Last blog on non resectible Lung cancer

With the Yahoo blog coming to the close.
I would like to write my last blog on target drug therapy for non small cell lung cancer which turn out to be unresectable.

The treatment of lung cancer always falls into a trap of discovering the tumour late.
For small tumour in young patient, the impact on breathing and systemic upset is minimal.
Only large tumour is symptomatic
But it is not necessarily that small tumour need to grow big to disseminate to other part of body.

Quite a lot of patient present with serious or widespread metastases when diagnosed lung cancer.

Today tissue biopsy is mandatory as genetic study is important to guide target drug therapy.

Usually the EGFR is tested first followed by EMLA- ALK and some time Kras study.

The latter is mainly for prognosis purpose.

Is testing for EGFR mutation and ALK-FISH testing mutually exclusive each other?
Since if EGFR is +ve, oral tyrosine kinase inhibitor is used with good efficacy.

If EGFR is -ve, traditional chemotherapy with cisplatinum + permetrexed is the norm.

With failure of response to chemotherapy, the use of monotherapy with crizotinib is considered after ALK testing,
response is usually remarkable.

The concern of cost makes crizotinib not popular. As in every new drug without competition, usually the cost or charge is arbitary.
with oral TKI, now Iressa and erotinib( Tarceva) has good and patient- benefited competition. Not long later, a new oral TKI known as Icotinib will be entering the market, this would further bring down the charges.

Also the percentage of alk FISH mutation +ve is only 6 - 8 % wihich is growing as more patient are tested routinely.

But oral TKI does not eradicate the disease.
It dose shrink the disease but in much longer duration compared to debulking surgery.
Eradication of remaining non dividing tumour cells remain either the chemotherapy drug or self immunity.

Non cessation or long term oral drug therapy with TKI is compulsory.

So after Complete remission by all radiological or chemical criteria and clinical assessment, chemotherapy may be worthwhile.
Post down-staging debulking surgery may also be considered.

Rechallange with oral TKI after stopping is also reported sometimes to be useful.

So practically all lung cancer can be successfully palliated either with oral TKI drug or iv chemotherapy. But to improve survival, early detection is much more effective.
Cessation of smoking helps but genetic factor predisposing adenocarcinoma is  best fought with screening low dose CT scan of thorax.

Surgery is still the gold standard for curative treatment of lung cancer.

Dr Chung Shiu Shek   Phone 3160 88 65 or HK side 3543 1814

Advanced Lung Cancer

After long interval, I want to discuss a topic not unfamiliar in health post or public education material. The topic on ADVANCED Lung cancer. (晚期肺癌)

The diagnosis of cancer is very important to patient's life.  There is no permission of any degree of error whatsoever.  In addition to the verdict of malignant disease, the

type and stage of the cancer and the approach of staging or treatment must be communicated in skilful and easy to understand manner.  The avoidance of pessimism

(悲观主义) must be balanced with honest and candid approach.

For lung cancer, it is quite common to find out that patient with this disease falls into late stage group.  The handling of such patients demand skill and empathy.

More crucial, it is the time for physician to spend with the patient indirecly convey the sense of "captain ordering vessel abandonment" in its worst scenario.

Patients, especially the young and working group, would seldom recieve the message in positive way.


Nowadays, as spoken by one eminent local oncologist, the development of orally administered target enzyme blocker drug  for anti- lung cancer treatment

(Tyrosin kinase inhibitor, or TKI in short)  is a miles stone in the treatment of all cancers.  Compared to the invention of penicillin (Fleming in nineteenth century)

discovery of insulin synthesis, the invention of exogenous corticosteroid (Cushing in early twentithed century) , the accidental notice of anti-tuberculosis chemotherapy

(Streptomycin, in parenteral form), the use of first TKI gefitonib (Iressa ^R 易瑞沙) in advanced lung cancer brought hope to only small group of patients with lung cancer.

But the concept of personalised treatment of all cancer has revolutionized the entire medical community,

It is rather a change of personal treatment concept that has significant impact on entire medical community that the pursuit of genetic marker for most diseases has the

implication of treatment.

For example, the association of chromosomal abnormality  with retinoblastoma, the use of target therapy in iv form for Gastrointestinal Stromal cancer (GIST), the use of

propanolol for the treatment of facial or other childhood haemangioma, the screening for congenital hypothyroidism and familial polyposis. All these discoveries are not

applicable to all form of diseases but the spirit has strong repercussion on medical knowledge advancement. It is in fact a change of paradigm. (though a cliche陳詞濫調)

but very true)


The diagnosis of advanced lung cancer is usually based on PET scan (正電子斷層掃描) or advanced symptoms such as pleural effusion, hoarseness of voice

or palpable lymphadenopathy or multiple lesions in X ray/CT scan.   With the need for tissue for genetic study, the requirement for tissue confirmation and

genetic marker study is mandatory irrespective what stage of disease or patients' status are.

Using efficient DNA extraction  and/or amplification technique, even a small amount of tissue or cells are sufficient for EGFR receptor study.   Sometimes, the shredded

cells in pleural effusion specimen or TBNA (transbronchial needle aspiration biopsy) is enough for marker study.  Another study for the ALK- receptor study is more

expansive and less easily available (in both Universities' lab.).  Radiological guided biopsy can generate core of tissue (with 20 G or 18 G needle) which is even better.

For TBNA , if performed by endobronchial ultrasound, the accuracy is very acceptable and risk-free.  The endobronchial ultrasound is now widely available in all HA

hospitals and most private hospitals.

However, the aspirated cells are still less abundant than mediastinoscopic biopsy and both procedures should be complementary and not mutually exclusive

to lung cancer patients.


Finally, the handling of message to patients and their familes must be careful and consistent. It is best dealt with by patient 's primary care physicians.  So the consulting

Oncologist can spare the effort of bad news breaking.  Clinical oncologists can concentrate on various form of treatment and pros and cons of chemotherapy.

With oral TKI, target drug therapy is main stay for advanced lung cancer treatment.

For the rest of patients who did not have EGFR +ve addenocarcinoma, induction and maintenance of chemotherapy with Premetrexed or other drugs are well

tolerated and beneficial to young and fit patient.


