June 2016 – CANCER STORY

Extravasation: Leakage of Chemo-drug

This is an e-mail we received from the brother of a 58-year-old breast cancer patient.

My sister has been diagnosed with breast cancer. The lump on her right breast had been removed on 23 March 2016. Upon strong recommendation by the doctors, first cycle chemotherapy (FEC regimen) was done on 24 April 2016 but due to chemo extravasation, she is now having a deep and large wound with pus on her left arm and needs daily dressing at the hospital, although it is recovering but the rate is slow.

Due to the harsh chemo side effects, we do not want to proceed further with the chemo anymore and decided to consume your herbs. She might not be able to go to Penang for the time being because of the need to do daily dressing for her wound, I am able to see you in Penang if necessary.

The patient’s brother came to seek our help. His sister was supposed to undergo 6 cycles of chemotherapy. But this has to stop because after the first shot of chemo, the injection site in her left forearm developed blisters which later progressed to deep wound (picture) below. It has been more than 2 months and the recovery of her wound has been very slow. Fortunately, the patient did not suffer any pain from the wound.

Comments

It is sad that such a thing ever happened. And I was curious why it could happen! I spent one Sunday afternoon surfing the internet for more information. Problem like this is known medically as EXTRAVASATION.

In my book, Cancer War, I had a picture as below but I would never imagine it could be that bad as the picture above.

Let us do some serious thinking!

If a little of the chemo-drugs leak out and spill onto your unprotected arm and cause such damage, dare you imagine what is going to happen when the drugs get into your body? Honestly, I dare not imagine and also I cannot understand how such a toxic or corrosive drug can ever cure anything.
Imagine again, just a few ml or drops can cause such damage, what could have happened if you pump in a bottle of such toxic drug.
I am amazed. Our blood vessel must be very, very strong and resilient to be able to withstand such corrosive drugs. Yes, they need to pump the drugs into the vein. Surprising indeed the vein does not “rot away” like the picture above.
From the information below, you will learn why such a catastrophe can happen. And such things should not have happened. Also in the literature we learn that such incidence is rarely reported!

Information from the Internet

Extravasationis the process by which any fluid or drug accidentally leaks into the surrounding tissue. In terms of cancer therapy, extravasation refers to the inadvertent infiltration of chemotherapy into the subcutaneous or subdermal tissues surrounding the administration site.

Source: https://en.wikipedia.org/wiki/Extravasation

Many cytotoxic agents can cause severe tissue damage if an IV needle or catheter delivers the drug into tissues rather than into the bloodstream. The term extravasation is used when a cytotoxic drug infiltrates into local tissues.
To avoid infiltration the larger veins of the arm are used for IV administration.

Source: http://www.rnceus.com/chem/admin.html

Data on the incidence of either extravasation are scant due to the absence of a centralized register of chemotherapy extravasation events.
Incidence rates vary greatly. Estimates between 0.01% and 7% are noted in various publications. Some data suggest that the incidence is decreasing probably due to improvements in the infusion procedure, early recognition of drug leakage and training in management techniques.
In order to minimize the risk of extravasation, the staff involved in the infusion and management of cytotoxic drugs must be trained to implement several preventive protocols.
Should an extravasation occur, it is important to remember that the degree of damage is dependent on the type of drug, the drug concentration, the localization of the extravasation and the length of time a drug develops its potential for damage.

Source: http://annonc.oxfordjournals.org/content/23/suppl_7/vii167.fulldefinitions

Incidence

Extravasation is not as rare as many people think, and it may occur even in the most closely monitored situations. A study which investigated extravasation over a five-week period in a UK hospital established an incidence of 39% in adults, almost double that of previously published reports.
Extravasation injuries remain uncommon, with an estimated incidence published in the literature of between 0.1% and 6% in patients receiving chemotherapy.
The published rate is likely an underestimation, however, as many cases of extravasation go unreported.

Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3664495/

The true incidence of chemotherapy vesicant extravasation is unclear since there is no central reporting mechanism. With an increasing awareness of the risks from extravasation, the frequency appears to have fallen.
As such, this rate probably underestimates the true incidence of chemotherapy extravasation injury.

