In the age of Covid, people often forget that cancer and cardiovascular diseases are still here and often lose sight of the need to screen and protect against these other deadly diseases. Before this webinar, I was, to be honest, confused about which executive checkup package to get, but now I’m more confident about taking charge of my own health destiny.
Here are my key learnings, together with the highlights of The Mu Sigma Phi Sorority of the UP College of Medicine’s webinar on “Taking Control of Your Health: Why ‘Executive Checkup’ Matters.”
• Mid-40s is the critical age to start cancer screening and to focus more on your periodic health checkup strategy while you are asymptomatic. It gets more difficult during this pandemic to go to hospitals and clinics in person, but make sure to put cancer screening tests in the same priority as getting a Covid-19 vaccine. Do this on your birth month as a gift to yourself.
• Design your own Health Checkup & Cancer Screening in partnership with a doctor you trust who will determine the right tests based on your risk factors and interpret the results. The one-stop shop executive checkup packages in hospitals and clinics are designed for the executive who has the money but doesn’t have the time to canvass or look for good value screening tests and at-home testing options.
• For foodies, start screening for colon cancer via colonoscopy aside from focusing on lowering your body mass index and checking for diabetes and hypertension because colon cancer is now #3 in the list of malignancy in the country with higher rate among younger individuals (probably because of the way we eat).
About Executive Checkup:
The Mu Sigma Phi Sorority of the UP College of Medicine’s inaugural webinar of the MUla Kay Doktora: The Dr. Julita Ramoso-Jalbuena Memorial Women’s Health Forum, co-presented by InLife Sheroes:
“Taking Control of Your Health: Why ‘Executive Checkup’ Matters“
(Ang Inyong Kalusugan ay Nasa Inyong Kamay: Bakit Mahalaga ang ‘Executive Checkup’)
July 13, 2021, Tuesday from 12-1 PM Manila Time!
Speakers: Dr. Alexandra Laya-Zinampan and Dr. Monica Therese Cabral
Reactor: Nizza Regalado, RPm
Moderator: Dr. Anna York Cristina Bondoc
Facebook: Mu Sigma Phi Sorority Webinars
Youtube: Mu Sigma Phi Sorority Webinars
Register for FREE to all webinars of the series at: https://tinyurl.com/MuWebReg2021
MUla Kay Doktora: The Dr. Julita Ramoso-Jalbuena Memorial Women’s Health Forum (Series):
• Executive Checkup: Design Your Own Health Checkup & Cancer Screening! (July 2021)
• How to Prepare for Surgery during Covid? (August 2021)
• How to Prevent Infection Post-Surgery? (September 2021)
There are a lot of one-stop executive checkup packages in hospitals and medical institutions that it is quite confusing to choose. They are also expensive.
The best executive checkup is the one that you design and personalize according to your lifestage.
Prevention and screening are two of the most difficult areas of medicine and there is no single source of recommendations.
Recommendations are constantly changing with new information, research and innovation.
The more apt term for Executive Checkup is Periodic Health Checkup & Cancer Screening.
(44:00 – 56:30 minute mark)
Cancer Screening by Dr. Alexandra Laya-Zinampan, MD
Dr. Alexandra Laya-Zinampan, MD
• University of the Philippines College of Medicine (Class 2001)
• Fellowship, Gastroenterology, University of Missouri – Kansas City Graduate School of Medicine, Missouri
• Consultant, St. Luke’s Medical Center Global City
Cancer Screening is for asymptomatic and average-risk individuals. For patients with symptoms, the approach is more case finding and diagnosis.
Skin Cancer – Visual inspection for those with a large number of moles or those who are out in the sun often.
Cervical Cancer – Pap Smear Test every 3 years starting at age 21 and Co-testing of Pap Smear + HPV every 5 years starting age 31 until 64.
Breast Cancer – Do a baseline screening at age 40, do yearly mammograms at age 45 and downgrade to every two years at the age of 55.
Colorectal Cancer – Starting at age 45, do a colonoscopy every 10 years or a Flexible Sigmoidoscopy every 5 years + Annual Immunohistochemical Test (FIT).
At age 45-75, focus on Individualized Surveillance Protocols using screening history, overall health condition and patient preference.
Lung Cancer – Annual Low Dose Chest CT for those who belong to the high-risk category, 50-80 years old.