I welcome all question on advanced lung cancer diagnostic procedure, such as CT guided Fine needle biopsy or core needle biopsy, Video assisted thoracoscopic,

Pleural effusion biopsy and eradication, Endobronchial ultrasound TBNA, Endoscopic Ultrasound FNAC and mediastinoscopy and Ultrasound guided neck or chest wall

biopsy.  My clinic no is 3160 8865.

My clinic in Mongkok (3160 8847) and in Central (3543 1814).

Lack of manpower in Cardiothoracic Surgery Divison in Prince of Wales Hospital

Doctors manpower supply is always a sensitive question to politician and general public.There is no point of satisfaction. More doctors mean more comprehensive service and shift the balance of power to patient's side. For all types of treatment approach, patient will have no choice or no say if there is an insurmountable statement of lack of man power.

In Cardiothoracic Surgery, this is creme de la creme of all surgical specialties. Competition for training post is difficult and learning of skill is tedious and demanding.The talent of the trainee will in some form or the other affect the maturity of the surgeon. The character of the surgeon in this field must be perfectionist in surgical skill, diplomat in dealing with relatives and colleagues and decision maker for difficult situation.  Training usually span for more than 6 - 8 years.

Also, the higher the professional ladder , the higher demand of time ane energy in this field.

Not long ago, this specialty has suffered a manpower loss with shift of senior surgeons to private market.

However, there is no lack of new comers and young budding surgeon to take up the challange.

There is no complaint of lack of surgeon then.

In fact, there is complaint of lack of cases and referral from their medical colleagues.

So, why is there a sudden outcry of lack of resources? Lack of doctors? Lack of trainees and expert surgeon?

This boils down to the surgeons desire of easy life and competition for resources.

For all 3 centres in Hong Kong, to speak the truth, I would say it is never the Prince of Wales Hospital that is lacking resources.

Indeed, the climbing of number of heart cases is evident to that.

The reason of demanding more manpower is just a gesture to demand for reward for the volume of cases.

In Cardiothroacic field, usually one doctor is shouldering responsibility that the mean number of works hours is among the highest in all field.
We cannot judge the number of expert surgeon needed in a large centre. Only that there is pros and cons of more expert surgeon. First the experience is diluted. Second the competition and challange of the team to meet different surgeons demand is high. The surgeons may be in standby time more than actual service. The number of operations delegated to experienced trainees are much less.

Overall, more supporting doctors are needed instead of mature surgeon in a busy unit.
Maybe it is Prince of Wales Hospital CT Surgery Division wish to recruit more basic or higher surgical trainee instead of saying there is failure of retention of experienced staff.

Who would like to see their surgery postponed or waiting list lengthened from patients perspective.
But it is still an unknown black hole of crying for more resources.

(Back in the old days, when I was the only cardiothroacic first call surgeon, I and one experienced cardiothoracic surgeon manage the whole services with annual number of open heart surgery 60 - 80 per year and 300 throacic operations and average 2 - 3 major trauma consultations in the same setting of the teaching hosptial. I have not expressed of lacking manpower in year before the turn of millenium)

Need of Histological confirmation of Advanced staged Cancer

Cancer is a lethal disease. However, cancer seldom lead to immediate death.
For patient in acute care setting, infectious disease, trauma and vascular events account for nearly all emergency collapse or demise of previously healthy patient.

Nowadays, we talk about personalised treatment of cancer, we need to know the type and DNA of the cancer cells to formulate a treatment plan for the patient.
In patient when cancer presented with advanced stage of disease, should the medcial personnel insist of obtaining histological or pathological confirmation before proceeding for treatment.

There is usually a dilemma. To obtain biospy of tumour. If deep seating tumour, the risk is considerable. And if the tumour has spread to important oragnas such as brain or heart, to touch this area means major suffering.
So the chance of cure, if absent, should not warrant aggressive biopsy.
However some lesser invasive means if done under good techniques will help obtaining tissue for lung cancer.

They are:

Video assisted pleural biopsy of effusion drainage- targeted pleural biospy and effusion drainage

Bronchosocpic biopsy or transbronchial biopsy under sedation and locan anaesthetics

Endobronchial ultrasound transbronchial fine needle aspiration of paratracheal and carinal lymph nodes

Percutaneous fine needle imaging guided biospy of lung

By obtaining biopsy sample , the nature of cancer can be defined. The genetic and DNA studies of cancer cells can be pursued.

Personalised treatment and palliation of cancer can be achieved.

Yet, those method are however expensive.

Judicious choice of investigation will determine the success rate. Do need to seek specialist advise. For lung cancer, a cardiothoracic surgical specialist is essential.

To excise nodules directly or take in biopsy first - an issue of taking chance

In private sectors, not all patients come for treatment. They are just coming for second opinion. This is a hypothetical scenario to seek help from two soucess. If different, they would not jump on the treatment plan. If more or less the same or the reason given is the same, they can then opt for the original treatment plan. Rarely, they may accept the suggestion of treatment plan of the second doctor. And switch to the new care giver.

For me, as an experienced surgeon, the line of thinking of pursuing one investigation or other is more or less natural to me. Some nodules in the lung, I wound quickly advise surgery. Whether it is open or minimally invasive is not a major issue. The chance of missing lethal lung cancer is the main concern.
For some nodules with background of lot of disease, with chance of multiple metastases or just more likely a reactive change, I wound suggest observation or biopsy. Not always matter with the size. But to balance the chance of morbidity free surgery versus over - positive thinking.

Indeed, as advocated in my earlier blog, size if more than 9 mm should be annually re CT and excised once the possibility of benign lesion cannot be fully established.
Size less than 6 mm can be safely watched. Above 6 mm, can be watched for 3 or 4 years and left alone.
But there is always some exception. Sometime for over cautious patient, needle biopsy is essential though clinically likely Ca Lung is well suggested.

And the way to deal with negative biopsy has to be evaluated. If patient or doctors are totally insecure of leaving the nodule alone. Needle biopsy can be omitted.
For patients where non operative option is highly favorable, like bleeding tendency, very elderly, bread winner of family, needle biopsy at least clear some uncertainty in this occasion.

If patient  otherwise fit and healthy, Video assisted wedge biopsy is always justifiable if the lesion is regarded as suspicious.
For highly likely non malignant case, say with normal CEA, non smoker and calcified mass or very low PET SUV, needle biopsy is safe to document the non malignant nature in a way better than sitting on X ray comment alone.

