The Cancer Journey
An Oncologist Should be Part of Your Cancer Journey
Whatever cancer you have or whatever stage it is, we recommend joint care between an oncologist and the surgeon or physician looking after you. An oncologist specializes in ONLY treating cancer and therefore, we are equipped to advise you throughout your cancer journey both early and late stage. Even if you do not need any therapy from us, we offer you invaluable advice, guidance and direction on your journey of treatment to recovery.
In some instances it is not the best approach to proceed directly from diagnosis to surgery. There are instances where going straight to surgery may lead to poorer survival outcomes compared to having some neoadjuvant treatment beforehand. In fact neoadjuvant therapy treatment (either systemic therapy or radiotherapy) given to shrink the tumour may enable the surgeon to more successfully remove the cancer, which translates to a better chance of cure. Examples of neoadjuvant therapy include radiotherapy before rectal cancer surgery, chemotherapy and targeted therapy for more advanced triple negative or HER2 positive breast cancer and chemotherapy before stomach and oesophageal cancer operations have all been shown to lead to better outcomes and cure rates.
Sometime after surgery, even though the main cancer has been removed, microscopic cancer cells may be left behind and if untreated will lead to recurrence and death. In these circumstances it is imperative to seek an oncologist to discuss if further adjuvant treatment is required. Some common situations are systemic therapy (including chemotherapy, hormonal therapy and targeted therapy) and radiotherapy after surgery for breast cancer. Chemotherapy after surgery for stage 2 or 3 colorectal cancer and adjuvant radiotherapy after head and neck surgery.
Choosing an Oncologist
Choosing the right doctor to walk with you through this cancer journey is crucial. The relationship may be years and it’s crucial to find the right oncologist to walk with you along this journey.
A good oncologist needs to be empathetic to your situation and communicate their thoughts and treatment plans clearly. They should also have the ability to listen well and appreciate the difficulties and struggles on the often long and hard road to recovery.
A good oncologist must also be up to date with the latest developments, their treatments must be evidence based and should not be based on hype. If in doubt ask your oncologist to justify and show you on what basis they are offering you a particular treatment; which guidelines are they referring to?(we recommend using NCCN guidelines or Reputable European Society Guidelines etc), Ask them to show or explain to you the actual research paper that justifies a particular treatment
How to Prepare for a Consultation
Check the qualifications of the oncologist concerned (see below)
Bring along all your records – of particular relevance are
biopsy results, also known as pathology or histopathology or HPE results
scans (radiology reports and the actual films or CD)
a list of drugs you are currently taking for any conditions related or unrelated to the cancer
Visit reputable websites (insert here link to procancer list of reputable websites) beforehand to get a rough idea of the options available for your cancer and the particular stage of cancer.
After the consultation double check your oncologists’ recommendations with reputable websites, relatives or friends who are medical doctors may help to explain and clarify certain points
What to ask your oncologist
1. What kind of Cancer Do I have ?
It is important to know – what the primary (where did the cancer start from). The origin of the cancer determines the staging and treatment for that cancer. For example if a breast cancer has spread to the liver is has
See “diagnosing cancer”
2. What Stage is my Cancer ?
Your doctor MUST tell you what stage you are. Cancers come in four stages, 1,2,3 and 4. Sometimes they are sub-categorized for example 1A, 1B.
Staging of cancer follows the TNM System:
T – tumour size and how much it has invaded the tissues around the primary
N – the degree of spread of the cancer to lymph nodes
M – metastases, whether the cancer has spread to other organs in the body.
Taking into account all T, N and M criteria we then assign the cancer stage be it from 1 to 4
3. What Treatment Options do I have ?
The most appropriate treatment for you depends on :
What type of primary – breast cancer, colon cancer etc. Targeted therapies, chemotherapy and immunotherapy that may work for one type of cancer eg. lung cancer may not work at all for other types of cancer eg. breast or colon cancer for example. So it is very important to determine the primary origin of the cancer.
Stage of the cancer – 1, 2, 3 or 4. The treatment strategy can vary quite a lot according to stage.