Source: http://www.uptodate.com/contents/extravasation-injury-from-chemotherapy-and-other-non-antineoplastic-vesicants

Source: Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740528/

Cytotoxic agents have the potential of causing destruction of healthy cells. Due to the relatively low number of cancer treatment centres, it is often not possible for a patient to take the complete course at the centre itself because of financial constraints and long distances from their home towns or villages. After the initial one or two courses, many patients find it convenient to take the remaining treatment at their nearest health institution. However, physicians in such nonspecialized centres may not be aware of the local side effects of the drug. Very often, even in oncology hospitals, the work of infusion of cytotoxic drugs is left to a junior house surgeon or an intern, whose inexperience in venupuncture and ignorance of precautions for infusing a cytotoxic drug can lead to extravasation of the drug.

Extravasation of the drug can produce extensive necrosis of the skin and subcutaneous tissue. This not only adds to the misery of the already seriously ill patient, but can also cause serious functional loss, as most often, the forearm and hand veins are used for infusion.

This study was done in the Department of Plastic Surgery of a Medical College in the period from January 2002 to December 2006. There were twelve patients. All the patients were from rural areas and belonged to lower socioeconomic strata. None of the patients was educated beyond middle school.

Mitomycin C was used in seven cases (58.33%), vincristine in two cases (16.66%), 5-Florouracil in another two cases while doxorubicin was responsible for extravasational side effects in one case (8.33%). The size of necrosis ranged from 3.75 cm² to 25 cm² with average area of 9.6 cm² [Picture below].

In terms of the area involved, the dorsum of the hand was involved in five cases (41.66%), the wrist in another five cases (41.66%), and the cubital fossa in the remaining two cases (16.66%).

Extravasation of cytotoxic drugs leads to symptoms which are self-explanatory for this catastrophe. The majority of the patients will complain of excruciating pain and itching in the infusion site. Within a few hours, the extravasation area will show erythema, edema, and induration. Within a few days, these signs and symptoms will increase and the skin will show discoloration and desquamation of the epidermis or blister formation will follow. If a large dose of a cytotoxic drug is extravasated or no intervention is taken at this step, the area will show ischemic changes and ulcer formation will be inevitable.

It is well said, “Prevention is better than cure” and this holds true for extravasation injuries also. Once there is an extravasational injury to the tissue, morbidity is inevitable. Extravasations of cytotoxic drugs further increase the suffering of cancer patients. This catastrophe can only be avoided by vigilance.

Source: http://www.cancerjournal.net/article.asp?issn=0973-1482;year=2015;volume=11;issue=4;spage=835;epage=839;aulast=Salunke

Use of chemotherapeutic drugs is commonly associated with substantial complications. These drugs are infused in veins of dorsum of hand or antecubital fossa.Subcutaneous extravasation is a known complication of intra-venous administration of chemotherapy agents. There are limited cancer centers throughout the globe with properly trained medical professionals. Due to lack of specialized centers and experienced medical professionals, chemotherapy infusions can lead to higher incidence of extravasation injuries. The overall incidence of extravasation injuries varies from 0.1-7%. It is characterized by drug escaping out of the vessels in subcutaneous tissue plane due to repeated venous punctures and its cytotoxic effect of the chemotherapy drug. The infusion area over dorsum of hand is having minimal subcutaneous fat tissue and so it is more prone for severe damage by extravasation injuries; this injury can damage underlying tendon, joint, and neurovascular structures.The extravasation injuries are difficult to treat due to lower immune status of the patient and complexity of the wound with exposed bone or tendons.

At our center over 3-years period, 32 patients were treated for chemotherapy extravasation wounds. Out of these 32 patients, seven had wound over dorsum of hand. Two patients were treated with chemotherapy for carcinoma lung. Other patients were of Non-Hodgkin’s lymphoma, Osteosarcoma, Breast carcinoma, Oropharanyx carcinoma, and Brain tumor.

Cyclophosphamide was used in four patients (81%), Doxorubicin in three patients (43%), Adriamycin in two patients (28%). Vincristine, Prednisone, Cisplatin, 5 Flourouracil, Adriamycin, Cyclophosphamide, Docetaxel, Procarbazine, Vincristine, Lomustine was responsible for extravasation injury in other patient.

Breast Cancer: She died after three shots of chemo

Mas (not real name) was a 44-year-old Malaysian lady. In May 2015, she felt a lump in her left breast and did not bother about it. About 7 months later, in December 2015, she went for a check-up. Why did you go for a check-up? Just to know what it was. An ultrasound and mammogram confirmed breast cancer. Mas also had pains in her backbone and a CT scan showed the cancer had spread to her bones and liver.