Milk powder issue - A medcial or marketing issue

Milk product is essential in every part of human life.  There is no doubt that the best choice for infant feeding being breast milk.  For practicality, in every modern society, milk formula is popular as alternative.

From 2010, there is widely known fact or news that milk formula is the target of every Mainland visitors.  Especially in northern district, the dispensary retail outlets run out of infant milk formular in days and weeks.  Actually, it also occurs from time to time in urban Kowloon. The situation in Hong Kong island may be better.  But the cost of inflation, salary and shop rental push the price of milk product to sky high. Therefore the search for cheap milk products in some selected retail is much keener.  In big retail chains, they transfer all cost of high rental to customer. The price of milk formula is higher in such chains. But in individual shop, the demand of milk formula is much more intense if they do not raise price tremenduouly.

So the problem is there for 2008, 2009 , 2010 then 2011 - 13.  Local birth rises and climaxes at year of 2012.  Therefore the voice of milk powder control is higher and stronger.  For same reason, the privilege of choice exists for mainland mother too. If not all Hong Kong mothers give breast milk to their kids, why can't mainland mothers give better quality milk formula to their off springs.  So there is no wrong or right for them to search milk formula in Hong Kong or through their agents.. Even if mainlanders buy milk formula in Hong Kong and resell for profit. They are not morally right or wrong.

To curb the high competition for milk formula in local stores, immigration control of milk formula is instituted.
This is drastic measure. Back in 2008 or 2009, the competition of milk products is left to the market force that the place where demand is high push up the price. When the price is high the customers drift to other region. Then the supply is back and price is adjusted down and the customer flog back and push up the price once again.
The market control is successful but slow.

Urgency for securing supply of milk formula is there.  So rules set in.
Some scholars advise the baby to switch to whatever brand the mother can get hold of. Theorectically it is sound. But we can do better by sticking to one brand.
Actually, on can observe the same strategy exist for mainland visitors too. They are not just buying on brand only. They prefer one brand. Then if it is out of stock, they don't mind and purchase other brands and transfer up to mainland.


Milk formula are no different from one and other. The only difference is the confidence in the brand.
So that lies on the marketing strategy of each brand.
For milk formula sold solely in HK without distributors in mainland, they can obviously attract more customer.
But of course, no firm or company will look down on the vastness of mainland market.
For some reason, they cannot enter to mainland market directly, then they promote itself more intense in HK so that mainland customers prefer to ship large amout ot it to China.

For local mothers, I would suggest that most infants are capable of tolerating adult milk formula once they reach the age of 8 to 9 months. There body system develop stronger adaptability. In fact the difference between adult and infant milk formula is only minute. As in dfference of different brand, the adult milk may contain more sodium or other substance. So long as trial of milk by infant is successful, they can tolerate adult formula. Then the competition for infant formula can be left to neonate under age of 8 months.

Lastly, I wound point out that milk powder demand fluctuate widely. Maybe in next 5 or 10 years, no one would buy infant formula from Hong Kong. They may buy it direct from supplier. Then, for Hong Kong government, they will limit their own business by insituting so called proctecting local mother rules.

Pneumothorax - a life threatening disease

 

Recently I came across a news peculiar to pneumothorax.  An adolescent aged 18 of a single parent family committed suicide becasue of health trouble of recurrent pneumothorax.  Even working in the field specialising for pneumothorax surgery, I am not aware of similar case.





Although there is high chance that this patient may have psychiatric illness, it is shocking such a treatable disease lead to this tragedy.  The adolescent with pneumothorax must be dissatisfied with the treatment. The recurrence must be frequent causing disruption of school and social life.  With the introduction of minimally invasive thoracic surgery (also named VATS for Video assisted Thoracic Surgery), pleural disease like pneumothorax is easily treated.  However, the popularity of using VATS do induce non -expert surgeons to operate more.  Recurrent pneumothorax (if recur after the first attempt of surgery) do need referral to specialised experienced thoracic surgeons with keen interest in VATS.

Operations maneuvers for treating recurrence must include:

1. Proper identification of lung bleb (weakness of lung causing air leak)

2. Consideration of additional procedure like: pleurectomy, limited deocortication and adhesiolysis esp for lung adhering to medial part of diaphragm
and pleural tenting or transient phrenic nerve paralysis

3. Adding chemical agents like talc insufflation and chemical agents silver nitrate, fibrin glue and oxytetracycline , concentrated glucose

4. Position of suitable drain or drains (2 drains)

5. If patient allow and prefer early discharge, use of ambulatory draiange device or drainage bag with valve.

Proper procedure can reduce the recurrence to less than 3 %.

With patient aging beyond 35, the possiblity is low by nature. But with good surgery, if there is no recurrence in the post operative 3 - 4 years, the chance of recurremce is much less though not unheard of.

Sometime, pneumothorax cause problem of immobilisation. In old days, a young patient has open pleurodesis operation and subsequent deep vein thrombosis. He was put on anticoagulant but unfortunately develop hemothorax in recent operated chest. A redo thoracotomy is needed and patient has prolonged hospital stay.

In patient with Marfan's syndrome, recurrent hemopneumothorax may be troublesome.


By Dr Chung Shiu Shek

Multiple recurrence of spontaneous pneumothorax

Treatment of pneumothorax has not been standardised until 18- 19 years ago with the introduction of video assisted thoracoscopic surgery.
With simplicity of steps inovolved in bleb ligation and mechanical rub pleurodesis, the vision and access to majority of chest wall by videoscope allow easy performance of pleurodesis for patient.

Also the patient is usually is young and fit other than the pleural disease, the general anaesthesia procedure with double lumen endobronchial tube is well tolerated.

I remember the excitement when the laparoscopic instrument was put in the first few patient for VATS surgery back in 1992. We have looked at the bleb and feel extremely appealing and derive great satisfaction of putting the endo-loop on the apex. But not long after two or three such cases, dislodgement of the endo loop occur and we stick to using the endo stapler (the first generation of Autosuture endo GIA) for pneumothorax bleb resection.

