Cancer of the Liver

[jjonz]

My neighbour - Thai male 54 years old - had recently been discharged from the Takuapa hospital in Phang Nga after several days testings, including blood and x-rays, to be told he had nothing wrong with him, except that he 'smoked too much'.?!

He told me he used to smoke around a pack of 20 a day and had then reverted (for financial reasons) to roll up tobacco of the Thai kind.

However, the reason he had admitted himself to Takuapa hospital was because he said he was feeling something was 'not quite right' and was feeling tired.

The Takuapa hospital had discharged him but four or five days when I found him collapsed in agony on the floor of his house. He called to me and told me he had a bad pain in his upper right hand side torso. I called an ambulance and he was rushed to the Wachira in Phuket.

Since then he has been on an IV drip and given an x-ray and CT scan. His legs have filled with water and his urine is dark coloured.

When I visited him this morning I was told, eventually, by the doctor there that he had 'advanced cancer and cirrhosis of the liver'. The cancer part was the most alarming - and confusing. He had no cancer anywhere else in his body and it is my understanding that cancer spreads from other parts of the body TO the liver.

I know for a fact that he hadn't drunk any alcohol since two months before Kao Pansah, the same as smoking four or five Thai rolling tobacco cigarettes a day. To wit, he'd been clean for around six months.

I am very alarmed by the fact that the doctor at Takuapa, with whom I spoke, simply laughed off his ailment, stating 'mai mii arai' and then sending him home. I am also confused re the lack of cancer in any other part of his body at all?

I want to help him. Any suggestions warmly welcomed.

[noahvail]

Sadly, it appears that a fair number of Thai doctors do not want to give their patients any bad news. My wife says it has nothing to do with the doctor or the patient losing face; rather, that many patients have a very difficult time dealing with the bad news, and the doctors grow weary of having to deal with that side of things. That's her opinion, but she's an educated woman who has worked with many doctors as a de facto patient advocate.

I've had several doctors here, and I stress to them that I want to know what is good and what is bad - that because of my personal history, I can deal with whatever news they give. My current doctor accepts this, and we get along fine; he speaks little English, I speak almost no Thai, but we share a common knowledge of how to med-speak, as it were. My prior doctor had given me a limited physical, including an EKG, blood work, and chest x-ray. He said that everything was good. I asked him for a copy of the EKG and the bloods...it said right on the EKG printout that the heart was abnormal (no surprise to me - the surprise was that he said it was normal); and while most of the bloods were good, some needed work. My current doctor also picked up a spot of calcification in one kidney which the prior doctor either missed or decided not to mention.

As far as your friend's cancer goes, I don't have an answer. There are many more knowledgeable people on this forum who might be able to address your concerns.

I wish your friend the best of luck in a quick recovery.

[Sheryl]

Primary cancer of the liver is relatively common in Thailand. That is why so many health check-up packages include ultrasound of the upper abdomen. Related to the high prevalence of chronic hepatitis, which can be asymptomatic. And possibly other factors as well.

It also, I am sorry to say, carries a very poor prognosis. It is rarely treatable and then only when caught in very early stages which this obviously has not been.

The quality of care in government hospitals in Thailand is generally OK from provincial level on up. District hospitals, which is what your friend first went to, are extremely limited in their capabilities and generally staffed by just a couple (sometimes even just 1-2) inexperienced young doctors doing their required rural stint to pay off their govt sponsored education. They have almost nothing in the way of laboratory or other diagnostic facilities, and worse yet do not seem to refer patients onward. I have seen this repeatedly. For which reason I do not recommend them for anything. Sick enough to need a doctor = worth the trip to the provincial capital.

It would not have made any difference in your friend's case though had he done so initially. His condition has been incurable for probably some time now.

Sorry to give such bad news. Where you may be able to help him is in getting proper palliative care (i.e. adequate medication to control the pain), which can often be an uphill battle in Thailand. He needs to be very assertive and might be worth consulting a pain specialist elsewhere if he is not given medications of adequate strength to keep him comfortable.

[Tywais]

Primary cancer of the liver is relatively common in Thailand. That is why so many health check-up packages include ultrasound of the upper abdomen. Related to the high prevalence of chronic hepatitis, which can be asymptomatic. And possibly other factors as well.

It also, I am sorry to say, carries a very poor prognosis. It is rarely treatable and then only when caught in very early stages which this obviously has not been.

I had researched this a few years ago as my wife's father was diagnosed with it and, as mentioned above, the doctors never discussed it with him but only the family. They got conflicting reports until one young doctor looked at the charts and blurted out "malign - or cancer" and informed them of 6 months life expectancy. They didn't believe him due to conflicting information and brought the records home for me to read as they trusted me more to be honest about it. Read the records and confirmed the worse to them and unfortunately it was late stages and he passed away within that 6 month window.

