The Author: Professor Christopher Cheng is the CEO of Sengkang General Hospital and Senior Consultant Urologist at SGH and Singapore General Hospital. He is a pioneer in using robotics in prostate cancer surgery.
I thought I knew about prostate cancer … I have done countless … cancer operation for the prostate. I thought I knew… until I became a patient myself, lying on a cold operating table one Saturday morning in December 2017.
The reality is cancer can hit anyone.
The naked truth of what I went through may be shocking to some who have been led to believe erroneously, that modern healthcare, will all its glamorous robots and high-tech equipment, has a solution to almost anything.
Not all prostate cancers need to be cured or even treated and not all cancers that need treatment can be cured.
The treatment should not be worse than the disease itself and often more treatment is not necessarily the answer.
There are many both young and old who … believe that when the time comes, they can just check into the hospital and have everything fixed.
We will take care of you, but you must take care of yourself too.
(Doctors should) provide guidance and gentle nudges and support rather than coercion in their (patients) decision making … they are the ones who are on the operating table, they are the ones who have to live with the consequences.
After reading this article, I became more curious and wanted to know more about who Professor Cheng is, and more importantly to learn from him what it is like to be a prostate cancer patient when he himself is an expert of prostate cancer.
Let me share with you what I have learned from the above two articles. To let you know, I did not stop at that – I ordered the book I Thought I Knew written by Prof Cheng himself. I read the book. Later I shall write again, Part 2!
Prof Cheng, CEO of Sengkang Health and Senior Consultant, Department of Urology, Singapore General Hospital wrote:
Some time ago, I bade farewell to a good friend. I have operated on him to cure his cancer barely three months earlier, but his condition still progressed rapidly.
This friend eventually died. Before his death, this friend told Prof. Cheng:
Don’t let me suffer pain and I won’t want more chemotherapy.
Prof Cheng quoted what Willet Whitmore – another prostate cancer expert at the Memorial Sloan-Kettering Cancer Center – said:
Is cure necessary in those for whom it is possible, and is cure possible in those for whom it is necessary?
According to Prof Cheng:
For a large range of cancers, cure may be necessary but not possible, as in the case of my friend.
For the rest, cure is unnecessary, even though it is possible.
We should question if more medicine is better.
So, cancer patients, ponder carefully and seriously what Prof Cheng said.
This is one reality that everyone of us need to know and accept – cure may be unnecessary, or cure may not be possible. I am reminded of a friend, Steve – a British engineer who chose to settle down in Bangkok. He too had prostate cancer. He went to Singapore and was put on Intermittent Triple Androgen Blockage Therapy. He then gave up this medical treatment and opted for alternative therapy. That was when he wrote to me for help. Diagnosed with prostate cancer in 2007 at the age of 63, Steve was till okay until 2023 (16 years without doctor’s medication).
In 2023, Steve had a swelling in his cheek. It was diagnosed as parotid cancer. He wrote me and asked for help again. He took our herbs for about three months, but the tumour did not go away. He was okay but had occasional pain. But every morning when Steve woke up, he looked into the mirror and felt (or imagined) that the tumour was getting bigger and bigger. Then Steve wrote that he had found “the best doctor in the best hospital with the best equipment” in Bangkok who could remove the tumour and make him live longer! Anyway, according to Steve, our herbal therapy is not a scientifically proven therapy! I fully agreed with Steve. So I told Steve: Go ahead and follow what your heart says. He went for surgery, suffered badly after that, and died 3 months 13 days later.
The Prostate Intervention Versus Observation Trust (PIVOT), led by Timothy Wilt, started in 1993 and analysed 731 patients over 12 years. The study compared surgically removing the prostate gland with ‘watchful waiting’.
The study found that there was little difference between the two.
Those who had an operation to treat the cancer had less than three per cent chance of survival compared with those who had no treatment.
Surgery has little or no benefit in extending the life of a patient.
Experts are believed to be ‘shaken’ by the news because thousands of men could have gone through painful and unnecessary surgery.
From the article Doctor diagnosed with advanced prostate cancer learns lessons on death, dying and compassion, written by Eveline Gan on 5 August 2023, I learned more interesting lessons from Prof Cheng:
I was this arrogant, impatient young surgeon, thinking I’m a godsend for mankind — until I became afflicted with prostate cancer, an area I’m supposed specialise in.
