforcement agencies have been aggressively nabbing and convicting them with serious punishment. Hopefully, with all these measures taken, there will be fewer people being duped by bogus dental providers in the future because the consequences, as discussed, can be grave, including loss of money and general health. HT

Fake veneers done by a beautician. (Photo by Dr Andrew Chan Kieng Hock)

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References: 1. The Star Online. Fake dentist grinning from ear to ear. Retrieved from https://www.thestar.com.my/news/nation/2017/10/10/fake- dentist-grinning-from-ear-to-ear-the-quacks-now-ive-got-fame-says-vocational-student-who-got-of. 2. The Star Online. Group denies helping to pay bogus dentist’s fine. Retrieved from https://www.thestar.com.my/news/nation/2017/10/10/group-denies-helping-to-pay-bogus-dentists-fine. 3. Attorney General’s Chambers of Malaysia. Private Healthcare Facilities and Services Act 1998 [Act 586]. Retrieved from http://www.agc.gov.my/ agcportal/uploads/files/Publications/LOM/EN/Act%20586%20KU%2028.12.2015.pdf

GETTING REAL ABOUT RABIES

October 22, 2020 Return

WORDS LIM TECK CHOO

Facts about Rabies

It can come from a bite. The rabies virus is spread through infected saliva. When an infected creature bites through your skin, the virus can enter the body through infected saliva.
It’s bad for the brain—really bad. Once it enters the body, the rabies virus can quickly move via the bloodstream to the brain, where it can cause swelling and inflammation. If left untreated, this can be fatal. Most deaths from rabies occur among children.

Does Your Dog Have Rabies?
In popular media, a dog with rabies is often portrayed as foaming excessively around the mouth, but things are a little more complicated in real life. It may not be easy to tell from a glance whether a dog has rabies. There is a window of time after infection when an infected creature will not show any symptoms of illness, but could still infect other mammals in the meantime.

We can get a clue that something is wrong with our canine pet, though, if it begins to behave in a strange manner. For example, they may become more timid and move more slowly. In fact, it is more common for dogs with rabies to behave this way, compared to the stereotypical aggressive, barking behaviour shown in popular media!

The rule of thumb here is to bring our pet to a veterinary physician for a check-up if we suspect that it may be infected by rabies.

Alternatively, vaccinate our pet every year with the rabies

vaccine, and we’ll have nothing to worry about!

If we spot any stray dogs behaving strangely, especially during a rabies outbreak, we should report them to the city council. In our report, we should include description (colour, species, etc) as well as location of the stray.

How to Protect Your Dog from Rabies during an Outbreak

Vaccinate your dog.
Keep your dog isolated in your house compound (no going out!), so that it will not come into contact with potentially infected dogs. Isolation is necessary even after receiving a vaccination, as a dog still needs some time after a jab to build up the necessary immunity against rabies.

What If Your Dog Has Rabies?
Unfortunately, at this time there is no effective cure or treatment for rabies. Rabies is almost always fatal; infected dogs will succumb to the disease less than a week after showing signs of infection.

Prevention is the only way to protect our dogs. The vaccine offers protection for about a year, so the rabies vaccine should be given to our dogs once every year.

What to Do If You Had Been Bitten by a Rabies-Infected Dog
Don’t panic. Health experts say that the most important

thing to do is to clean the wound with soap and running water for 10 to 15 minutes.

Then, visit the hospital right away, and inform the doctor that you have been bitten by a dog.

Children may not voluntarily inform adults that they have been bitten by a dog, so if you suspect that their injury is a dog bite, ask them for confirmation first. Wash the wound as described above and send them to the hospital immediately after.

USING VIRUSES TO IMPROVE OUR GUT MICROBIOTA

July 01, 2020 Return

Our digestive tract contains tens of trillions of microorganisms, comprising the gut microbiota. It is well known that they play a role in our health. If the population composition favours microorganisms that play a role in supporting our digestion and protection from infectious diseases, all is well. What if we do have a direct way of influencing the composition of gut microbiota? Researchers from San Diego University, USA, believe that the answer to this is through the use of viruses that affectbacteria, or prophages. Prophages exist in an inactive state in the gut. There are many types of prophages, each type affecting only one specific type of bacteria. Therefore, what the researchers seek to learn are the triggers that would cause a certain type of prophage to become active and kill a specific type of bacteria. While research is still in its early stages, the possibilities are intriguing indeed. Just imagine: if we have too many of a harmful type of bacteria in the gut, we can consume a type of food that would trigger prophages to kill that bacteria without harming the beneficial ones in the gut. This could be a game-changer in our efforts to cultivate a thriving healthy gut microbiota.