For successful pleurodesis, certain amount of dense or extensive adhesion should be formed after the drain pulled and patient went home. Not infrequently, we do see patients with failed adhesion formation.

The means to prevent this include:

1. Keep the drain longer (but ususally drain has to pulled out after 6 or 7 days, usually the maximal duration that a young patient can tolerate without complaint.

2. Meticulous rubbing of pleural surface and chest wall is required.

3. Secure sealing of air leak point in lung

4. Modification of technique with addition of chemical sclerosant for every case.

There is discussion of the philosophy of first operation for VAT pleurodesis.
Some surgeon propose inclusion of small axillary or small maximally minithoracotomy in anteior port for better stapling of weak apex. The lung is mobilised down to the lung root near the SVC and hilar and lung apex delivered to outside through the throacotomy and single GIA application +/- oversewing is better than multiple fire.
Through the thoracotomy, the air leak can be tested and additional procedure of limited open pleurectomy can be added. Also the problem of intercostal neuralgia due to fulcrum pressure on the port site is avoided. The only small instrument port site will be the final drain site.

So there is revertion to minithoracotomy and Video assisted open thoracic surgery rather than keyhole VATS for pneumothorax.

The recurrence rate can be brought down from previously 10% to 4 or 5 %.

Recently I come across patients with immediate persistent air leak after first VAT surgery for pneumothorax and contralateral recurrence of pneumothorax.
I applied VAT endoscopic pleurectomy and ambulatory drainage method. The success is high and expected adhesion formation is secure.

I am practising specialist in pnemothorax and all kinds of thoracic surgery. I welcome question and queries for their problem with reasonable low consultation fee.
Clinic phone number: 3160 8865

Current trend of wound-less surgery in lung cancer: pushing to the limit of single 25mm wound

Single port surgery is the current trend in minimally invasive surgery. For lung cancer surgery, the adoption of extreme small wound is cautioned by the possibility of compromise of oncological clearance. However, as experience accumulate since the introduction of VATS surgery, the worry of delayed relapse or early recurrence is less of a concern. More and more surgeon believe in the reverse. With less immune suppressive effect of minimal access surgery, survival is prolonged for VAT operable lung cancer.
Recently I attend a workshop for the update of VATS in lung resection. Without expecting anything new to discover, the enthusiasm of speakers for VATS experience remains high despite coming along all those years of minimally invasive surgery. Yet they stress on the fact that only surgeon with a vision can push for limit of traditional belief and constraint.
So long as the surgeon believe in doing surgery with due care and good suprevision, pushing to the limit of two small wound then single uniport wound is best to achieve good recovery for same type of lung resection surgery. However, there is limit to everything. If it takes hours for the lung cancer to be removed when a slightly larger wound could allow swifter but not necessarily better clearance of tumour. One may not be too dogmatic to fight for shorter wound length.
Moreover, the reason of learning curve is not short for Uniport surgery.
From example of uniport laparoscopic cholesystectomy, the time will much vary with the inflammatory condition of the gallbladder. In occasional attempt, surgeon will take twice the usual time for difficult gallbladder.
I believe well trained surgeons do know the limit of his own and possiblitly of fatigue and psychological burden of prolonged surgery, they would convert at appropriate time. The imperative is patient's safety and the least of concern is surgeon's ego.

I applaud the skill and determination of surgeon pursing uniport VAT lobectomy. But  I personally would select less than 10% of all operable lung cancer for such attempt.

Value of Life or Health - Perspective from health care helper

As doctors, most of the medical ailments are commonly known to us. We understand that most of the complaint about pain and ache or discomfort did not signify important illness. This is to be said with a caution such as coughing out blood, severe weight loss, depression with suicidal thought or severe spontaneous syncope.
Conversely, some severe life threatening disease may not have symptoms.

I have talked about screening in previous blog and stress that the benefit of screening for example in lung cancer is not to be down played. However, there is a need for mentality and financial resource for proper screening. Acutally the drive is more important than money in such cases.

But when it come to important illness such as severe pneumonia, renal failure, severe trauma or stroke, medical personnels are the least to cope with this. Their knowledge would bring some advantage but add worry to the treatment course.

To me, the loss of life turn out to be some daily events. More eye cathing are victims in natural disaster, violence such as rape or terrorism or medical mishap or early cancer in young adults. Acutually, life is quite vulnerable. The possibility of serious blow to it is always there.

To treasure it is really necessary for us to rethink eveything. Our existence certaily would be transient in the history of time. If at one time and at one place, we can make our surrounding or family happy. Out existence will add meaning to us all.

For me, I would try my best to give the best possible treatment to them. I cannot change my patient's fate. At most, I hope to give them the best attiotude to face life and death. Treasure existing life but forget tommorrow trouble.

Dr Chung Shiu Shek tel of clinic: 31608865

Sino Japanese Relationship

As a medical professional, we like to talk about politics but seldom take it serious. With wide coverage and nearly daily report of riots in China, the tension between China (PRC) and Japan is on every news' front page.  We all know from the day of birth that Chinese and Japan are competing countries and seldom in good terms. But the value of peaceful coexistence is more than everything to avoid mutual terror at World War II.  As Chinese, the sense of being treated unfairly is especially sharp. From Japanese society, their education may be deviated towards self righeousness; but most japanese are well educated and also believe in peace rather than militarism.

Why do the approach of the subject create so many news and tension?  The answer should be timing. As Diaoyu island is an old problem, whehter you want or not, practically it is under the control of Japanese force.  As these problem has been years, and nearly no interest about it by Japanese governement. Why japanese want action or something to be done recently. Usually the target against another nation help stabilise force and create unity in home country in favour of the existing power. They are used by both government to consolidate  power. In China, the future of post HU Jianto governement has been clear but not fully established. To push aside discrepancy of opinion, the need of unity for different ages or different force within the central government is important. More than anything, the hate against japanese invasion can be used once again for Vice Premiere Xi to assume good central control of power.

To Japanese government, the power of democratic party has never been stable since take over of premiereship from opposing self democratic party. They are faced again by tragedy of nuclear incident. They need more fame and esteem to stay solid in control of Japan. To unify the parliament, the pride of owning Diaoyu island is brought in again. In fact Japan own this island for ages. is there any need for power or petroleum over there? I thnik no, the economic advantage is not great, The susceptibility of being invaded or destroyed by other force make investment risky. From recent report on Japaneses newsmedia, there is comment or criticism of current act of Japanese government. So not all japanese want War as depicted by chinese media.