Mas underwent a mastectomy in January 2016. In February 2016, Mas was started on chemotherapy (drugs: EC). The treatment was scheduled for 6 cycles but after 3 cycles the doctor stopped the treatment because of her deteriorating liver function. Blood test on 22 March 2016 showed ALP = 455 (high), ALT = 96.1 (high) and AST = 200.4 (high).

Mas and her family came to seek our help in late April 2016. She was prescribed herbs for breast and liver.

Comments

A few weeks later Mas’s cousin to seek our help. At the same time informed us that Mas had passed on about 2 weeks after her visit to us. Mas benefited from taking our herbs. She felt much better.

This is indeed a sad story. But can we learn anything from such a tragedy. Let me quote what others say and leave them there for you to ponder on deeply.

Michael Gearin-Tosh was, for 35 years, a tutor in English at St Catherine’s College, Oxford. But he became famous as the author of Living Proof – A Medical Mutiny (2002) in which he described how he had challenged the medical establishment after he was diagnosed with myeloma (cancer of the bone marrow) in 1994.

He was given six months to live. He was told to undergo chemotherapy.

Gearin-Tosh discovered that, according to one cancer statistician, chemotherapy brought significant hope of survival to just four per cent of patients with the same cancer, and that many doctors would not prescribe it for themselves. His conclusion was simple: “Touch it, and you are a goner.” Instead he embarked on a series of “alternative” treatments. Confounding the medical prognosis, he survived a further 11 years and when he did eventually die (on 29 July 2005, at age 65), it was from a blood infection rather than cancer.

Living Proof triggered angry responses from doctors and from patients undergoing chemotherapy. Some accused him of peddling false hopes and ignoring statistics which indicated a higher survival rate for patients given chemotherapy. “If there was anything in this stuff,” wrote one consultant physician, “don’t you think that the medical profession would have grasped these ‘cures’ with both hands years ago?” But for others Gearin-Tosh was living proof that alternative therapies do work, and that it is possible not to be dehumanised by the disease or its specialists.

Source: http://www.telegraph.co.uk/news/obituaries/1495451/Michael-Gearin-Tosh.html

Let’s do some calculation!

Gearin-Tosh was given 6 months to live. He refused chemotherapy and opted for alternative therapies. He went on to live for another 11 years before he eventually died of blood infection (and not cancer).

In May 2015, Mas found lump in her left breast. Eight months later, she had an operation to remove her whole breast. Even with cancer growing in her, she was still alive but of course with some discomforts and anxiety.

In February 2016, Mas was started on chemotherapy. Three months later, she was dead.

Is it not better to just learn how to live with the cancer and not do anything? Gearin-Tosh reasoned: Why treat if you cannot cure?

Is doing nothing a better option?

Dr. Atul Gawande is a surgeon and professor at Harvard Medical School. He shared his thought as below:

Before you folks undergo chemotherapy, do you ever ask what the treatment can do to you?

Recurrent Pancreatic Cancer Metastatised to the Bone and Lung

GG was 77 years old when she had problems with her pancreas in November 2007. MRI indicated that she probably had an intraductal papillary mucinous neoplasm. In her medical report the doctor wrote: This lesion has malignant potential and should be treated accordingly. GG underwent a distal pancreatectomy in December 2007 in Mt. Elisabeth, Singapore. After the surgery no further medical treatment was indicated.

Nine years later, in 2016, GG started to cough, had fevers, nausea and vomiting.

An ultrasound on 3 May 2016 in Kuala Lumpur showed a solid mass lesion in the region of the body to tail of the pancreas measuring 28 x 33 x 67 mm … suggestive of recurrence. There were multiple cysts in her liver and solid nodules of unknown nature in the neck of the gallbladder. Further examination showed metastasis to the lung and bone.

Her CA 19.9 was at 234 and CEA was at 5.3.

GG is now 85 years old. It was at this point that we received an e-mail from her daughter-in-law.

Dear Dr. Chris Teo,

My name is L and my mother was diagnosed with breast cancer in 2004 and was taking Breast M and Capsules as prescribed by you. She continued with your prescriptions without having major complications i.e., no pain and suffering until she passed away in 2011 due to high fever. We are extremely happy because she did not suffer much and managed to live for another 7 years.