Prostate Cancer – Routine Screening is recommended for healthy men starting age 55-69 using Prostate Specific Antigen (PSA) Blood test or Digital Rectal Examination.
(56:40 – 1:05:00 minute mark)
Periodic Health Checkup by Dr. Monica Therese Cating-Cabral, MD
Dr. Monica Therese Cabral, MD
• University of the Philippines College of Medicine (Class 2001)
• Fellowship, Endocrinology, Diabetes and Metabolism, UPCM-PGH, Philippines
• Consultant, Asian Hospital Medical Center, Makati Medical Center, St. Luke’s Medical Center Global City
Periodic Checkup is recommended every 3 years for adults less than 49 years old without chronic conditions and annually for adults more than 50 years old.
All adults should be assessed every doctor’s visit for the major modifiable risk factors for cardiovascular disease.
Hypertension – You are at risk if your day time blood pressure is 130-139/ 80-89 mmHg.
Generally, healthy individuals do not need a routine electrocardiogram (ECG) because it has low sensitivity for detecting the presence of coronary heart disease.
Generally, exercise stress test is not recommended for asymptomatic patients.
Diabetes Screening – Test for the following markers: Fasting Blood Sugar => 126 mg/dL, 2-hour blood sugar => 200 mg/dL, or Random Plasma Glucose => 200 mg/dL.
Note: HBA1C is not the screening test of choice because this is the average blood sugar for the past 3 months.
Lipids/Cholesterol Screening – Do a Fasting Lipid Profile for men age > 35 years old and women age > 45 years old.
Osteoporosis Screening – Bone Mineral Density test for women for > 65 years old and men > 70 years old with no risk factors or family history.
Note: There is no symptom for osteoporosis and you can only detect it when you have your first fracture.
Anticipatory Guidance – Check for Body Mass Index, Exercise and Psychosocial issues.
Immunization – Make sure your family is up to date with immunization boosters if needed.
The most recommended are the Flu, Pneumonia and Covid-19 immunizations and make sure to get Human Papilloma Virus (HPV) vaccine.
Thank you to Dr. Alexandra Laya-Zinampan, MD and Dr. Monica Therese Cating-Cabral, MD for sharing the latest information and strategies on Periodic Health Checkup & Cancer Screening. I’m now more confident to design and take charge of doing preventive strategies for the family. In this age of Covid, we have become more aware of boosting our immune system and being more proactive in checking for cancer markers and health risks.
(Note: Mental Health is not covered in these periodic checks and screenings. Make sure to check on and ask your family and friends if they are OK during this pandemic and do it consistently.)
Join the next MU Webinar this 2nd Tuesday of August:
“Ready, Get Set, Go Surgery!“
August 10, 2021, Tuesday from 12-1 PM Manila Time
Register for FREE to all webinars of the series at: https://tinyurl.com/MuWebReg2021.
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P.S. HERE IS THE COMPLETE TRANSCRIPTION:
[PANEL DISCUSSION PROPER]
Dr. Laya-Zinampan: When you go on the internet, if you Google checkups this is what you are going to see. You are going to see things about executive checkups (ECU). Because of busy schedules it’s very appealing to do an ECU. These are packages that make for a one-stop shop, like a top to toe health check. The thing is, the kind of tests included in these packages differ from one package to another, a different hospital to another. Also, the cost of these checkups run from as low as a few thousand to sky’s the limit. So if it’s overwhelming for us as clinicians, imagine how it must be for our patients.
So it’s our role to help guide our patients choose, or better yet help our patients design their own ECU package that will suit their needs. So how do we go about this? Today, we hope to review the various aspects of health check-ups, to empower you to recognize important risk factors for common illnesses so that we can help our patients personalize their health checkups, screen for cancer, and initiate prevention programs. We also want to go beyond the ECU, so we can become partners for our patient’s health. We’ll also talk a little bit about warnings and caveats of testing and cancer screening.
I think that’s the best place to start — prevention and screening is one of the most difficult areas of medicine. There’s no single source of recommendations. Multiple organizations and societies produce guidelines on the same topics. The recommendations are constantly changing, with new innovation, research, and information coming out. We should remember that the benefits may be overestimated, and the harms of screening may be ignored or minimized. Admittedly, industry and government funding can greatly influence screening and prevention practices.
Before we go forward with talking about the ECU, we have to keep in mind that the more apt terminologyis more of “periodic health checkup and cancer screening”, which brings us to the two aspects and partsof this, the periodic health checkup and cancer screening. Our beautiful colleague and sister will focus on the periodic health checkup, and I will focus more on the cancer screening aspect.