Liver of the cancer doesn't have to be due to metastasis from other areas and in his case was either cirrhosis (due to his drinking) or hepatitis that started it.

I don't know if he ever was told what was wrong with him.

The estimated incidence of primary liver cancer in Thailand is very high, Liver cancer is the leading cancer in males and third in frequency in females. There is a very marked regional variation, with the highest incidence in the northeast, the age - standardized incidence rate of liver cancer in Khon Kaen is highest in the world.

Source: PubMed.gov

[jjonz]

Thank you all for your replies so far. I have of course started doing some research re liver cancer and have found that liver cancer very common in Thailand and Khon Kaen is the liver cancer capital of the world. Why is this do you think? Lao kao?

What is this country's position on transplantations? I did ask the doctor at the Wachira and he merely brushed it off. Is this because it's too expensive? Or simply not feasible for advanced cancer of the liver?

I am also researching diet, which I believe plays the most important part in maintaining a healthy body. I stopped eating meat over thirty years ago, just fruit, vegetables and occasionally fish, and have never had a day in hospital.

I found something about turmeric (kamin as it's known here) and it's recently having been scientifically proven to not only ward off cancer of all kinds, but to reduce the tumors by way of helping reinforce health red blood cells.

Turmeric is everywhere here in the South, although my former teacher from Kanchanaburi said she didn't like Phuket food as there was too much turmeric in it. This I assume is because of the Muslim/Malay influencing cooking here. Would it be a good idea to at least have him prepared at least one food portion containing fresh turmeric per day? Green tea is also recommended, together with some brand from South America, but am wary of 'fads' in the form of particular brands.

I've also read acupuncture to be effective for cancer. Anyone have any experience of this? Many acupunturists here owing to Chinese influence.

I am trying to be realistic, but definitely see holistic medicine of all kinds to be a better alternative than the usual bag full of pills every day.

All recommendations and comments again, very welcome.

[phetaroi]

I have only had a few interactions thus far with medical personnel here in Thailand...and at Bumrungrad. Nothing serious, just continued long-term treatment of some life-long conditions. If anything, I found the Bumrungrad doctor too eager to go through all sorts of testing, for something that had already been diagnosed 6 different times over 45 years. I finally said just that and she said, "Well, we just don't want to make a mistake that the symptom is actually cancer when you think it is just irritable bowel syndrome." I said, "Well, if I'd had intestinal cancer for 45 years, I think I'd be dead by now. Besides, I've had two colonoscopies, one recent, a lower GI series, frequent tests for occult blood in stool, and other tests. Let's give it a rest and not keep re-diagnosing the same condition!" She backed off a bit after that. I do know that Bumrungrad has a reputation of doing many tests...not sure whether to be efficient or to take in $$$. Overall, I do like Bumrungrad, however.

And let's not be unrealistic about the medical profession "back home". They make some pretty gross errors on occasion, also. When I was about 20 I had minor major surgery (does that make sense) that required 5 days in the hospital. I was in a semi-private room and the man in the next bed had to have a leg amputated. You guessed it. They amputated the wrong leg!

[Sheryl]

Thank you all for your replies so far. I have of course started doing some research re liver cancer and have found that liver cancer very common in Thailand and Khon Kaen is the liver cancer capital of the world. Why is this do you think? Lao kao?

What is this country's position on transplantations? I did ask the doctor at the Wachira and he merely brushed it off. Is this because it's too expensive? Or simply not feasible for advanced cancer of the liver?

I am also researching diet, which I believe plays the most important part in maintaining a healthy body. I stopped eating meat over thirty years ago, just fruit, vegetables and occasionally fish, and have never had a day in hospital.

I found something about turmeric (kamin as it's known here) and it's recently having been scientifically proven to not only ward off cancer of all kinds, but to reduce the tumors by way of helping reinforce health red blood cells.

Turmeric is everywhere here in the South, although my former teacher from Kanchanaburi said she didn't like Phuket food as there was too much turmeric in it. This I assume is because of the Muslim/Malay influencing cooking here. Would it be a good idea to at least have him prepared at least one food portion containing fresh turmeric per day? Green tea is also recommended, together with some brand from South America, but am wary of 'fads' in the form of particular brands.

I've also read acupuncture to be effective for cancer. Anyone have any experience of this? Many acupunturists here owing to Chinese influence.

I am trying to be realistic, but definitely see holistic medicine of all kinds to be a better alternative than the usual bag full of pills every day.

All recommendations and comments again, very welcome.

Sorry again to sound grim but from what you describe the simple reality is that it is too late for any type of curative treatment.

Acupuncture will have no effect on the cancer but may indeed be helpful for the pain and general comfort.

Tumeric has strong antioxidant properties and as such it has been postulated (but not proven) that its consumption might help reduce the incidence of cancer. There is no evidence at all to suggest it would cure an existing cancer.