Recently my mother-in-law did an ultra sound and x-ray as she was not feeling well. The results showed her pancreas having cysts and lung having numerous nodules. According to the doctors, cancer is almost positive unless biopsy is done to confirm. She had done surgery to remove part of her pancreas about 10 years ago due to the growth (non-cancerous). She appears to be healthy now with some minor coughing but complained of some phlegm. As she is of advance age i.e. 85, we wish to seek your advice on the best possible treatment for her. Family members are not agreeable to chemotherapy and radiation.

I attached below the medical reports, blood test and results of ultra sound and x-ray for your reference. I am hoping to receive your feedback soon as we are from Kuala Terengganu and are prepared to take her to Penang to consult you if possible. Thank you.

GG was prescribed herbs.

Dear Dr Chris Teo,

My mother-in-law started to take Capsule A-D, M Tea, Bon, Pancrea, Live P, Lun about two days ago. Each time after about 2 hours of consuming the herbs, she started vomiting the herbs. On the first night of taking the herbs, the phlegm and cough reduced significantly but vomited about 2 hours later. She doesn’t have good appetite now, always belching and feels weak. We seek your opinion whether to continue with the herbs or to reduce the types and amount. Hoping for your answer soon.

Reply: I expect that. She will have to suffer for the next 1 to 2 weeks to get better. Continue taking the herbs.

Dr. Chris Teo,

Thank you very much for the herbs prescribed to my mother-in-law. I noted that her condition now has improved tremendously … I would like to continue with the herbs. At present, she sometimes feel uncomfortable at her of stomach after taking pain killer. She has been taking pain killer because her outer thigh has been nagging her for more than 20 years. Actually, the pain is due to the disc fracture at the spine as informed by the doctors. I don’t know whether the pain is caused by her spine problem or other reasons. I would like to substitute the pain killers with your herbal remedy.

The son of GG called to say that GG was better. She had more energy and now can sit up. Before she had to lie down.

Comments

We are glad that at least when patients (or doctors) give up medical treatment for advanced cancer, there is still something that we can do to help — to make patients’ quality of life better.

GG is already 85 years old. Do you think subjecting her to chemotherapy or radiation make sense?

Reflect on this story written by Dr. Ken Murray.

Not too long ago, a man came to our centre on behalf of his 71-year-old father who was in a critical condition in the hospital. His father was semi-unconscious, couldn’t even open his mouth to eat or drink and had to be tube-fed. Looking at his medical condition — lung cancer that spread to his brain — we suggested that it would be better to do nothing than to try heroic acts. A biopsy was done followed by radiation. The question is: What is the purpose — what do you expect to achieve?

If you don’t take care, you will die. Your husband can find a new wife!

Sixty-two-year-old WG is from Indonesia. She came to see us in October 2012. Her problem started after she found 2 lumps in her right breast about 3 years ago. She did not consult any doctor then. She took Chinese herbs for a few months. The lumps grew bigger.

In October 2012, WG came to Penang and consulted a doctor in a private hospital. The doctor suggested a mastectomy. She was told that the cost of the surgery would come to about RM 4,000 and she has to stay in the hospital for about 5 days.

After seeing the doctor WG came to seek our advice. These are what we told her:

Yes, she should go ahead with her surgery.
The doctor whom she met was also the “right” doctor. So there is no reason to go “shopping” elsewhere.
Tell the doctor not to do any biopsy — just remove the whole right breast right away.
After the surgery, she could come back with all the medical reports and we shall then decide what to do.

WG went for surgery as suggested. The total hospital expenses came to RM 4,800 and she stayed in the hospital for 8 days.

The histology report dated 16 October 2012 indicated the following:

A well defined solid necrotic tumour measuring 45 x 30 x 30 mm.
The subareolar tissue contains a cystic tumour with papillary structures measuring 30 x 30 x 20 mm.
One out of 8 lymph nodes shows metastatic deposits of tumour.
The tumour is negative for estrogen, progesterone and c-erb-B2 receptors.
Stage 3 B — T4bN1 Mx.

WG had a metastatic triple negative cancer. The doctor suggested that WG undergo follow-up chemotherapy. She refused and came back to seek our help. She was started on herbs and was told to take care of her diet.

The following are the blood test results over the years.