The aim of the treatment – cure versus palliative
How physically fit you are to receive the treatment – some consideration may be given to those who are unwell from other conditions for example diabetes, heart and respiratory illnesses, the elderly. Under such circumstances the treatment may have to be modified to be less aggressive, or at least initially and then slowly intensified
Qualifications for an Oncologist
MBBS, MBChB, MD – basic medical qualification
MRCP or FRCP (UK) – this signifies the doctor has passed the specialist examinations in internal medicine and is a member or fellow of the Royal College of Physicians UK
FRCR (UK) – this signifies the doctor has passed the specialist examinations in clinical oncology and is a fellow of the Royal College of Radiologists UK. This is the minimum qualification to practice as a Consultant Clinical Oncologist in the UK, but in itself does not allow a person to qualify as a consultant in the UK, they must have the CCT (UK).
CCT (UK) – Certificate of Completion of Training. This demonstrates the doctor has completed the MRCP(UK) and FRCR(UK) and 5 years of recognized training in a cancer center in the UK and is now able to be a Consultant Clinical Oncologist in the UK.
MCO – Masters in Clinical Oncology, this signifies the doctor has trained in Malaysia and passed the specialist examinations taken in a Malaysian University
An oncologist in the private sector in Malaysia must be registered on the National Specialist Register (NSR) to practice oncology. You can do an online search to ensure the doctor is indeed a registered specialist https://www.nsr.org.my/list11.asp
What is not Recognized as Specialist Qualifications
Diploma : a diploma is usually a taken as a taught course, whilst it is done for self-improvement it is rarely recognized as a specialist oncology qualification (except for historical reason in some countries)
Membership of :
ESMO (European Society for Medical Oncology)
ASCO (American Society of Clinical Oncology)
ESTRO (European Society for Radiotherapy and Oncology)
ASTRO (American Society for Radiation Oncology)
Membership of these professional organisations are made by registering and paying subscription fees, any doctor can be a member, even if they are not an oncologist. It is similar to joining a normal community club or society. Most oncologists will not include society membership as part of their official titles
Don’t be Pressured To Make a Decision
Please do not succumb to the pressure to make up your mind instantly. It is understandable that upon receiving the news of cancer, after being hit with a devastating diagnosis one may be tempted to react instantly and agree to the first solution offered.
Please bear in mind there are certain conditions that are immediately life-threatening and medically those may need immediate treatment. However, for the majority of cancer cases there is a window of opportunity to do a bit of self research, seek a second opinion or even to take a deep breath, process what is going on and ready yourself for the next step.
Patients should be given the opportunity to make an informed choice of what treatment they want and who delivers it. Patients should be given the opportunity to seek out a doctor who is an expert in their field who is able to give them all the options available, to refer to an oncologist or surgeon for joint care, and deliver the most effective treatment with the most modern methods.
For example after a colonoscopy and diagnosis of colon or rectal cancer, the patient may want to explore a good colorectal surgeon and oncologist and explore if they wish conventional or laparoscopic surgery or if neoadjuvant treatment is required. With complex surgical cases such as brain, pancreatic cancer or lung cancer surgery these types of surgery are best performed by experienced doctors who have sub-specialty training in these fields. In some cases after learning of a diagnosis of stage 4 cancer, some patients may be pressured to start chemotherapy the same day itself which is often unnecessary. As health professionals, there is no need to apply such pressure tactics.
Hype and Marketing versus Evidence Based Medicine (EBM)
It is not easy for the cancer patient to wade through the confusion of the multiple treatments on offer which are being advertised from all directions with impunity. Please be wary, people who shout the loudest may not have the best therapy for you, and even worse may do you harm. Cancer can be a lucrative business and not everyone out there purporting the latest treatment has your best interests at heart.
Whilst it may be “fashion” to offer expensive immunotherapy and targeted therapy treatments to patients, however these treatments will be of absolutely no use if used incorrectly. For example, offering immunotherapy such as nivolumab or pembrolizumab to colorectal and ovarian cancer patients who do not have mismatch repair instability (MSI) has a miniscule chance of benefiting the patient and moreover exposing the patients to unnecessary risk of side effects not to mention a huge financial burden.
Do not Delay
Whilst it is often reasonable to take a few days to consider the best treatment option. Due to overwhelming emotions such as fear or denial we have had patients who avoid treatment altogether only to return several months later with very advanced disease. Can if untreated will continue to grow and spread.
Seeking a Second Opinion
It is the patients’ right to seek a second opinion before they start any treatment and choose their treating oncologist. Patients should not be worried they may “hurt the feelings” of their doctor.