I have seen many, many people with terminal cancer over the years resort to all manner of alternative/"holistic" treatments. Some of them lived a tad longer than might have been expected, but all of them died. Other than cost (which can be considerable, I have seen people wipe out their estates in search of miracle cures) no harm in these things though. IF your friend feels he wants to try them.

Which is the key point. I know you want to help him and he is lucky to have someone who cares as you do. But in order to help him you'll need to separate out your own feelings and need to believe that this isn't really happening from what he needs and how he is inclined to handle this.

He is dying from an incurable condition; that is the fact. People react differently in whether and how soon they can accept this. Some feel a need to grasp at straws and try anything that anyone claims will work, and unfortunately there is a huge industry that makes profit off that understandable urge. But nothing you have said indicates he is one of these and it may be more your need.

Don't push or suggest anything to him other than things that might make him more comfortable. Take your cue from him in terms of whether or not he wants to discuss his prognosis or ignore it. Don't offer him false hope or push him to try this that or the other. If he feels a need to do that he'll do it without any encouragement from you, there are just as many false cures being touted in Thailand as anywhere else.

One of the difficult decisions a person with a terminal illness has to deal with is at what point to stop fighting. This is made all the harder by the fact that Thai doctors seldom directly tell a patient the prognosis or involve them in the decision making process about, for example, whether the side effects etc of various life-prolonging measures (e.g. chemotherapy or radiation) are worth living a few weeks or months longer. So the patient is left to figure all this out for themselves. Pressure from friends and family to "fight" often make matters worse and often stem from their own inability to accept the prognosis.

Don't push anything on him unless it is directly related to his comfort. He has much less time left than you may realize. Just provide emotional support and do what you can to see that he is as comofortable as possible.

[Tolley]

On the topic of Hepatitis I had Hep B 25 years ago.

Could I still contract hep A or C and if so is my risk factor much greater having already had hepatitis B?

[jjonz]

Thank you all for your replies so far. I have of course started doing some research re liver cancer and have found that liver cancer very common in Thailand and Khon Kaen is the liver cancer capital of the world. Why is this do you think? Lao kao?

What is this country's position on transplantations? I did ask the doctor at the Wachira and he merely brushed it off. Is this because it's too expensive? Or simply not feasible for advanced cancer of the liver?

I am also researching diet, which I believe plays the most important part in maintaining a healthy body. I stopped eating meat over thirty years ago, just fruit, vegetables and occasionally fish, and have never had a day in hospital.

I found something about turmeric (kamin as it's known here) and it's recently having been scientifically proven to not only ward off cancer of all kinds, but to reduce the tumors by way of helping reinforce health red blood cells.

Turmeric is everywhere here in the South, although my former teacher from Kanchanaburi said she didn't like Phuket food as there was too much turmeric in it. This I assume is because of the Muslim/Malay influencing cooking here. Would it be a good idea to at least have him prepared at least one food portion containing fresh turmeric per day? Green tea is also recommended, together with some brand from South America, but am wary of 'fads' in the form of particular brands.

I've also read acupuncture to be effective for cancer. Anyone have any experience of this? Many acupunturists here owing to Chinese influence.

I am trying to be realistic, but definitely see holistic medicine of all kinds to be a better alternative than the usual bag full of pills every day.

All recommendations and comments again, very welcome.

Sorry again to sound grim but from what you describe the simple reality is that it is too late for any type of curative treatment.

Acupuncture will have no effect on the cancer but may indeed be helpful for the pain and general comfort.

Tumeric has strong antioxidant properties and as such it has been postulated (but not proven) that its consumption might help reduce the incidence of cancer. There is no evidence at all to suggest it would cure an existing cancer.

I have seen many, many people with terminal cancer over the years resort to all manner of alternative/"holistic" treatments. Some of them lived a tad longer than might have been expected, but all of them died. Other than cost (which can be considerable, I have seen people wipe out their estates in search of miracle cures) no harm in these things though. IF your friend feels he wants to try them.

Which is the key point. I know you want to help him and he is lucky to have someone who cares as you do. But in order to help him you'll need to separate out your own feelings and need to believe that this isn't really happening from what he needs and how he is inclined to handle this.

He is dying from an incurable condition; that is the fact. People react differently in whether and how soon they can accept this. Some feel a need to grasp at straws and try anything that anyone claims will work, and unfortunately there is a huge industry that makes profit off that understandable urge. But nothing you have said indicates he is one of these and it may be more your need.

Don't push or suggest anything to him other than things that might make him more comfortable. Take your cue from him in terms of whether or not he wants to discuss his prognosis or ignore it. Don't offer him false hope or push him to try this that or the other. If he feels a need to do that he'll do it without any encouragement from you, there are just as many false cures being touted in Thailand as anywhere else.