Ok, cancer screening. Remember what we said about multiple societies recommending things on the same topics? It can get confusing. So I did a bit of research on what societies recommends, what experts say, and also what we do in local practice. We’re gonna talk about that. These are not lotto numbers. These are important age milestones when we talk about cancer screening. It’s important to note that screening is for asymptomatic average risk individuals. This is in contrast to patients who have symptoms, where the approach is more of case-finding and diagnosis.
The first one we’ll talk about is skin cancer. Mole checks or screening for melanoma is simply visual inspection. There is no specific recommended age to do this. We can encourage patients to do their own skin checks. It’s just important that we remind them or we get to look at the parts of a patient’s body that they don’t usually get to see. Focus on higher risk groups: those with fair skin, those who have history of sunburns or use of tanning beds, occupational risks (those who are under the sun all the time), patients with personal or family history of skin cancer, and patients who have a lot of moles.
Papanicolaou smears (PAP smear/test) are important in the fight again cervical cancer. This is the next cancer we’re going to talk about and how we can screen for it. It is recommended to initiate screening at age 21. Now, between age 21 to 30, a PAP smear every 3 years has been recommended. Between the ages of 31 to 64, you continue PAP smears every 3 years, or you can opt to perform co-testing with HPV detection every 5 years. For patients older than 65, routine screening can stop, particularly if screening has been normal in previous years.
40 is an important number when we talk about breast cancer. Although big societies, like American Cancer Society and the USPSTF, recommend mammograms to start at 45 or 50 years of age, most local and international societies that manage breast cancer follow the 40 year-old cut-off. What I tend to do is have a sit down with patients when they turn 40 and offer a baseline screen. After that, you can do a yearly mammogram when they turn 45. Downgrade to a mammogram every 2 years at age 55, and you can continue on so long as patients remain in good health. Generally, it is recommended to stop screening at age 80 or when their life expectancy is less than 5-10 years.
Colorectal screening is close to my heart. I’m a gastroenterologist. I have seen a rise in pre-malignant lesions among younger patients in the last years. So the more recent updates from societies have been very much needed. 45 is the new 50. We always thought 50 was the colon cancer screening age, but it’s now 45. There are various screening strategies for colon cancer. Scope, scan, or stool. So there’s 3. For scope, you either do a colonoscopy every 10 years, or a flexible sigmoidoscopy every 5 years in conjunction with an annual stool exam called an “FIT”. You can also opt to do a scan — a CT colonoscopy every 5 years, or you can do simple stool exams (FIT) annually. Now there are pros and cons to each testing option. It would really be best individualized to each patient. Regardless, I often tell patients “pick one” because any one test is better than no test. Again, the recommendation is to start at 45 and continue on until patients are around 75 years of age. The surveillance protocols during this period really depends on an individual’s screening history result, overall health, and preference. I often tell patients when they turn 76, they graduate. With patients over 76, the decision to continue screening has to be individualized. With gains in life expectancy, we have an increasing population of healthy geriatric individuals. So we need to think: “how long are we going to continue doing this?” We know that the benefits of a polypectomy are delayed by 7-10 years, and so the benefit of screening is very limited for those with a shortened life expectancy. The cutoff is around 7-10 years.
Lung cancer is on the top three malignancies in the Philippines. The screening test recommended for this is an annual low dose chest CT. The limiting factor for us with this screening test is still cost. The general population cannot afford an annual low dose chest CT. A surrogate has become the chest x-ray, but we still would want to encourage low dose chest CT for those who are at high risk (current or former smoker who quit less than 15 years ago, those between 50 and 80 years of age, those with a 20 pack-year smoking history). You can opt to stop screening at age 81 if they’ve quit more than 15 years past or if their overall health status is poor.
Prostate cancer is not in the forefront of cancers, but it still ranks number 4. The screening test for prostate cancer includes a digital rectal exam or a PSA blood test. Routine screening for prostate cancer for healthy men between 55 to 69 years of age. Just as important as knowing who to screen, it is also important to know who not to screen. It is not recommended to screen those younger than 40, older than 70, or whose life expectancy is less than 10-15 years.