Reference: Boling, L., et al. (2020). Dietary prophage inducers and antimicrobials: toward landscaping the human gut microbiome. Gut Microbes, doi: 10.1080/19490976.2019.1701353

Toothbrushes: Manual Or Electric?

March 19, 2020 Return

WORDS PANK JIT SIN

If you are like everyone else who practices good dental hygiene, you’ve probably brushed your teeth this morning. Which toothbrush did you use? It is safe to assume most of us use a manual toothbrush. I recently went for a regular dental checkup and was told my gums were receding. My dentist advised me to get an electric toothbrush as it would prevent my gums from receding further. Having recently seen a video of how manual toothbrushes were better at removing dirt than electric ones, I was somewhat confused. So, what does a good writer do? We do some research. Here’s what I found.

Electric may be better
According to a scientific review, which looked at 51 studies with about 4,600 participants, electric toothbrushes are capable of significantly reducing plaque over short- and long-term use.¹ Similarly, electric toothbrushes reduce the risk of gingivitis more than manual toothbrushes in the short and long term.¹ However, as it is a review of existing studies, the strength of the review was considered to be of moderate quality. This means it isn’t a foregone conclusion and further research may change the situation. For now, it looks like electric toothbrushes are better than manual ones.

It can get a little confusing though, as not all electric toothbrushes are equal. There is a difference even within electric toothbrushes. It appears that electric toothbrushes that oscillate and rotate (makes circular motions) are better at cleaning plaque than those that create side-to-side movements.

I asked Dr Catherine Chong, a dentist in private practice, on how to determine which toothbrush is better. According to Dr Catherine, electric toothbrushes are indeed better. However, some people do just as well with manual toothbrushes. She recommends the use of plaque disclosing tablets to determine which toothbrush is more effective for an individual person. She says a person can perform a simple test of using a manual toothbrush to clean their teeth and then using the tablet to check for plaque remnants. Then the next day, the person can try brushing their teeth with an electric toothbrush and testing with the plaque disclosing tablet again to see the amount of plaque left after brushing. The difference will allow the person to decide which is best for him or her.

DID YOU KNOW?
Plaque disclosing tablets are chewable tablets that stains plaque on teeth. It is usually made of vegetable dye that makes the plaque stand out and is either red or blue in colour. Although it isn’t a common item, these tablets can easily be purchased online.

Manual Toothbrushes
Manual toothbrushes are much cheaper than electric toothbrushes. They usually range from a few ringgit to tens of ringgit, depending on their unique selling points. Generally, toothbrushes are divided into soft, medium and firm bristle types. But within these three types are the numerous designs, angles, and materials that go into the bristle production.

How about the measurements of the toothbrush and bristles? A Korean study says the length of the bristle head should be 2.14 to 3.05 cm for men and 2.09 to 2.96 cm for women. The length of bristles should be 1.07 cm for men and 1.03 cm for women. The width of the toothbrush head should be 7.7 mm. Finally, the neck of the toothbrush should be 3.13 cm for men and 3.0 cm for women.² While the study was done on Koreans, they should not stray too far from our measurements as they are also Asian in terms of size.

While this may sound confusing, the best advice would be to test out a few types of toothbrushes and find out which one fits you the best.

Electric toothbrushes
Electric toothbrushes are less common but are seeing better uptake in recent years. As mentioned earlier, some models oscillate and rotate while others only move in a singular side-toside motion. While the hard work of manual brushing is already done by the motor of the toothbrush, the highspeed movement and vibration of the device can still cause damage to gums and teeth if the user is not careful.³

“THE BEST ADVICE WOULD BE TO TEST OUT A FEW TYPES OF TOOTHBRUSHES AND FIND OUT WHICH ONE FITS YOU THE BEST”

Specific types of toothbrushes
Beyond the usual round or oblong toothbrush heads we are used to, there are some uncommon types in the market. First is the interdental toothbrush, which is good for cleaning between teeth and dental braces.

We also have end-tufted toothbrushes which are specially made to clean the wisdom tooth area and also crooked teeth with odd angles that are hard to reach using normal toothbrushes.

Whichever toothbrush you choose, remember it doesn’t negate the recommended twice-yearly visit to your dentist. Regular visits to the dentist not only ensure your teeth and mouth are in good condition, it will also help doctors detect abnormalities early. These includes receding gums, oral cancers, dry mouth, fungal infections, and taste impairment.