One of the difficult decisions a person with a terminal illness has to deal with is at what point to stop fighting. This is made all the harder by the fact that Thai doctors seldom directly tell a patient the prognosis or involve them in the decision making process about, for example, whether the side effects etc of various life-prolonging measures (e.g. chemotherapy or radiation) are worth living a few weeks or months longer. So the patient is left to figure all this out for themselves. Pressure from friends and family to "fight" often make matters worse and often stem from their own inability to accept the prognosis.

Don't push anything on him unless it is directly related to his comfort. He has much less time left than you may realize. Just provide emotional support and do what you can to see that he is as comofortable as possible.

And here's the rub! He still thinks, after my dragging the doctor (quite literally) to his bedside to explain exactly what was wrong with him, after which, he promptly left after a very short explanation, that all that needs to be done is a good flushing out!

But given that most Thais haven't a CLUE about the inner workings of their bodies, and all the trumpeting and hypocrisy by the various Thai government incarnates merely LECTURES but never ever explains about the outcome of drinking too much lao kao which in my view, should be outright banned along with Yabaa - you don't DIE from Yabaa. But it's the drink of the poor. Their one escape from the humdrum of day to day poverty. Ban the damned poison, just as they did with pocheen in Ireland! And really educate the Thais about the different properties of alcohol.

Which leads me on to another rant re the latest government 'crackdown' on pirated software, completely ignoring the fact that ALL the bottles of Gilbeys Gin, Absolut Vodka, Jack Daniels, everything - are ALL COPIES out of Bangkok factories. Could it possibly be that it's because the Thais are not known for their development of software, but for sure, a LOT of big businesses belonging to BIG families here are into alcohol?

I am, and have always been, a pragmatist. I will do what I CAN for him, because from what I've seen so far in the hospital, he's going to need someone with some knowledge of the proper diet, just for starters. When I visited him today, they were deliberating whether he was yet ready to move from a purely liquid diet to a kao thom based one. It took them over five hours to decide amongst several differing doctors and nurses, and one doctor suggested he might try that godawful sweetened faux yogurt drink they sell everywhere in those tiny bottles, completely disregarding the fact that sugar is to be avoided at all costs at this stage.

I am not a straw grasper but I've lived here many years and seen even the most educated Thai doctor completely neglect to inform their Thai patients regards prognosis and most particularly, diet. Has anyone ever seen a dietician in a hospital here? Mandatory in the West because we are taught diet incredibly important. Albeit that seems to have gone by the wayside with the upsurge in diabetes. A former poster pointed out that his Thai wife was of the view that doctors here don't like to give bad news as Thais don't like receiving it. I believe it's about time to properly educate the Thais and not patronize them, prevention far far better than cure.

Edited December 15, 2009 by jjonz

[nidhogg]

Thank you all for your replies so far. I have of course started doing some research re liver cancer and have found that liver cancer very common in Thailand and Khon Kaen is the liver cancer capital of the world. Why is this do you think? Lao kao?

Liver cancer is extremely high in Thailand as a result of three main causes:

1. Rampant alcoholism

2. High incidence of Hep B and to a lesser extent Hep C

3. high incidence of infection of liver flukes (Opisthorchis viverrini or Clonorchis sinensis).

The flukes come from the "pla rah" they put in som tam, particularly in the north east of Thailand.

I strongly advise anyone NOT to eat som tam plah rah.

[Sheryl]

And here's the rub! He still thinks, after my dragging the doctor (quite literally) to his bedside to explain exactly what was wrong with him, after which, he promptly left after a very short explanation, that all that needs to be done is a good flushing out!

But given that most Thais haven't a CLUE about the inner workings of their bodies, and all the trumpeting and hypocrisy by the various Thai government incarnates merely LECTURES but never ever explains about the outcome of drinking too much lao kao which in my view, should be outright banned along with Yabaa - you don't DIE from Yabaa. But it's the drink of the poor. Their one escape from the humdrum of day to day poverty. Ban the damned poison, just as they did with pocheen in Ireland! And really educate the Thais about the different properties of alcohol.

Even very uneducated Thais know that cancer of the liver is usually fatal. His believing that all he needs is a "good flushing out" likely has a lot more to do with his (understandably) not being ready to accept that he is dying than anything else. That is normal. How long the denial will last is an individual thing, some people come around pretty fast and some people never do but rather maintain the denial until literally their last breath.

You have done a good (and not easily accomplished!) thing in ensuring that the doctor actually told him what is wrong. From this point forward his understanding will be a matter of what he he is able to face. I find that this will flunctuate even in the same patient from moment to momenn; they may at times express understanding of their prognosis and talk about their forthcoming death or arrangements for their family etc and then just a few minutes later be back to talking about getting better. Learning that you are going to die, especially if the news is sudden and comes at a comparatively young age, is a major shock and the mind has its own ways of protecting the person from more shock than they can handle. It is best to neither confront nor assist the denial, just let it be, answer any direct questions he asks you honestly but don' volunteer information he doesn't give signs of being ready to hear.