It’s pretty amazing how much innovations have developed in terms of testing and screening, but we always have to remember that we have to individualize. We have to talk to our patients so that we can have a shared decision when it comes to screening. On the upside, a normal screening test is reassuring and can lead to prevention of cancer and promote good health. Early detection can lead to cure, mitigate complications of cancer, and can even prolong life. On the downside, there are risks inherent to each screening test or procedure. We have to deal with cost and availability of resources. We have to talk about false positive and false negative results. Sometimes, it triggers more tests or unnecessary procedures.
Dr. Cating-Cabral: While there are certain ages for when cancer screening is recommended, there are no strict guidelines for the optimal frequency of periodic visits, however. Annual examinations are not indicated for most younger patients. Although, people with chronic health issues such as diabetes do warrant regular visits, with or without a periodic health maintenance visit independent of your age. So most physicians and physicians like myself, as an endocrinologist I see patients with diabetes at least every 3 months because this coincides with HbA1c, one of the markers that we check in diabetes. In the absence of such indications, experts suggest that periodic health maintenance visits should be done every 3 years in adult patients <49 years old who dont have chronic conditions, and once you turn 50 you get an annual checkup. For people who have no chronic conditions and rarely see a clinician, a periodic health evaluation may be the only opportunity to discuss preventive care. Thus, the popularity of the annual wellness visit or the ECU.
All adults should be assessed for risk factors for cardiovascular disease (CVD) at every visit. These modifiable risk factors include the diet, high BP, overweight/obesity, diabetes, current smoker, high cholesterol, sedentary lifestyles. When it comes to hypertension, screening is recommended for adults 18 and above. While the optimal interval is not known, most patients have their BP checked at each visit anyways. Screening should be done every year for adults 40 years and above if you’re at high risk for high BP, meaning you’ve already had measurements with a daytime BP of about 130-139/80-89 and those who are overweight or obese. Adults under 40 who do not have elevated BP and do not have any of those disease risk factors that I mentioned should be screened every 5 years. But again, everybody gets their BP checked when they see a doctor. Now, when you get a high BP reading in the office it is recommended that you get an out of office BP measurement to confirm the diagnosis before starting treatment. Some patients can have just elevated high BP in the office, or what we call white coat hypertension. Surprisingly, a routine ECG, even for a “baseline”, is not indicated in asymptomatic adults (meaning adults who do not feel any chest pain or chest discomfort) and if they are at low risk for CVD.
Generally, healthy individuals do not need a routine baseline ECG. Unfortunately, a routine ECG has a low sensitivity for detecting coronary heart disease in patients who do not have a prior diagnosis. Another thing that may come as a surprise to most people is that even though most wellness packages do offer an exercise stress test, in general it is not recommended for patients without symptoms. It may be appropriate, however, to screen patients who are in certain high-risk populations or occupations (e.g. pilots or bus drivers, where if they had an acute cardiac event or heart attack during their job, this could endanger a large number of people). It is also recommended to do a stress test in individuals with a high risk for coronary heart disease who are beginning an exercise program. So you have a patient who is living a sedentary lifestyle and decides to embark on a marathon run. Maybe these patients should have a stress test first.
We should really consider screening for diabetes in high-risk individuals beginning at the age of 40-45. In the Philippines, we have a prevalence of 7.1% of adults who are now diagnosed with diabetes. That number goes up to about 12% if you consider patients with pre-diabetes. At age 40, the prevalence does increase. Thus, the recommendation to start screening at 40 years old among Filipinos. Other guidelines around the world suggest starting at 45 years old. This can be done annually or in 3 year intervals, depending on the frequency as clinically indicated by what’s going on with the patient. If the patient has borderline tests in the past, are overweight or obese, have very strong family history, then you should test them even before the age of 40. If patients do have glucose readings that are abnormal, they should receive intensive behavior counselling interventions to promote a healthful diet and physical activity cause this alone may be enough to get their sugars under control. We can test with either fasting blood sugar or oral glucose tolerance test. The HbA1c is not the screening test of choice because this is an average of blood sugars over the past 3 months, and it may mask elevated sugars that could be obtained from a glucose tolerance test instead.
When it comes to cholesterol, most adults should have it screened every 5 years, beginning at the age of 20 and more frequently if there is a higher risk of developing artherosclerotic disease.