A dentist also trained to look at the muscles of the head, neck, jaw, tongue, salivary glands, and the nervous systems of the head and neck. They can quickly refer the patient to a specialist if they suspect there is something serious going on. HT

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References:References: 1. Yaacob, M., et al. (2014). Powered versus manual toothbrushing for oral health. Cochrane Database Syst Rev;(6):CD002281. 2. Chun, J.A., et al. (2014). The Standardization of Toothbrush Form for Korean Adult. Int J Clin Prev Dent;10(4):227-235. 3. University Health Service – The University of Hong Kong. Types of Toothbrushes. Retrieved from http://www.uhs.hku.hk/he/msg/doc/201206e.pdf.

‘ACTing’ Mindfully On Anxiety

March 19, 2020 Return

WORDS HANNAH MAY-LEE WONG

Dr Phang Cheng Kar

CPsychiatrist Sunway Medical Centre

A psychiatrist and mindfulness-based therapist expands on the topic of anxiety, a crippling yet common mental health issue. He also explains how Acceptance and Commitment Therapy (ACT) can work as a treatment option for those with anxiety disorder.

How would you define anxiety disorder?
Anxiety symptoms are part and parcel of life. For example, it’s normal to feel anxious when you have a deadline for an assignment approaching. Having anxiety disorder on the other hand, means to have anxiety symptoms (fears, worries, and psychosomatic symptoms) that are more intense and frequent, to the extent that it interferes with a person’s daily activities such as job performance, school work, and relationships.

What are the more common causes of anxiety disorder?
The common mental disorders under the anxiety category that I encounter in my adult psychiatric clinic are: panic disorder, agoraphobia, generalized anxiety disorder, and social anxiety disorder. It’s also common for anxiety to occur with depression. The causes of these are multifactorial— it could be biological (caused by hormonal disorders such as thyroid problems, or stress from a physical illness like cancer); psychological (such as traumatic childhood experiences, stressful life events like unemployment, etc.); environmental (natural disasters, haze), or social (political instability such as riots or demonstrations that are prolonged).

Can anxiety disorder run in the family?
If yes, does this mean that there is a genetic component to the disorder? Yes, that’s one of the biological causes of anxiety disorder. I have a strong family history of anxiety disorders. I know the condition inside out. The genetic risk factor partly contributes to my particular interest in anxiety education and treatment.

When should someone with a possible anxiety disorder see a mental health professional?
Someone with a possible anxiety disorder should see a health professional when:

It interferes with his or her daily activity at school, work, or home.
He or she makes excessive or unnecessary visits to doctors due to psychosomatic symptoms (a physical illness or other bodily conditions caused or aggravated by a mental factor) or is frequently absent from work due to poor physical health.
The anxiety leads to depression symptoms such as: loss of interest in daily activities; feeling hopeless or helpless; experiencing changes in sleep, appetite, or weight patterns; having irrational guilt, anger or irritability; or having suicidal thoughts.
Loved ones can’t tolerate the negativity of the person with anxiety disorder, giving rise to interpersonal challenges eg, marital and parenting issues.
A person copes with anxiety using unhealthy or harmful methods eg, excessive alcohol consumption, illicit drug abuse, self-harm, or binge eating.

What could happen if the disorder is not properly controlled or treated?
The following complications could occur:

The affected person could continue to have frequent psychosomatic complaints which could lead to excessive use of medical services—these people tend to “doctor shop”. Due to their weakened immunity, they are also more prone to getting various physical illnesses.
The person could develop other anxiety disorders (eg, generalized anxiety disorder combined with panic attacks and social anxiety), depression, or suicidal thoughts.
The person could also turn to alcohol or substance abuse. It can also lead to behavioural addictions like gambling, pornography, or computer gaming addictions.

What is Acceptance and Commitment Therapy(ACT)?
Acceptance and Commitment Therapy (ACT, typically pronounced as the word ‘act’) is an action-oriented and scientifically supported approach to psychotherapy for conditions such as anxiety disorders, major depressive disorder, and substance-use disorders.

Please tell us more about ACT.
ACT teaches various mindfulness and acceptance-based skills (such as present moment awareness, thought defusion, emotional acceptance, and observing mind) in therapy sessions. These methods are intended to help people befriend anxiety symptoms rather than fight or feel bad about them. ACT also uses a set of exercises that help patients identify and commit to their meaningful goals and values in life.

What is the goal of ACT?
To act towards our value-based goals. In ACT, we don’t aim to get rid of anxiety symptoms (such as panic attacks); it’s to embrace anxiety and move towards meaningful goals in life.

Aside from ACT, what other common therapies are recommended for anxiety disorders?

Cognitive Behavioural Therapy (CBT) eg, challenging thoughts, exposure therapy, and social skills training.
Antidepressant and anti-anxiety medications may be prescribed by a qualified doctor.
Relaxation training eg, progressive muscle relaxation, pleasant imagery, and deep breathing. • Emotional Freedom Technique (EFT).
Eye Movement Desensitization and Reprocessing (EMDR).
Exercise, meditation, hypnosis, and prayer.