Personally I'd let him eat anything at all he wants and can tolerate. It is not going to make much difference at this stage.

One important caveat: Everything I have said assumes that the diagnosis is certain. Has a liver biopsy been done to confirm?

It is not too likely they's get this diagnosis wrong but best to make certain as the management and prognosis are different if for example it is just cirrhosis.

He's really lucky to have such a caring friend at his side.

[Sheryl]

On the topic of Hepatitis I had Hep B 25 years ago.

Could I still contract hep A or C and if so is my risk factor much greater having already had hepatitis B?

Tolley,

Yes, you can still get Hep A and C.

The fact that someone has had one type of Hepatitis does not predispose them to getting others in and of itself, but because the routes of transmission/ behavioral risk factors are similiar, people with a history of Hep B are considered to be high risk for other forms. If behavioral risk factors no longer present then risk of contacting hep A or C is the same as anyone else's. However i consequences if you do will be worse.

There is an effective vaccine for Hep A, get it.

And if you have not already you need to be tested fr Hep B antigen to make sure you are not a chronic carrier. If you are, you are at increased risk of liver cancer and should (1) consult a specialist regarding antiviral therapy and (2) get periodic ultrasounds of the liver as if caught very early -- which usually means before any symptoms are present -- it is sometimes possible to cure.

[jjonz]

And here's the rub! He still thinks, after my dragging the doctor (quite literally) to his bedside to explain exactly what was wrong with him, after which, he promptly left after a very short explanation, that all that needs to be done is a good flushing out!

But given that most Thais haven't a CLUE about the inner workings of their bodies, and all the trumpeting and hypocrisy by the various Thai government incarnates merely LECTURES but never ever explains about the outcome of drinking too much lao kao which in my view, should be outright banned along with Yabaa - you don't DIE from Yabaa. But it's the drink of the poor. Their one escape from the humdrum of day to day poverty. Ban the damned poison, just as they did with pocheen in Ireland! And really educate the Thais about the different properties of alcohol.

Even very uneducated Thais know that cancer of the liver is usually fatal. His believing that all he needs is a "good flushing out" likely has a lot more to do with his (understandably) not being ready to accept that he is dying than anything else. That is normal. How long the denial will last is an individual thing, some people come around pretty fast and some people never do but rather maintain the denial until literally their last breath.

You have done a good (and not easily accomplished!) thing in ensuring that the doctor actually told him what is wrong. From this point forward his understanding will be a matter of what he he is able to face. I find that this will flunctuate even in the same patient from moment to momenn; they may at times express understanding of their prognosis and talk about their forthcoming death or arrangements for their family etc and then just a few minutes later be back to talking about getting better. Learning that you are going to die, especially if the news is sudden and comes at a comparatively young age, is a major shock and the mind has its own ways of protecting the person from more shock than they can handle. It is best to neither confront nor assist the denial, just let it be, answer any direct questions he asks you honestly but don' volunteer information he doesn't give signs of being ready to hear.

Personally I'd let him eat anything at all he wants and can tolerate. It is not going to make much difference at this stage.

One important caveat: Everything I have said assumes that the diagnosis is certain. Has a liver biopsy been done to confirm?

It is not too likely they's get this diagnosis wrong but best to make certain as the management and prognosis are different if for example it is just cirrhosis.

He's really lucky to have such a caring friend at his side.

Thankyou Sheryl for all your advice. Yesterday, after much consultation and differing opinions between the staff, the doctor who'd delivered the bad news said he could start to eat kao thom (rice porridge). So at least he's being able to get some food inside him.

He told me last night that another doctor (I'd never seen) had said that surgery 'might be possible'?! The first doctor seemed pretty emphatic that it was not. And no, a liver biopsy has not been done. Only x-rays and a CT scan. He's becoming pretty sceptical about what any of them say, he says several call by per day, all with differing opinions. I'm not straw grasping, but the fact that the 'cancer' is so localised and hasn't been detected anywhere else, together with the fact that his symptoms are very much the same as any disease of the liver raises a red flag.

I'm wary of asking a government hospital to conduct a biopsy. They do the best they can given the limited resources and number of patients they have to deal with. But I definitely get the impression questions are unwelcome.

Do you have any advice as to whether a government hospital here would carry out a biopsy? Move him to a private one for it to be carried out properly? Again, advice warmly welcomed.

Edited December 16, 2009 by jjonz

[Tolley]

On the topic of Hepatitis I had Hep B 25 years ago.

Could I still contract hep A or C and if so is my risk factor much greater having already had hepatitis B?

Tolley,

Yes, you can still get Hep A and C.