When it comes to osteoporosis, screening with a bone mineral density test should be done for women who are 65 and older and men who are 75 and older. If women are post-menopausal but are less than theage of 65, you can check them with the bone density test if they already have risk factors. This goes as well for younger men. Anyone who has a family history of osteoporosis and fragility fractures, underweight, history of smoking or alcohol use, history of medications which decrease bone density and chronic steroid use should really be screened earlier. All adults who have had a fragility fracture (a low trauma fracture) should also be screened for osteoporosis. This is important because patients do not have symptoms with osteoporosis. You do not know that you are losing bone. Sometimes, the first symptom is a fracture and the pain that comes with it. So we want to avoid that very first fracture.
Other aspects of a patient’s health should also be addressed at these periodic checkups. This is probably the only time patients may be assessed for their weight and their body mass index (BMI), which is how heavy they are for their height. You can assess them for any time spent exercising (if any), if they smoke or are exposed to secondhand smoke, any possible substance abuse, increased alcohol intake, and their dental intake as well. This is also an opportunity to advise women who are planning pregnancy or not on healthy behavior, intake prenatal vitamins, and counseling of fathers to be as well. A periodic health check may be the only time we can help patients deal with any psychosocial issues such as depression and anxiety.
Adults should also be offered catchup immunization or boosters as appropriate. Most often, adults ask about the annual flu vaccine, the pneumonia vaccine, and in this pandemic age about COVID-19 vaccines. The Mu Sigma Phi Sorority also has its vaccination advocacy program as well called “ImMUnity”.
Screening for health conditions does matter, but remember that when we order a test we should understand how to (1) interpret these results, (2) the implications of negative or positive results, and (3) if these results will make an impact on our patients health. Many healthcare providers do understand the need for these screening tests, and they have really made it convenient for patients to get their tests done in 1-2 days. Patients and doctors should work together to decide what are the most appropriate tests for them.
Ms. Regalado: Of the many things that we learned today, I wanted to emphasize 2 key takeaways. First, is that as physicians we should be emphasizing the importance of the ECU. Second, as physicians we should really strengthen the primary healthcare in our healthcare delivery system. First off, throughout the talk we’ve stressed the importance of the ECU. At the very start of the webinar, Dr. Laya-Zinampan states that prevention and screening is one of the most difficult areas of medicine. Throughout the talk, we saw that it’s not just difficult but more importantly it is essential for our health. I found this very interesting cause Dr. Cating-Cabral mentioned the concept of anticipatory guidance, which is a concept that personally I’m more familiar with in pediatrics. If you’ve noticed, in the pediatric population there’s such an emphasis on well baby visits and if the parents or baby are having any difficulties, they immediately bring them to the doctor. For some reason, as we get older and gain more responsibilities as part of the working population, we seem to not come in for checkups as much as adults. I think that as physicians, this is a perspective that we should be changing. Now that we’re adults, now that we do have more responsibilities, all the more that ECU and periodic checkups are more important. I think that we can’t mention this without also mentioning the role of primary health care in ensuring that people see a physician and that people have periodic checkups. It was mentioned by Dr. Laya-Zinampan that there’s no single source of recommendations, and that multiple organizations and societies produce guidelines on the same topics, but then also the institutions that do provide ECUs are hospitals, are tertiary institutions. That’s actually how I would like to end this reaction, specifically as someone who is starting off their journey as someone who is trained to be a GP and not yet specialized and not yet associated with a tertiary hospital. My question for today is that if the goal of the ECU is prevention and screening, in order to not just prevent early mortality but also to reduce morbidity, wouldn’t we as a healthcare system be better able to meet this goal if we brought ECUs down to the level of primary care or down to the level of the community? That’s something I want us to think about in terms of our role as physicians not just in taking care of the patients, but our role as physicians in ensuring systemic change so that we may be able to reach as many patients as possible.
[QUESTION & ANSWER]
Q1: My question for today is that if the goal of the ECU is prevention and screening, in order to not just prevent early mortality but also to reduce morbidity, wouldn’t we as a healthcare system be better able to meet this goal if we brought ECUs down to the level of primary care or down to the level of the community? Kamusta na yung public sector sa pagbigay ng ECU or preventive medicine?
A (Dr. Laya-Zinampan): I’m gonna give a few examples, more in the GI perspective. Let’s try to decentralize. For example, when it comes to colon cancer screening, we have all these big programs (screening, prevention, colonoscopy), and they can get really expensive. When it comes to the general population, Philhealth is the backbone of our healthcare coverage for the average FIlipino. Philhealth has already created these packages that will cover colon cancer screening and treatment. If I’m not mistaken, this is not available for the private sector. It really is for government hospitals. So it’s designed to be able to reach the average Filipino. So we do have these things. I guess we just have to look for it so that we can offer it to our patients. So meron naman. I guess because of how healthcare is set up here in our country, sometimes it’s tough. People pay out of pocket, and so if you don’t have insurance coverage we are a bit compromised. So we have to really find a way to advocate for our patients.