Why the newspaper always focus on this? To sell more paper and be only source for news. In War times, newspaper sell. Remember 9/11, suddenly everyone want to grap newspaper as research by reporter attract more attention and bring satiety to news hunger in public.

So we would heard about riots , tension, demonstration against Japan in Chinese news. But not after the 18th NPC commitee. By then, every protest will be suppressed. Peaceful talk with Japan will begin. Concession for mutual benefit will be granted. Any civilian upset about government weakness will be gone. No news about Diayo island will be publicised. Like the control of internet, there would be information control as tight that even thought there is protest, it will not be reported or mentioned in any media.

As for the Japanese, the status of the island will remained the same. You can call it nationalisation. You can call is isolation. Thus, there is no real owners and no transaction of money ever to be made in the Bank for the ownership of the island. Japanese media has no interest and never want to be made use of by their polictian. The Diaoyu island cannot be anything of financially as one thousandth of Tokyo or even the nuclear accident town. They are just hyperbole of the news media.

Thank to the gift of life: on the recieving end

As medical professional, the preciousness of life make some of our patients extremely grateful to us. But is it our preference to have such feeling and reaction. Or is it the absence of such action make us uncomfortable or dissatisfied. From the patient point of view, will our action of grafeful feedback secure better follow up service?

I recently read about the ICU dying patient news about recieving a generous cavdever organ donation. The news state that as an emotional reaction, the heart surgeon shed his or her tears saying that the patient should treasure this timely gift of life.  I usually feel uneasy about that emotional side of providing medical treatment. But the meaning of doctors act should however touches heart of most patient and people.

For doctor either recieving pay from public money or from paying patient 's pocket, they are suitably remunmerated with proportionally correct sum. The doctor has the de facto responsibility to carry out a good and technically right work.  Compliment to doctor success is thus an extra.  Having said that, doctors usually appreciate very much the thankfullness of their patient. Sometime these are driving force for doctors altruism.

Once I have the experience of being touched by my patient's word. He is a gentlemen and always thanks me for whatever procedure or treatment I provide him.  Once I talked casually to him. Do not be too courteous , you know you have paid me for my professional service. I owe you the trust. He responded calmly. Dr Chung, I know I have paid all the professional fee related to my treatment and I knowed I am entitled to high standard care. But regarding your service and careful adminstration of care, I still owe you a words of thank because of trueworthiness of your work. Our care and attention if acted from our heart are much valued by our patient.

Occasionally as private specialist, the care of long term disease bring much concern to financial burden.  So some of my patients will not return for follow up. This is reasonable as chronic disease can bear the burden of waiting list and these conditions can best be dealt with in public sectors. Anyway, I would not anticipate that all patient will be my faithful followers for life.  Sometimes, I heard complimentary words about my service but later default in follow up. I find it perplexing to understand. But In the real world, this is not uncommon.

In essence, I do feel good on the recieving end of thank and gratefullness. But do not take it too serious as your driving force. Some patients and most indeed has the concern of financial constraint.  They are entitled to develop way to secure best mode of care to them. So they would swarm between private and public care depending what fit them most.  However, I do feel satisfied after tough surgery or long operation, the patient or patient's relative say from their heart: You have done a great job. You have done a favour to them.

Surgeon with a heart: I am Dr Chung Shiu Shek specialist in Cardiothoracic Surgery, Clinic phone no: 3160 8865

Cancer: cure or control

Lung cancer is common and a fatal disease if not treated early and appropriately.  Quite a number of patient with lung cancer has physically normal lifestyle until the time of detection. The psychological trauma is no doubt great. With the improvement of drug and radiation treatment, more option is available on top of curative surgery. Are over treatment always produce good result and ensure good long term outcome?
This question has occurred more than couples of time for real cases.
Usually they are relatively young patient and locally advanced disease.

I personally would stick to traditional guide line but allow oncologist to have tailored made decision with different patients. Most oncologist has keeness for chemotherapy and less favor towards post operative RT. (of course they are exception)

So the cancer boil down to control or cure debate? Must all treatment be comprehensive to be exhaustive that near absolute cure is the best?  In fact life is in a cycle. No living organism is blessed with everlasting existence. Most persons are destined to have limited lifespan about 70 or 90 years.  If the treatment can restore our body to near normal life expectency, then probably this is already the best.  Say if the cancer recur at age of 90 or even 87, we would rather not treat but palliate the cancer. Cancer drug itself may be carcinogenic in long run. Too much treatment , if not necessary, may even do harm then good.

For a different group of cancer patients, they are elderly with moderately advanced disease. So the primary aim is opting for cure within the tolerance ability of the patient. Secondly, control of symptom will be more important than too aggressive treatment.  Minimally invasive surgery are therefore of most benefit to this group of patient.  I have done a few such cases with small wound for old patient. They all come around the surgery satisfactorily. In such group of patient, too aggressive chemotherapy may be of considerable side effect.

For terminal cases where palliation of symptom is most important. Control with oral anticancer or target drug is the best. Luckily, these drug are well tolerated even in elderly. However, the cost may be substantial. Recently I heard about interesting presentation stating thalidomide, metformin and some other old style drugs has anti cancer effect that their use can bring palliative symptom relief at low cost.

I am Dr SS Chung specialist in Cardiothoracic Surgery and expert in lung cancer treatment. My clinic no is 3160 8865

Need for more doctors in public sector

As a private medcial specialist, the public service is not my major concern. In fact one may eye public sector as direct competitor for patients.
However, as part of the medical community, the state of running of public sector has a lot to be in consideration.

Over 60% doctors registered in Hong Kong are in private practice. Less than 40% work in the public sector.  Over 90% of patient are attending public hospital or clinic services.  The demand is already under control by crowding or long waiting list or concern for delay aspect.  Also the public sector has to shelter the purpose of training, internship supervision and front line reseach and other continued medical training problem. Last but not least, there is a lot of public services such as the arena of East Asian games, preparation of disaster, SARS drill training and mangerial work.