The fact that someone has had one type of Hepatitis does not predispose them to getting others in and of itself, but because the routes of transmission/ behavioral risk factors are similiar, people with a history of Hep B are considered to be high risk for other forms. If behavioral risk factors no longer present then risk of contacting hep A or C is the same as anyone else's. However i consequences if you do will be worse.

There is an effective vaccine for Hep A, get it.

And if you have not already you need to be tested fr Hep B antigen to make sure you are not a chronic carrier. If you are, you are at increased risk of liver cancer and should (1) consult a specialist regarding antiviral therapy and (2) get periodic ultrasounds of the liver as if caught very early -- which usually means before any symptoms are present -- it is sometimes possible to cure.

I never even knew I had had Hep B until I did blood tests to go and work in Saudi Arabia.

Apparently it resolved itself according to the doctor i spoke to.

I think i got it in India about 25 years ago although i am not sure but that is the only time i was ever really sick and i was terribly sick there for months.

[FBN]

On the topic of Hepatitis I had Hep B 25 years ago.

Could I still contract hep A or C and if so is my risk factor much greater having already had hepatitis B?

Yes, there is no cross-immunity with A or C. Risk for A & B remains the same.

About 60% of people who do get Hep B develop full immunity and 10% may remain carriers; so useful to check out your status on this one.

[FBN]

[

Do you have any advice as to whether a government hospital here would carry out a biopsy? Move him to a private one for it to be carried out properly? Again, advice warmly welcomed.

The indications for a biopsy are if there is some doubt about the condition but, in very advanced stages, may not be possible due to complications such as bleeding due to deranged liver functions etc.

Usually, clinical examination, ultrasound and blood tests such as Alpha-Fetoprotein levels and other liver function tests, including the Hep B, C profiles would be sufficient to make a diagnosis.

The only surgical option is a liver transplant but few centers world-wide will consider advanced/terminal liver Ca candidates for such procedures; I am not aware of any such in Thailand.

[Sheryl]

He told me last night that another doctor (I'd never seen) had said that surgery 'might be possible'?! The first doctor seemed pretty emphatic that it was not. And no, a liver biopsy has not been done. Only x-rays and a CT scan. He's becoming pretty sceptical about what any of them say, he says several call by per day, all with differing opinions. I'm not straw grasping, but the fact that the 'cancer' is so localised and hasn't been detected anywhere else, together with the fact that his symptoms are very much the same as any disease of the liver raises a red flag.

I'm wary of asking a government hospital to conduct a biopsy. They do the best they can given the limited resources and number of patients they have to deal with. But I definitely get the impression questions are unwelcome.

Do you have any advice as to whether a government hospital here would carry out a biopsy? Move him to a private one for it to be carried out properly? Again, advice warmly welcomed.

A provincial government hospital can do the biopsy but it appears that this one either thinks it unnecssary or too risky to do. Unnecessary would imply that the CT results are so strongly inidcative that there is no reasonable room for doubt; too risky would be if, as is often the case, his blood coagulation profile is abnormal.

As FBN indictaed there really is no curative surgical option. Resection of liver tumors is possible only in very early stages without cirrhosis; transplantation in addition to being very costly and hard to obtain is indicated only in very early cases where the lesions are quite small, and from his clinical condition this is not the case. .

It is hard to know what to make of his report of what the other doctor said especially since (1) patients having trouble coming to terms with a terminal diagnosis tend to have very selective hearing and may distort what they are told (unconsciously of course) and (2) Thai doctors are very, very hesitant to give bad news and nmay tend to equivocate in ways that allow false hope.

You are quite right that government hospitals do nto welcome questions, in fact that is the main problem with them. Among many other things it tends to create unnecessary mistrust and doubt in the patient and friends/family.

Based on my experince odds are that there is nothing at all wrong with the care he is being provided, just big problems with the way his doctors are communicating with him, which is I am sorry to say par for the course.

The expense entailed in transferring him to a private hospital would be considerable and it would almost certainly not alter the final outcome. However it migth be useful for him to be able to have a private consultation with a specialist in liver disease in order to get an another opinion of the findings and diagnosis and the kind of detailed explanattion and recommendations that are seldom forthcoming in a government facility. IF he is stable enough to either be discharged or to leave the hospital for a few hours, such a consultation might be helpful and would not cost much. It will probably just confirm what his doctors have already said and done, but may at least put to rest any doubts he has in them.

I had a smiliar situation with a neighbor who was diagnosed at age 30 with Parkinson's disease. Not so common at such a young age and due to very poor interpersonal communication by the doctors he was left confused and doubtful that they knew what they were doing. Took him to the country's foremost expert in it who spent 30 minutes explaining things and it resolved his doubts. Did not, unfortuntely, change his prognosis but at least he coukld then proceed with his care at the government hospital knowing that they were just bad communicators, not bad clinicians.