A (Dr. Cating-Cabral): It really boils down to the primary care physician to help tailor this type of testing for our patients. If you look at the ECU packages, they’re actually called “ECUs” because they were designed with the executives in mind. In the beginning, they were the only people who could afford these things.
Now you have HMOs that also cover them, but mostly limited just to labs. Not everyone gets the colonoscopy or the stress test. They really just get the basic labs, maybe an ECG. Although, as you’ve heard it’s actually not something that we need to routinely check so maybe that’s something we need to routinely check, especially if the patient is asymptomatic or at very low risk for developing cardiovascular disease. It really depends on the doctor that will make the decision — “What does my patient need?” You need to look at the patient’s risk factors and age. A lot of Filipino patients are becoming more overweight and obese with a lot of family history of diabetes, so these are really things you need to ask about when the patients come to the clinic. It’s part of your basic history and physical. This will also lead you down the path onto what the right tests to check for the patient are. In terms of maybe formulating a public health package, we can design it really for them. Maybe one thing we could bundle together, certain labs to make it cheaper for the patient. Of course, eliminate things that are unnecessary depending on their risk factors.
A (Dr. Bondoc): Equipment pa lang, malaking problema na. I’m hoping the DOH could level up po.
Another thing is how could we even screen for breast cancer when we’re full with COVID patients so no one wants to go to the hospital. I’m hoping that we move forward from this pandemic and realize that once we screen, it’s better for persons kasi nakukuha natin ng maaga imbis na napaka late. As Dr. Mitos said, talagang epidemic na ang high blood at diabetes. So yun na lng kung nagawa natin yun, napakalaking bagay na. Then let’s work on the more difficult or the more-procedure oriented screenings na nangyayari. Hopefully, wag tayo magtanggap na yun yun and magmove forward tayo.
Q2: Is there a way to screen breast cancer in the comfort of our home?
A (Dr. Laya-Zinampan): Regular physical breast exam, whether it is performed by the individual or the clinical in the clinic, research hasn’t shown that it does much benefit. It really is geared towards more or imaging (mammography). But that doesn’t mean you shouldn’t examine your breasts. The take home message on that part is you need to know what your breasts are like, you need to know what they look like, what they feel like, if there’s anything unusual or different with your breasts. That should trigger a conversation with your provider. Although the clinical studies show the clinical breast exam isn’t part of the screening programs, it should be very important in maintaining your own health.
Q3: Why is it necessary for the presence of osteoporosis among women of post-menopausal age?
A (Dr. Cating-Cabral): Osteoporosis is a silent disease. Wala kang mararamdaman habang humihina yung buto mo. The burden really of the disease is if you fracture. Even if you have osteoporosis, but you never break a bone then you’re fine. It’s just when your bones get weaker, konting tapilok lang, mapaupo ka lang, even very forceful coughing, or just bending over to pick something up from the ground you could already fracture. If you do fracture, about 20% of those who do fracture will die within the same year from complications from a fracture. About 80% won’t be able to do independent activities of daily living. They may not be able to walk properly or do other physical activities unassisted. 30% will have permanent disability. If you fracture once, your risk of fracturing again is 50%. So when we screen patients for osteoporosis, it’s a very simple test. It’s called bone mineral density. Hindi po siya ultrasound ng wrist, hindi siya yung ultrasound ng heel. Those are peripheral density tests. These are central bone density tests that are done in a hospital. Hihiga ka lang. The machine will pass over you, and then you will turn from side to side, and that’s it. Low radiation, much less radiation than an X-ray. You have to do it at least once a year in the same hospital or the same place it was done before so we can compare it from year to year. If we already see that you’re at high risk for fracture, we can already put you on medications. Kasi yung buto po natin, manghihina pa yan ng tuloy-tuloy. Once you hit menopause, you lose the estrogen which is protective for your bones and keeps them strone. The reason why for men it’s older, it’s because they usually lose testosterone at an older age. There’s no set time when you can tell if they’ve gone through andropause. For women, if you don’t have your regular menstrual period anymore, that’s menopause na. When you lose your periods for a year, then you’re definitely menopausal na. That’s why we need to screen for this. Would you believe that about 1 in 3 women and 1 in 5 men at the age of 50 will suffer a fracture in their remaining lifetime if they have osteoporosis. For women, the risk of a hip fracture is even higher than the risk of breast, ovarian, and uterine cancer combined. For men, the risk is also higher than that of prostate cancer. Baka may magtanong, paano po yan wala kaming bone density test? So there’s actually a way of looking at a patient’s weight and age. If you’re very very thin, underweight, and you’re much older, there’s a tendency for your bones to really be weaker. The screening toll we have is called the Osteoporosis Screening Tool for Asians (OSTA). It’s very easy to use in the clinic. You just look at the patient’s weight and age. It doesn’t completely replace the bone density test but at least you can tell your patients “Hey, you’re at risk for developing osteoporosis maybe we should already intervene”. You can already tell them to avoid falls and have enough calcium and vitamin D in their diet.