Can one’s anxiety disorder truly go away?
It’s normal to have some anxiety in daily life. It’s also not uncommon that anxiety disorder does not truly go away. Therefore, the aim of ACT is not to eliminate anxiety. It’s to learn to cope with anxiety and move on with life to achieve what is meaningful to us.

What is your advice to people who decide to self-diagnose and “DIY” their own ACT using information found online or in a book?
If it works well for you, good; if not, get guidance from a mental health professional who is familiar with ACT. There is no one-sizefits-all or best treatment plan. Most importantly, do not give up; explore with a therapist on methods or combinations of treatments that suit you. HT

Breaking The Chains Of ‘Bacne’

March 19, 2020 Return

WORDS HANNAH MAY-LEE WONG

Dr Ch’ng Chin Chwen

Consultant Dermatologist

It’s certainly no fun when it seems only pimples have got your back. Want to get rid of them? Take the advice of a dermatologist.

Having acne can really ruin one’s confidence and having them on your back is no less embarrassing. Back acne or ‘bacne’ is particularly frustrating as they appear in places that are hard to reach. Thankfully, according to consultant dermatologist Dr Ch’ng Chin Chwen, there are things you can do to alleviate back acne. In this article, Dr Ch’ng debunks some common myths about back acne and gives us helpful dermatologist-approved tips on how to get rid of them the right way.

What causes back acne and why do only some of us get them?
Acne, no matter which part of the body it appears in, is mostly triggered by genetic and hormonal factors. There is some recent evidence pointing to high sugar foods and milk/dairy products as key contributing factors to acne breakouts as well.

A variety of medications are known to be associated with acne breakouts. These include oral corticosteroids, hormones (such as anabolic steroids, certain contraceptive pills, and testosterone), certain antiepileptic medications, antibiotics or antidepressants, and some chemotherapeutic medications.

Why is the skin on our back particularly prone to acne?
This area has more sebaceous glands. The formation of acne on our skin involves sebaceous glands, which are more abundant over our face, upper chest and back. Areas without sebaceous glands don’t develop acne (for example, the palms).

What worsens back acne?

Using harsh skin care items like antibacterial soaps, astringents and abrasive scrubs can disrupt the skin’s natural protection layer, irritate the skin, and worsen acne. Hence, excessive washing, scrubbing or use of drying skin care products can also exacerbate back acne.
Use of oily/thick textured skin care products that clog the pores can worsen back acne. For people with acne-prone skin, it’s best to stick to oil-free or non-comedogenic skin care products.
Back acne may be more common in our country because of our hot and humid weather. Sweating, wearing thick or tight clothing, or working in an oily environment can clog pores and worsen back acne.
Stress has long been known to be a contributing factor to acne breakouts.

What should we do to get clear skin on our backs? Any medication or topical treatment options available?

Avoid trigger factors as mentioned earlier in this article.
Practice good skin care habits: no excessive washing/ cleansing, diligently use sun protection, avoid hot and humid places, shower immediately after sweating, wear loose and airy clothing made of cotton, and regularly moisturize your skin.
Topical acne medicines (similar to those that treat facial acne) are available in most pharmacies. Perhaps look for products that can cover large surface areas easily, such as products specifically formulated for body acne or spray-on products.
Your dermatologist may prescribe oral medicines such as antibiotics, spironolactone, and isotretinoin to treat your acne.
Light and laser treatments provided by your dermatologist may also help treat back acne. Do you recommend those with back acne to use a loofah/ back scrubber? Gentle scrubs can help clear clogged pores, but harsh scrubs can disrupt skin barrier and cause more inflammation—the balance may be difficult to strike. If you want to use loofah, use it softly, and remember to wash and dry the loofah properly after each use for hygiene reasons.

It’s easier to opt for a chemical exfoliator rather than physical scrubs for a gentler effect. Use products with AHA (alpha hydroxy acid), BHA (beta hydroxy acid) or salicylic acid. Note that salicylic acid is stronger and may not be suitable for those with dry skin to use regularly.

Are those ‘special acne body wash’ the best option for those with back acne?
Yes. Body washes that contain AHA, BHA or salicylic acid may help with back acne.

When should we see a dermatologist?
If you have tried changing your diet, lifestyle, skin care products, and have regularly used over-the-counter acne gels but still have uncontrolled acne, you should see your dermatologist.

It’s hard to care for our backs as some areas are hard to reach. Are there any products that can help us solve this problem?
Some products come in a spray form for difficult-to-reach areas. HT