[jjonz]

I went to the Wachira yesterday afternoon to visit my friend who had had two puncture holes in either side of his lower abdomen, to let the air out - rather like a sheep.

He was then being wheeled into a ward full of incredibly thin men, he was the largest of them there, which turned out to be the 'terminal cancer' ward.

I spoke with the young doctor re a biopsy and he confirmed what you'd said about the fact that the CT scan showed it to be certain. He also said, when pressed, that he would need to stay up to another week before he 'might be let home'.

My concern now is to make sure he is as comfortable as possible, and given the fact the young doctor also told me, after some prodding, that he was only administering pain killing drugs (morphine), and nothing to prolong life, added to the fact the ward is indescribably awful, I would like to have him moved.

He's a very lovely man and it's heartrending to see him amongst all these poor terminally ill people in the latter stages - a constant reminder of what is to come. And I don't know if any of you have ever visited a Government 'terminal' ward, but the overall impression is that they are in the main, treated perfunctorily to the point of brusqueness by some, (but we needn't digress here now).

The ward is packed full, noisy and in my view, would absolutely hasten the death of anyone having to stay there due to lack of funds. It really is simply a 'dumping ground' for the poor.

Can anyone suggest where on Phuket he might be able to be transferred for the few days the doctor says he must be monitered in a hospital environment to check there are no further complications please? Bangkok Hospital not too far away, feasible?

I'm not leaving him there to rot.

Just as an aside, re Sheryl's remarks regarding liver transplantation. I have researched this and all the sites (not all commercial) say it is for 'later stage' cancer, even some with cirrhosis, not necessarily early stage, which in my view would make sense as the liver is the most regenerative of all the organs of the body - even living donors are sought to donate half, which grows back to normal size after only 4 to 5 weeks. By the by, the Bangkok offers at 60 USD, but the Chulalongkorn Mission Hospital in conjunction with the Red Cross in Bangkok, is credited as being the best hospital for transplant surgery in Thailand.

Edited December 17, 2009 by jjonz

[jjonz]

This is getting rather urgent as I need to have my friend transferred asap.

I called the Bangkok Hospital here on Phuket to ask about their cancer services. The advertise screening, but no specialist.

Does anyone know of a Private Hospital here on Phuket who has a CANCER SPECIALIST, and a good one to boot. (PS - what's the mo of, after having screened a patient and found them to have cancer? - Where are they transferred?)

[Sheryl]

From your description of his clinical state he is not a surgical candidate and would be unlikely to survive major surgery even in the very unlikely event you found a hospital and doctor willing to perform it.

I am not altogether clear what the purpose of keeping him in the hospital at this point is i.e. what other than paid meds are they doing for him?

The best thing for a terminally ill person, where possible, is to be cared for at home. However need to see if the hospital is prepared to provide him morphine on an outpatient basis (done all the time in the West but Thailand rather behind the times in this), and also need to consider his living situation in terms of how feasible that is, i.e. what family does he have? Can hire caretakers (even if necessary registered nurses) to look after him at home but there really needs to be someone else around supervising all that and ensuring his needs are properly addressed.

[Sheryl]

I am combining this with the other thread as the information in the other is necessary to addressing your question. Have edited title to make it more pertinent to where things are in the discussion, hope that's Ok with you.

"Cancer specialists" come in many different types.

If one is looking at attempting surgical treatment, that would a be A GI specialist with subspecialty in cancer of the liver. i do not believe this is an option for your friend but if he wishes could consult one to get another opinion on it. At Bangkok Hospital Phuket that would be the following:

Dr.Jirasit Thawornbut

Specialty: Gastroenterology

Language: Thai, English

Education:

• 1990-1994 : Staff in Medicine division, plublic health centre of Bangkok metropolitan administration

• 1994-1997 : Residency training

• 1997-1999 : Gl fellow training

• 2000 : ERCP training, Siriraj Hospital, Mahidol University (Dr.Yuttana Sattawatthamrong)

• 1999-2001 : Gastroenterologist and Hepatologist, National Cancer Institute, Bangkok, Thailand

Degree :

• 1984-1990 : Doctor of Medicine, from Siriraj Hospital, Mahidol University

• 1994-1995 : Postgraduate Clinical Science, from Siriraj Hospital, Mahidol University

• 1994-1997 Fellowship of Royal Thai College of Internal Medicine, from Siriraj Hospital, Mahidol University

• 1997-1999 : Fellowship of Gastroenterology, from Siriraj Hospital, Mahidol University

Research Field Research :

• Effect of lamivudine in chronic hepatitis B infection

• Interefron alpha-2b treatment in patients with chronic hepatitis B infection

• Efficacy of interferon alpha-2b combined with ribavirin in patients with chronic hepatitis