In April 2016, WG came to Penang for a routine check-up. It has been more than 3 years since her breast surgery. Over the years her blood test seemed to be satisfactory (see table above) We have always cautioned her about her diet — Do not eat anything you like! Take care of your diet. Unfortunately, our plea did not get into her head! She admitted at times she did “curi makan” (eat the forbidden food), but not often.

Since our message did not seem to sink into her, we had to be more blunt but we tried to pass that message in a jovial and joking manner. We are glad that WG and her husband took our message in good spirit. Listen to your conversation that day.

Chris: Your liver function does not look good (table above, April 2016). Did you take care of your diet? Never pantang?

WG: Yes, I ate bad food once a while. If I don’t eat my legs and hands felt numb.

C: Well, I really don’t know what I can do. You have survived more than 3 years now. It is good that you can live that long. Some breast cancer patients would not even last that long. So please take care of yourself. I can’t really do much. So learn how to take care of yourself. Please don’t eat too much of bad food!

WG: Eat also die, don’t eat also die!

C: So, go home and eat what you like and then die faster after that.

WG: Yes, better die sooner so that I don’t have to come and see you anymore.

C: Good, you don’t have to disturb me also. So, go home and eat a lot of bad food and die faster.

GW: I also don’t have to spend any more money.

C: Ah, your husband can find a new wife. Prettier and younger one some more! See, uncle is smiling.

Comments

It is most unfortunate that most cancer patients feel that they are “cured” after being alive and well for 2 to 3 years. They often go back to their own lifestyle and diet. No one likes to know or be reminded that the cancer can recur. Unfortunately, cancer does recur in most cases. A study in Italy showed that the critical year for recurrence is at the 2nd and 5th year. And cancer does not go away even after 15 years!

Most patients are being taught to believe that after 5 years they are “cured.” This is NOT true. My aunty died when her cancer recurred 13 years after an apparent “cure”. Last month, a breast cancer patient suffered recurrence after 14 years. Read what Dr. Susan Love has got to say:

Breast Cancer: Six years without chemo, radiation or hormone. Happy, happy only!

ES was 49 years old when she was diagnosed with an invasive lobular carcinoma. The lump in her right breast was small, 15 x 10 x 10 mm. ES came to Penang for surgery. The doctor did a wide excision with right axillary sentinel node biopsy. The tumour was cleanly removed with margins clear of tumour. The four sentinel nodes removed from the armpit were also free of tumour.

The tumour was positive for estrogen and progesterone receptors and negative for c-Erb-2.

After the surgery, ES was asked to undergo follow-up treatment of chemotherapy, radiotherapy and oral medication, Tamoxifen. ES flatly refused and opted for CA Care Therapy instead. The doctor was unhappy her. He warned ES, I am your doctor. If you don’t want to go for chemo as I told you, I am responsible if anything happens to you. You take that risk.

ES went back to her doctor every year for check up. For the first two years, the doctor kept insisting that ES should go for chemo. At the third annual visit, the doctor stopped “pushing” ES to go for chemo.

ES went to see her doctor again in April 2016 — six years after the operation. The meeting with the doctor and an ultrasound cost her RM 212.00, The doctor said, Good. He was aware that ES was taking herbs instead of the chemo he had suggested. No, he did not ask ES about this “alternative treatment.”

Below is our conversation with ES and her husband in May 2016.

Some main points of our conversation:

Chris: Did the herbs help you?

ES: Yes. My blood pressure became normal, before it was always low, 90/60. I felt healthier.

C: During your six years after surgery, do you experience any problem?

ES: No. Happy, happy only.

C: Now, did you ever worry that the cancer can come back again?

ES: Before in the first two years or so, yes. Now, I have no fear.

C: Some patients are reluctant to take the herbs after some years. What actually is the problem?

ES: Lazy to brew them!

Comments:

What could have happened if ES were to undergo chemotherapy, radiotherapy and took Tamoxifen as suggested by her doctor): Would her six years after surgery be a “happy, happy only” life?

What would happen if she had chemo and radiation? Surely, she had to spend a lot of money. In addition she would suffer side effects. Seriously or not, no one could predict.
Would she be able to have problem-free life after chemo and radiation? That depends on your “luck” (according to one onco).

3 Recent research result has shown that about 50% of women with breast cancer have been receiving chemo that they don’t need! So, is chemo given to women just as a matter of routine or SOP (standard operating procedure)?