So we need more working hands in public sector, as versus we want more doctors in community. As in many large corporation, retention of human resources or experienced worker is key to success of an institution. So we should look into individual institution and develop ways to retain experienced person. Every year, there is new graduate who would largely join the public services. Out of all these trainess,only one third of them are fully trained and worked satisfactorily in their position. Although, for healthy institution, some movement of manpower is inevitable. However, for particular field such as medical field in Tuen Mun Hospital, A/E department in various hospitals or anaesthesia field. Shortage is constant.

So why did doctors move to private practice despite advantages of stable salary in public sector.
In fact, it is a competition to be retained inside the research based institution in oversea medical field.

Constraint of medical practice and overwork is keypoint for dissatisfaction.
Human resources control is another factor.

The burden of public doctors in senior role is always higher than their private counterpart.

Hierachy in pulbic service is also the reason for stress,

For example, every newly qualified specialist has to shoulder the clinical burden fo patient complaint or untoward event or even to unjustified complaint. However, the doctor has the right to choose his patient, call pattern or working subspecialty.

The clinical hierachy has been two tiered, resident and specialist.

However, the managerial hiearchy is long. HCE - COS - Team Head - Senor specialist - specialist - resident. So there is high likelihood that the senior guys choose the gem of the department and leave the tough and donkey work to the lower tier. Even worse, the reporting mechanism in HA is causing constraint of whistle blower, the poor performance of the senior is never reported and will be penalised. The senior control the promotion and yearly assessment of lower class workers.

Further more, the competence of junior doctors is largely reliance on altruistic sacrifice of the senior person. If the senior person would not teach his helpers for skill and training, the junior will foreever will be untrained unskilled doctor that see no satifaction of job. With such situation there is no way to ensure the senior doctor to do their job. They claim to provide consultant level to all patients by depriving the less experienced training opportunity.

For health care administrator, the over dominence of COS or department team head make job satisfaction ot lower class doctor impossible to be achieved.

Therefore the proposal of two tier system and the non-involved third party for specialist consultation or assessment must be implemented to eliminate such problem.
So as clinical duty is two tier, the managerial or reporting duty should also be two tier. An non involved committee is created to assess the capability and performance the two tiers. For junior specialist,they should care for less number of patient and be remnumerated less. As their performance justify more patient, more patient load is directed to him and more salary is given to the two tier team.

This is a preliminary thinking of how we should improve our public care system. Will discuss more in future.
Thank for reading. I am Dr SS Chung
Chung Shiu Shek Specialist in Cardiothroacic Surgery

Reward to doctor

I am discussing the satisfying experience as a specialist doctor. In fact, although there is everyday news of mis management and medico legal incidence. The number of successful medcial treatment far outweigh the complaint case.
Also for chronic disease, the compliance of the patient is partly the success of communication skill delivered by his care givers.

Peolple usually measure the amount of gratefulness by the amount of fee they are paying their doctors.  However, the art of charging medical treament professional fee is the skill of making compromise.  No same doctors charge same amount. No same cases are charged same amount. I think the customer would anticipate variation of service fee. Of course, in free market, there is no rule to set the price limit. The affordability is a guide. The supply and demand of the doctor's time is a factor. But as doctors are deriving their satifsfaction from successfully treating one disease, the amount they charge should be reasonable to induce patient to turn to private sector for more efficient and personalised care.

Recently I have performed two operations for two patients with severe retrosternal mass causing aerodigestive compression. The courses of the medical treatment is challenging and difficult. One patient required temporary tracheostomy for prevention of repeated aspiration because of temporary paralysis of the vocal cord. She made satisfactory but testing recovery from her operation. Although she has some loss of confidence in her own physical ability and treatment progress, she is overall compliant of necessary step for rehabilitation. Deep in her mind, she has felt relief of potential hazard of airway compromise and dysphagia she had for long years. I was impressed by her stamina and honest trust and doubt on the course of treatment. She paid for the medical cost out of her savings without complaint.

For the second patient, he has airway compromise and rapidly desaturation after induction of anaesthesia. Though previously without any symptom of breathing difficulty, the weight of the mass and relaxation of muslce tone cause compression of airway deep down on the bifurcation of windpipe. Forutnately the anaesthetist has placed the long enough breathing tube (an endobronchial ventilation plastic tube) to the right main bronchus, maintaining good oxygen supply to the body despite lack of air to the L side.  With time constraint and possible disastrous outcome of irreversible hypoxia, I  with two experieneced surgeons' help expeditiously removed the compressing mass with tedious but careful steps. Airway patency was achieved after the mass was delivered out of the wound. She made rapid and uneventful recovery. She was grateful to the surgeons and their team.  Even without being told exactly the challenging moment of the perioperative difficulty, she understood the complexity and the risk of the operation involved. She revealed her fear when other physicians describe how difficult and risky will be an attempt on the operation.

As an experienced specialist thoracic surgeon, I did not underestimate the risk of the operation. With good preoperative planning and prepartion (including to solicit good assitant surgeons help and anaesthesia and last but no least nursing team), the risk was minimised as much as possible. Preop counselling and education to prevent sputum retention, wound complication and post operative deep vein thrombosis were done. Post operative ICU care and prepartion to standby for any unexpected deleterious outcome was pre arranged.  With confidence and knowledgable communication, the patient was inspired to think positively and to overcome the fear.
Good cooperation helps the perfect outcome.

I did not ask for high financial reward for difficult operation. The trust and willingness to put their life to me is the highest honour the patient would give. Like the second case, I would anticipate the market price for such operation would be double the fee I collected. Given the dangerous and stressful situation, the operation is very demanding. A reward proportional to risk and preoperative planning skill is not unreasonable. But the happiness in seeing a fruiful outcome is immensely rewarding.

Lastly I mention two situations when I was in public hospital to make contrast with private health care.

First, for the very first heart transplant patient in Hong Kong dating back to 1992, I witnessed the harvesting surgery as I was assisting the harvest of the liver on the same donor in public hospital late in the night. After 21 year, the patient appears in the media for celebration of the Hong Kong University heart transplant team anniversary, most surgeon appears cheerful and delighted. I am also impressed the satisfaction derived from minor role I take part for this patient.