Q4: Among all the vaccines that you mentioned, what is the most important?
A (Dr. Cating-Cabral): The only way we’re gonna get out of this pandemic, kung hindi pa kayo nagpapabakuna, please get the COVID vaccine. Very rarely is there any contraindication to it unless you have a severe allergic reaction. Kahit may diabetes kayo, high blood, osteoporosis, kahit nga kanser. Kung hindi active yung chemotherapy and and very immunocompromised kayo, pwede magpabakuna. Other than that, for the general population you should really get the annual flu vaccine. Madami rin namamatay sa flu, just the regular flu, not even COVOD-19. As for pneumonia, it really depends on what age you get it. Either before or after 65, you can get 1 or 2 doses. There’s a whole list of the other vaccines that are available to adults. If you’re unsure of what you got when you were younger, you may need a booster also so talk to your doctor about it. If there’s any one vaccine you should get right now, please get the COVD-19 vaccine.
Q5: Please tell us more about colon cancer and the need for screening. We are very well aware of breast cancer and lung cancer in smoker. Colon cancer, I hear, is really going up in the list for Filipinos. Lalo na, going up in terms of frequency and going down in terms of age.
A (Dr. Laya-Zinampan): In the past, we would always peg colon cancer as number 4 or number 5 on the list of malignancies in our country. Just recently, there was an update that colon cancer is now number 3. Not only is it number 3, so the number has practically doubled between 2010 to 2015. We’re also finding it among younger individuals, and so we are realizing the numbers that we’ve been basing things from years past are different. We assume it’s because our lifestyle is different, our exposure to carcinogens are different, and we eat more junk food. All of these things increase the risk of developing polyps which eventually deteriorate into cancer. In terms of being younger, we also don’t know. Is it because we are screening more aggressively now? Has it always been there? Hindi lang natin napick-up before because we never really encouraged doing colonoscopies or alternative colon cancer screening programs. It might be a combination of all of the above. It might be that we are screening more. The bottom line is when it comes to colon cancer, there is really a possibility of cure if we find the problem early enough we have a good fighting chance of achieving cure. If we do get the screening programs in, may benefit. Many people are intimidated by a colonoscopy because it is a procedure. It involves anesthesia, you come into the hospital, you don’t know what’s going on, a camera is inserted in your backside. Many are intimidated by this procedure, but I talk to patients about it and most realize that it’s the best way to go. Definitely, there are alternatives to a colonoscopy. That’s not the only test that we have. We have an option of doing a scan, an option of doing a stool test. Although I am partial to encouraging a colonoscopy because right there and then you can take care of the polyp and prevent cancer, I don’t want to necessarily sway people that way because it has to be an individualized choice. We always offer and always give alternatives. The important thing is they get to pick something because if you don’t pick, that’s going to be where our problems start. We just need to encourage someone to choose.
Q6: Ano ba ang hemorrhoids and how can we move forward from that issue?