We are all human. All of us have our ego. It is only a matter of degree. Most cancer patients told me that if they asked the doctors too many questions, the doctors would become angry at them. Some doctors reacted this way – You are the doctor, or I am the doctor – meaning, if you don’t listen to my advice get out of my office! One patient once told me the oncologist just threw away my file against the wall because I did not agree with him.
Since not many cancer experts themselves get cancer, it appears that it is hard for them to understand what it is like to be a cancer patient. So, in this case Prof Cheng is an exemption. And he shared his experiences and feelings. Bravo! Thanks.
Over the years, at CA Care, I have adopted an open attitude when dealing with cancer patients – we are here to help those who need our help. We hope to make your life better after all medical treatments have failed. The language of love and compassion is not about trying to prove who is right or who is wrong. It is about recognizing limitations and exploring opportunities. What matters is our patients should get better.
Hidden Agenda.
Prof Cheng’s PSA was at 17.8 when he was first diagnosed with prostate cancer. He said:
In some (overseas) centres, if you have prostate cancer with a PSA of 17, the top surgeons will not operate on you because it would tarnish their results.
Prof Cheng explained further that some famous centres do not offer potentially curative treatment to patients with a PSA of more than 10, because poor outcomes may affect their reputations unfavourably.
This is a most shocking, a new knowledge that I have learned! It never occurred to me that in medicine there is such a “hidden agenda” as this – that is, certain medical experts would not offer treatment just to preserve their reputation. They want to pick and choose – only cases that they are sure they can win only! Is that a noble mission?
Over the years, I have been writing about experts giving all sorts of treatment just to “make money” – never mind if the outcome is unattainable. Professor Welch describes such attitude as You eat what you kill!
Over the years, I have seen many prostate patients. It never occurred to me that PSA 17.8 is very alarming, although it may mean the patient has cancer. Many patients who came to us had PSA of 531, and in some cases their PSA was even at 6,963 or 7,292. It never occurred to me that 17.8 is already a disaster! Another new lesson learned.
No to “kitchen-sink” treatment after surgery.
After his prostate cancer surgery, Prof Cheng said the oncologist proposed an “all-in kitchen sink” approach to treatment. In my twenty-seven years dealing with cancer, this is the first time I encountered this word – kitchen sink treatment! In layman language it means going for maximum treatment available.
Indeed, I was surprised and baffled at what Prof Cheng said:
I didn’t want an all-out treatment that would most likely give me many side effects.
I don’t think that being at the receiving end of the kitchen sink is going to make me any happier.
In other word, Prof Cheng did not want to undergo chemotherapy! Perhaps we need to recall what he had said earlier: In cancer, cure is unnecessary, or cure may not be possible. Unfortunately, not many patients buy this idea. They believe that with money they can go to the best doctor in the best hospital, and they can “buy” their cure! No, the reality is you may end up in a more dire situation – money gone and the patient died a miserable death.
While writing this article, I received an e-mail from the daughter to a prostate cancer patient.
Hi Dr Chris,
My Dad is suffering prostate cancer Stage 4. It had spread to bone, liver and some other area. He is 77.5 years old. He had received:
Hormone therapy
Chemotherapy
Lutetium LU 177
But his cancer is still spreading.
My Dad is a bit weak now, he lost his appetite and is also anaemic. Thank you so much Dr Chris, hope to hear some good news from you soon!
From the medical report, I came to understand that:
In 2016 he had radical radiotherapy and adjuvant ADT (androgen deprivation therapy).
PSA went down to 0.5.
On ADT throughout except a period in 2020.
In early 2021 his PSA rebounded. Recommenced ADT with brief response.
Later in April 2022 Casodex was added to the treatment.
No PSA response.
In June 2022, he took Daroltamide.
In August 2022: Suboptimal response to Darolutaminde.
In December 2022 his PSA was at 27. Right inguinal node at least 3 cm.
21 December 2022: Underwent chemo with Docetaxel.
Carboplatin added to Docetaxel in C3, as PSA was not dropping much initially.
PET scan post C6: Mixed response with one new spine metastasis.