• Radiofrequency ablation in primary and secondary liver cancer

• Internal radiation therapy with Yttrium-90 for liver cancer

• Clinical utility of PCR for diagnosis of tuberculous peritonitis

Special Interest :

• Benign and Malignant dissase of Gastrointestinal tract, Liuer and pancrease

Membership in Societies :

• Member of Royal Thai College of internal meoicine

• Member of Thai Gastroenterology and Hepatology Association

• Member of Thai Medical Counsil

• Member of Thai Medical Association

Awards :

• 2nd award of Gastrointestinal

• Research of Thai Gastroenterology Association (1999)

Oncologists on the other hand provide chemotherapy. I don't think that is indicated in his case as the most he would gain would be a few more weeks or months of life at the expense of unpleasant side effects and more of it being spent in hospital. There do not appear to be any oncologists at Bangkok Phuket.

Lastly there are doctors who provide palliative care for the terminally ill. In Thailand there are very few doctors specializing in that, in fact I offhand only know of 2 and both of these are at Bangkok Hospital in Bangkok. However any doctor can provide palliative care if so inclined and sensitive to the need. Your friend is already getting morphine for comfort in the government hospital. As I indicated in my last post a key issue to settle is the feasibility of his being cared for in a home setting and then whether the doctors there will provide the necessary pain medication on an outpatient basis. In the west here are well developed hospice programs which do this but in Thailand you have to sort of put it together on your own, and it can be hard to get doctors to prescribe adequate pain killers for outpatient use.

I would guess -- and it is just a guess -- that the Mission Hospital might be better at palliative care, and certainly they would be less costly. And almost certainly a better atmosphere than in the government hospital.

So to make a long story short, for a second opinion on prognosis/treatment options, the doctor listed above at Bangkok Hospital. BH may or may not also be able to provide palliative care on an outpatient basis, if his living situation is such that this is feasible. If it is not feasible and he therefore needs to stay in a hospital jsut for palliative care I would suggest trying Mission Hospital first as Bangkok Hosp unlikely to be worth the considerably higher expense.

[jjonz]

I have now had my friend transferred from the abomination that is the terminal cancer ward of a Government hospital here in Thailand. And I am by no means squeamish.

The patients are give only morphine every day to relieve the pain, but nothing to relieve their various symptoms, in the case of cancer of the liver, itching of the skin and massive water retention are the two primary causes of incredible discomfort.

They are not able to sleep - even with the morphine - due to the constant noise of various breathing apparatus, coupled with on particularly horrible female orderly actually slapping some of them to get them to 'Go Shower'! at 2.30 in the morning?! Together with the awfulness of having to witness your co-patients in considerably distress, together with the distress of their constantly in attendance families - No privacy, No dignity, does not make for an environment of quality of life, let alone any chance of being able to make the best of what is left of one's health.

My friend is now much more comfortable, although extremely weak.

I asked the doctor regards transplantation (no harm in asking). He told me that donors were very hard to find here in Thailand (have no idea why - you should see the emergency admittance at the Wachira early every morning - brimming with moto casualties).

The doctor also confirmed my worst fears in that his white blood cells were too high and he would quite possibly either die during surgery, or if survived, live only a year or two after.

My concern is that he told me that he could probably to home on Monday, but when pressed, did say that further monitoring would be an option and that he could stay another two or three days if necessary. Bearing in mind this is a private hospital, they are by no means attempting to milk the patients, as has often been stated on this forum.

I can arrange for care for him at home should he need to be discharged - any info on home nursing here appreciated.

Given that the Bangkok Hospital, albeit a world apart from the Wachira, it still does not have an Oncology Department, the nearest being in Bangkok. My friend looks as though he could barely make it home, let alone Bangkok. Is there anything else available to treat/defeat the white blood cells amassing his body?

Again, to any Oncologists (or referrals out there), all advice warmly welcomed.

Edited December 20, 2009 by jjonz

[Sheryl]

I think the doctor may have referred to low platlets not high white blood cells. Which places him a t risk of hemorrhage.

AFAIK the only place in Phuket likely to have oncology services would be the government hospital, which obviously did not feel it would be advisable.

Chemotherapy is of very limited benefit in cancer of the liver and at best just gains the patient a few more months. From your description of this man's clinical condition, it would do more harm than good in his case.

I realize it is very hard to accept, but the sad fact is that your friend is terminally ill and has only a few months left. This would be true even if he were in the most advanced cancer facility in the world.

You need to come to terms with this if you are going to be able to help him through the next few months.

It is by far better for the patient to be cared for at home, just make sure the doctor will prescribe adequate pain killers oin an out-patient basis. I don't thibnk there is any organized home care program , you'll have to piece one together yourself. Ask the hospital staff if any of them know of any nurses and nurses' aides who do private duty work. I am also posting an inquery on your behalf in the Phuket forum.