Shortly before I left my previous public surgical unit, I encountered two patients with late presentation of thymic tumour invading through pericardium into heart. In one patient I peformed debulking with thymectomy and pericardectomy and shaving of most tumour from R ventricular surface. Before operation I mentioned to the patient that the operation result was not guaranteed as remaining tumour would persist and rendered the operation unsuccessful. The patient told me that she put her life and hope on my hands without hesistation. Not suprisingly I found out that in more than two occasions, she was refused surgical treatment in private market. Eventually she was referred by private surgeon to oncology unit of public hospital that eventually channeled to surgical department once again for second opinion. I did not know the final outcome of this patient after she recovered and left hospital. But I achieved at least in prolonging her hope for life. I felt satisfied and rewarded.

The second patient with similar findings of extensive mediastinal tumour invading the root of left lung. Major surgery with resection and simultaneously L pneumonectomy through midline incision and exposure is needed.  As the patient is elderly (>70) female, and there is a chance of incomplete resection. No operation was proposed until I met her in out patient follow up for lung function studies as preparation for pneumonectomy. I proposed early surgery without delay as the chance of unresctability grew with time. I explained briefly the risk and possible operative death. The patient instead of the accompanying relatives strongly accepted the surgical plan. She had "blind trust" on me and had possibly encountered too much controversial or in-decisive doctors. Operation went well though difficult and I had only sacrifice the upper lobe vein with intrapericardial left upper lobectomy en bloc with the tumour. The patient recovered uneventfully and was sent for further radiotherapy despite clear resection margin. My satisfaction was more than anything financially or compliment from family.

Patient recovery is greatest reward to doctors.

To get the most from public hospital

In previous blog, I have mentioned difference in public versus private medical care. As consumer who pays for medical service either by direct charge or indirect charge through taxation but time consming waiting list, one would seek the best means to obtain good and personalised service in public system

1. Stress on making appointment to new case clinic

Usually the new case clinic is seen by senior doctors or specialist directly. This help to prevent missing important ill patient who may not have correct diagnosis on referral. This is much better than going back to the old clinic with regular FU and reporting a new symptom or new disease. Stree on getting referral addressed to the new case time slot of the specialist clinic.

2. Ask politely for being interviewed by senior team member of the in charge physicians team.

So always allow for being interview at day time. At rush hours or non office hour, usually the front line doctors or even the on call doctors are available. There is absolutely minimal effect in asking question or challange the care mode when you are interviewed by person without authority.

3  Make a gesture of asking for well documented information but do not make threat to complain

Human nature make public servants sensitive to clients requiring thorrough documentation of every details. But never pose a threat to complain, This iwill destroy the original relationship with caregiver.

4. Make careful research on mode of treatment of your own disease. Make suggestion or pose rational queries on the selected mode of treatment.

5. Before committing to have operation in this or that hospital. Do research on number of similar cases handled in those cedntres.also some hospital has shorter operatoperation waiting list than other. Borrow other address if necessary

6. Trust your care givers and maintain harmonious relatioship by mutual respect.

For private care, word of mouth and transparency of charge is important and reflect the professionalism of individual specialist.

If the specialist refues to discuss the cost or fees before committment of care or hospitalisation, beware of that. If the care of the specialist are to be split among other profession, the client retain the right to know how the fee is splitted or on which ground.

I am Dr Chung Shiu Shek specialised in cardiac and thoracic surgery. Feel free to discuss your own or your family medcial need with me. I strive to give my best possible advice to any questioners. Phone: 3160 8865  E mail: chungss@ymail.com

Thank you

Medical checkup : A devil or an angel

Recently I came across previously healthy persons having major pahtology after medcial examination for relatively non urgent symptoms.  It dose reveal how life is so fragile and the relative inaccuracy of sense of being good as indicator of own health.

One relatively young middle aged women complaint of feeling mass in the abdomen. Being regarded as inexperienced person, self reporting of a mass in the abdomen is usually wrong. The possiblity may be nothing, fecal loaded colon or ballotable kidney or transmitted abdominal aorta pulsation.

Further enquiry about the symptom is none. There is no change of bowel habit and appetite and body weight is normal.  She has early menopause and otherwise healthy. Routine USG examination review nodule and echogenic shadow in the liver. Subsequent high power imaging showed multiple enlarged cystic and cavernous haemangioma in liver. Haemangioma is one of the most commonest benign tumour in liver. It is even more benigh than polycystic disease.  The pathology of haemangioma is not certain but autopsies study did reveal lot of people dying with asymptomatic large cavernous haemangioma. She was told to lead normal life until condition change. Of course, rupture of haemangioma will be fatal and under reported because they seldom arrive alive at Emergency department.

Another patient has chronic appetite loss. X ray show upper mediastinal mass. CT showed huge mediastinal cyst displaying the esophagus and abutting trachea.
Early surgery is advised even if the chance of malignancy is low. Patient is feeling unexpected diagnosis being serious blow to life.

Following previous blogs on asymptomatic lung cancer, early lung cancer is usually not detected and can be found normally by low dose CT screening.

Whether we should screen ourselve for common disease or not?  Some may prefer not to know seious potential disease. However, cure of disease is usually only possible for early diagnosed cancer. So screening is useful for individual person althought nor always cost effective for whole society. (Because extra resource is needed to diagnose or rule out asymptomatic and normal but looking suspicious area.

If one afford to do screening with time and money, I think occasional CXR say every 3 - 4 years, stool x occult blood and exercise test (simlified with only resting or stress ECG and saturation monitor may be all required for middle aged person. For female cervical smear, breast examination is useful.
For elderly male, PSA for prostate and USG for hepatitis carrier will be necessary.

For whole society, immunisation of Hepatitis B vaccine, and health education and policy to eliminate promotion of smoking, alcohol and bad fast food is useful.
A postive attitude to life and treasure of life is always good.

So precious moment seems to be gone if one did not make preparation of possible bad things.

I have help cure some individual who only got news of advanced cancer in screening procedure. Hope they grow strong after difficult therapy pathway.

My name is Dr SS Chung, andrew, My clinic no is 3160 8865, I welcome question and query on helath issue and I practice general medicine, heart disease, chest disease and chest surgery and minimally invasive heart and lung and aortic surgery.