A (Dr. Laya-Zinampan): I have picked up many cancers with the starting premise that they have hemorrhoids only. In fairness, it could be hemorrhoids, it could be both hemorrhoids and cancer. We just need to go back to what I showed na parang lotto numbers. You just remember those cut-off ages. Sokung sa hemorrhoids, but if you’re already 45 years old, we still need to talk about cancer screening. So it always goes there. If patients are having symptoms, this already falls beyond the screening ECU panel. So if the patient already has symptoms (masakit ang puwet, merong dugo kapag nagpapahid ng tissue paper), that falls beyond the ECU. That becomes a symptom based, case finding diagnosis investigation. Medyo iba yun. So many times, nagpapasalamat din ako sa hemorrhoids because I have 30 year olds coming to me for hemorrhoids only to find large polyps, cancer. It also leads you to get to do the appropriate tests. Just don’t fall into the “hemorrhoids lang yan kasi hindi ka pa 45” mindset. So always remember, symptoms are different from age screening cut-off. Everybody’s so scared with the COVID pandemic, that the issue of screening has fallen into the backburner. We always need to remember that we shouldn’t forget about it even though there is a pandemic. Many institutes are able to institute healthcare protocols so that we can still continue with our checkups and screening. My worry is that 5-10 years from now we will suddenly see a shoot up in cancer because everything was shut down during the pandemic.
Q7: You mentioned COVID has really exposed how the healthcare system works in this country. In the provinces and here in Western Visayas specifically, hindi pa ganoon kataas yung cases ng COVID; but there was a time that there were more mortalities due to mental health related problems compared to COVID-19. If you trace it back, we know that these people have these problems. These didn’t just star during COVID. They could’ve been triggered during this time, but these problems started much earlier. As Doc mentioned, if we screened this and caught this early then maybe this patient could have gone into therapy or some sort of treatment. So my question is: we’ve been talking a lot on the medical aspect of prevention and screening, but from a psychiatric perspective, do we have programs in place for psychiatric or mental health screening?
A (Dr. Bondoc): I think our ECU should also look into this. Even if we are not psychiatrists, but I think since tayo ang unang puntahan ng pasyente, then we should also be aware kung may problema sila o may pinagdadaanan.
A (Dr. Cating-Cabral): Mental health checks aren’t really part of the ECU, and you’re right it’s something we should add or start looking at. The advantage of having patients who come back to you on a regular basis, you can sort of tell if something’s not right if they’re not the same the next time you see them. In general, with any patient as part of your bedside manner, you just ask them “How are you doing?” “How are things at home?” While you’re typing out your prescription or lab request, ask them how they’re feeling. Patients really tend to trust their doctors. They open up to their doctors when they don’t open up to other people. We don’t have a lot of mental health programs out there, but they do exist. There are several non-profit organizations and schools that provide mental health assistance. Of course, I personally have some numbers for certain psychiatrists who are open to taking teleconsult because that’s how it is right now, takot pumunta sa hospital. But if you need to go to the hospital, please go to the hospital. Like Dr. Dang said, if you need to be screened, don’t wait 2 years later after you’ve had that bleeding in your stool to get checked. By then, it might be too late. Sa mental health, wala pa talagang very robust program, but it’s a good thing we’re starting to recognize these things. Maybe all of us should be more cognizant of where we can refer these patients kasi kung hindi ka naman psychiatrist or psychologist, mahihirapan po talaga tayo. It’s a big burden on the physician if you aren’t able to handle it well. Know that there are public and free programs out there for these patients.
A (Dr. Laya-Zinampan): We have to look at the patient holistically. I know I’m a specialist in gastroenterology, but I don’t just focus on “may dugo ba stool mo”. I look at the whole patient and kind of build a relationship. As we’ve been trying to underline, this is a partnership. You have to work in partnership with your patients in order to improve their health. Isang tao lang tayo. So kunyari, ako I can only see 10 patients a day. I can’t see a whole bunch of people, and I guess this is where healthcare institutions come in. Although the ECU becomes almost like a de kahon package, it instills in people that “hmm maybe I need an ECU” and then they call their doctor to ask their opinion. Ako naman, I try to see which one we can do for patients, try to add on or cross out. In terms of mental health, sometimes it’s just a one-liner. “Are you doing ok?” “How has this pandemic treated you?” “Did you lose anyone during COVID?” Sometimes just opening up a question like that already gives you an insight on an individual’s emotional and mental health. Then, as Dr. Mitos said, If you pick up a problem, then you can turn to your psychiatrist colleague. Sometimes just asking that question and telling your patient that they matter has already given them a big impact. We can even go beyond the mental health aspect. One-liners are all we need. I tell the younger professionals that come into my clinic “don’t drink, don’t drive, don’t do drugs”, and it sticks with them. They remember it. Those are the little things that we can incorporate in our own practice to be able to help people.