By C9, PSA trending upwards from 16.3 to 16.8 to 17.9.
6 June 2023: Started on lutetium 177. PSA 15.0
20 July 2023: Legs showed DVT (swollen below the knee due to deep vein thrombosis).
1 September 2023: C2 luteteum. PSA rose to 43 (this is 8 weeks post C1 letuteum).
11 September 2023: PSA decreased to 38.
Creatinine rose from 108 to 150.
13 September 2023: Repeat PET scan metastasis in multiple nodes and other parts of the bones.
The daughter wrote: After that he went to China and received radioactive particle seed, and one cycle of chemo using mitoxantrone.
Question: Did the patient get any better after spending a bomb for these treatments? What was the total cost of the treatment? I did not have a chance to ask this question because the daughter did not turn up for her appointment!.
The blood test results on 30 November 2023 showed the following:
PSA = 249.90
SGOT/AST = 82 (normal less than 40)
Gamma-GT = 436 (normal less than 71)
Alkaline phosphatase = 513 (normal 40 – 129)
Creatinine = 2.69 (normal 0.67 – 1.17)
eGFR = 23.64 (less than 15 means kidney failure).
According to the doctor the patient has progressing mCRPC (failed NHA, chemotherapy and more recently lutetium) complicated by left hydronephrosis … causing new renal impairment. He has new PSMA avid liver lesions. He may also need early radiotherapy to the left pelvic node and posterior iliac bones.
One more important question to ask: If he is your father, who is already 77 plus years old, would you agree to let him go for more treatment? What do you expect to get at the end of the game?
Cancer: Fight it or Live with It, Your Choice!
We recognize that our work at CA Care is at odd with current medical thinking. Modern medicine wants to kill or shrink the tumour. And in the process kill the patients too. In The War on Cancer – an anatomy of failure; Dr. Guy Faguet, a cancer researcher, and medical doctor, wrote:
An objective analysis of cancer chemotherapy outcomes over the last three decades reveals that … the cell-killing paradigm has failed to achieve its objective … a model based on flawed premises with unattainable goal, cytotoxic chemotherapy in its present form will neither eradicate cancer nor alleviate suffering” (pg.89).
At CA Care we teach patients to live with their cancers. Concentrate on what matters. We don’t know how to cure your cancer and we don’t pretend we can cure your cancer either. But we know how to make your life better. If you can eat, sleep, walk, have no pains, and can live a bit longer of meaningful life – what else do you want?
Prof Cheng reminded us:
However rich, however powerful (they) are, they’ve all had to face death eventually. They all have to let go,
The difference, however, lies in how one faces death.
Death is Not a Failure
At CA Care we tell our patients not to fear death. Everyone has to die. You don’t have to have cancer to die. I have seen many cases where the cancer patient did not die but it was the healthy spouse who died first.
Dr. Bernie Siegel wrote:
I experienced being unhappy as a doctor. I was uncomfortable with the mechanical approach that we are taught in medical school. My success is measured by whether or not I saved your life. If I can’t save your life, I’m a failure. But now I don’t feel like a failure. I can help you live. After all you’re not going to live forever, no matter what I do.
There is an Indian saying:
When you are born, you cried and the world rejoiced. Live your life in such a manner that when you die, the world cries and you rejoice.
To me, this is the secret of how we can triumph and give meaning and beauty to our own death. We leave this world with a sense of pride and accomplishment knowing that we have done our best to make it a slightly better place for those we leave behind.
Richard Reoch (in Dying Well) wrote:
People who have lived fully are not usually afraid to die. We must all die. Death is, after all, the natural end of life. Yet some people fear death.
We often make the mistake of trying to keep a dying person alive as long as possible, no matter what the cost.
There are many occasions when the kindest thing to do is not to hunt for “better medicine” or a “better doctor” but to be close to and supporting the person who is dying. Let them know that you are glad for all the time, the joy and sorrow you have shared … In the last hours, love and acceptance will do far more good than medicine.
Dr. Bernie Siegel (in Peace, Love & Healing) said:
It is important that we realize that we can never cure everything. We will never find … cure for all the diseases. Dying can be a healing, ending a full, rich life for someone who is tired and sore and in need of rest.
CANCER STORY 
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