To be or not to be: ON call 36 小時

I have briefed the internet surfer that to be a doctor, one needs to sacrifice own lifestyle and time. Further doctors are not much respected nowadays as they need to dealt with personal conflict with patients at front line. Stress in life decrease quality of life of care taker. But is it worthwhile?
To many young people who graduate recently from secondary school. They may have to decide early in their life whether to take up the profession or not.

As one of the specialist in this field, I have every capacity that I need to make statement of this. It is worth while and still much challanging. To make sacrifice requires strength and determination. It is worth the effort to endure until you finish the training. Training takes 6 to 8 years on top of medical school teaching and life long commitment for further education is also required,
But it is worth while to devote oneself to meaningful life. Further, the recreational aspect for doctors education is fun.

So young people, do go for the touch job as medical student and future challange is worthwhile.

On call 36 hours 小時

Doctors need to be on call for whole day and night and finish work only after the usual 8 or 12 hour daily schedule before going to bed. But this happen to be only apllicable for trainee. For specialist doctor or chief of service in each major specilaty involving emergency care and surgical operation. They are on call for life or on call 24 hours a day and 7 days a week.

Who pay them for the on call? None but the devotion to work and satisfaction in treating patients. Hospital authority would not compensate for that. Neither would the chief of service ask for the compensation like the hours counted in recent doctor- HA settlement on contract hours court case in Hong Kong High court.

The court or judge does sympathise on call doctors but the judge cynically approve for minimal or bare inevitable counting of hourly paid for Sunday "voluntary" or traditionally implied obligatory duty in Sunday or rest day ward round and coverage.

So private specialists doctor are on call everyday for their patient. Neither would they charge a standby fee. But they can choose to accept patient or not. So their call is not compulsory.

To be a doctor , think twice about that. You may need to study 18 hours a day to get finished the medical school. Work with on call 36 hours or at least 32 hours once every three or five days during training. Then on call every day practically for life.

Is it worthwhile, in future blog, I would explain to you that it is worth.

My name is Dr Chung Shiu Shek, specialist in cardiac and thoracic surgery. My clinic number is 3160 8865

The most live-able city in the world HONG KONG 香港最能活的城市

Despite all the bad comment on the future of Hong Kong, the Economist Magazine/News corporation has rated Hong Kong the best city to live in the world in year 2011.
I would not doubt about it but the ranking surpasses previous years of being rated the fourth to tenth comes so abruptly amidst the political turmoil of this place.

Hong Kong is my home and my birhplace. I have no hesitation to admit my citizenship as Chinese or Mainland china civilian but the tie to region HKSAR is more close to my blood and knowledge than ever. Before the 1997 change over, I have much reservation but a real practical issue to wirte down my nationality as Overseas British National with my HK passport. I would rather wirte down Chinese bracket BON (British overseas National) in Hong Kong rather than identifying myself as second class UK countryman but without any right of citizenship or residency.

How come other people recognise the strong points of living in Hong Kong but other people including most Hong Kong people thought the glory of the Jewels of the East has faded out more or less entirely. We are only one but not the most recogisable independent cities in Mainland China. We cannot surpass but to be surpasssed by cities like Beijing, Shanghai, Tianjin and Chongqing. Even the size of economy will be taken over soon by Shenzhen and then Guangdong or even Xiamen.

The one and probably more significant factor is the medical facility and accessibility in Hong Kong. I am proud of myself being one the medical supplier (specialist doctor in cardiac and lung surgery) in Hong Kong. I would not agree this is perfect but would say it is keeping on improving. But most Hong Kong majority would criticise the apparent self sufficiency of the medical system available in Hong Kong.  In prinicple, all public health care is  free but rationed. All specialist care are availabe at nominal charge and the care provided is up to international standard. However, this is far from the truth to see primary care is failing badly in preventive medicine aspect. Lots of people complaint the general satisfaction lacking in Hospital authority hospital.Thousands of hospital authority staff be in professional or allied health voted by foot to leave the system.

Yet , vaccination is nearly universally compliant, control of disease like SARS or swine flu is superb, major surgery like liver and heart transplant, sex change or conjoint twins operation are successfully done from time to time. For the problem of private medical care. It is not regulated and a lot of over charging is suspected. However, the success can be illustrated by the fact that lot of wealthy mainland people come to HK for medical consultation or even treatment and lots of wealthy businessman enjoyed good care by lot of private specialists.  Care in Hong Kong is good provided that there is no counting of cost of time in public HA service or no restriction of charge or resources for private market.

In Hong Kong, the proportion of national expenditure is only around 9 to 12 percent of GDP.  But the standard of care is good and doctors and nurses enjoyed good living support. If hong kong is so good in providing first class medical service at such an efficent expenditure. Then other countries should model their health system to simulate Hong Kong.  Everyone knows there is no free lunch in the world. So the local or insider would recognise a lot of hidden problem of heath care in Hong Kong. Thanks to the marketing or image controller persons in Hospital Authority. The drawback of the system is not exposed or shown to journalist who are only expatriate or visitor in Hong Kong.

If you ask one of British overseas worker or Philipino maid in Hong Kong. Are they enjoying good medical care system in Hong Kong. They would certainly point out that medical care in Hong Kong tends to be fragmented and haphazard and accessibility is far from simple or intuitive.  The specialists is availabe at high price and competition among health provider is not transparent and open.  A few giant specialists clinics or doctor dominate the private market and the fees they charge are ususally not afforable from general public.

I remember not long ago (actually availabe in Wikepedia) that one overseas Malaysian British citizen died of treatable disease in one of the public hospital in Hong Kong. Her Causcacian husband spent more than eight years to secure out of court settlement for the lack of care or even discriminative care availabe in public hospital system.
Although this isolated event has lot of overtone of cultural or racial difference, this illustrate the medical care in Hong Kong is like a cat and mouse game. Those who is familiar with the system can play the game well. thouse who do not or just take it for granted would not recieving expert care.

As an insider, I would expose the skill and trick to recieve good medical care in public system and private care to all. Hope everybody get the best care in Hong Kong.
Three cheers to the journalist who choose Hong Kong to be the best place to live because of an "excellent" medical care system.

My name is Dr Chung Shiu Shek who provide 24 hours emergency medical care to all enquirers and  I am specialist in cardiac, lung, chest surgery.
My clinic no is  3160 8865