(BO):  Magkakaroon po tayo ng 10 minute na open froum.  Kaya po 10 minute dahil late ho tayo nag-umpisa. So paki compress yung ating mga questions at nang mga sagot ng ating dalawang magiting na panauhing doctor.  Bawal lang pong hingiin kung ano ang kanilang cellphone (laughs) dahil selosa ako. 

Okay, open forum.  Sinong maunang magtatanong? Okay, Raquel Naval. 

RAQUEL NAVAL (RN):  My first question is about Vitamin C.  There’s this study made by Healthy Options,  I think it was last month, saying that Vitamin C alters DNA and that we’re supposed to take only 230 mg a day.  And then I was talking to this friend who hasread that study and she told me, ‘ Maybe you got cancer because you’ve been taking high doses of Vitamin C all these years.’  Well, because I’m a mountaineer so I was taking a lot of multivitamins in the past and specifically Vitamin C.  My question is, is it true it alters DNA? I used to take like 2000 milligrams a day, especially during chemo.  I just have a question before I go. The second question is about Tamoxifen. I’m taking it and I was told that it causes uterine cancer.  So are there many patients with uterine cancer na because of Tamoxifen?  Although my Oncologist told me it’s only 0.8% but I heard that there are some women who had uterine cancer because of Tamoxifen.  So should I stop taking it?  Thank you. 

(FL):  Yung Vitamin C issue muna ano?  Yung Vitamin C issue, all of us has a minimum amount of Vitamin C that we need to take.  You know that the Vitamin C deficiency is related to diseases like Scurvy and all that things, all that stuff.  And it’s really important or one of the essentials in our daily function.  But beyond that, more than that, we don’t really know for sure.  There have been a lot of studies, in fact, conflicting.  There’s this Nobel Prize winner also from from LA, from Cal State who advocated Linus Pauling who advocated Vitamin C for everything, for every disease.  It’s supposed to be the cure, even for cancer.  Yet, there are studies for example that showed that if you take too …The study goes like this..  You put cancer cells in a dish.  You give chemotherapy to the dish without Vitamin C, then the cancer cells die.  But in another dish that you put Vitamin C in, the cancer cells live despite chemotherapy. 

We don’t know in the living person how much Vitamin C it takes to inhibit the action of chemotherapy.  We don’t know if it’s 2000 mg or more than that.  So the data again, is not very clear.  So what we say is that you know, you don’t have to take Vitamin C, just enough for you to get by, to live well without Vitamin C deficiency.  There’s not enough data to say that it does increase your risk.  On the other hand, you also asked the question regarding Vitamin C causing breast cancer.  Ang sagot dun siguro naman hindi kasi normal naman yung Vitamin C sa atin.  Pero hindi rin natin nga alam kung marami o kung mega doses of Vitamin C, if it can cause alter DNA or such.   

(FL):  Well, as I’ve mentioned earlier, if you take your 5 fruits and vegetables, you already have enough of your Vitamin C.  Point number 1.  Point number 2, if you take too much of Vitamin C, you just urinate it. And it can also affect your kidney, and also cause gastritis – gastric irritation.  And studies haven’t really shown that Vitamin C has a protective effect on cancer.  It may have anti oxidant effect also.  Higher doses have not been shown to be proven, to be helpful in preventing breast cancer recurrence.   

Question #2, the Tamoxifen.  You know, tamoxifen works in 2 ways.  It blocks the estrogen receptors and at the same time, it also has some estrogen like properties that can stimulate several organs in the body, mainly the liver, namely, the bones and maybe the uterine lining.  So one of the complications of taking Tamoxifen is thickening of the uterine lining and then you can have bleeding.  And a very small percent, I think you were rather generous in saying 0.8% because what I know it’s roughly 2% chance of developing uterine cancer.  But since the first sign is bleeding, that will lead you right away to your OBGYN, and they will check you and so the treatment there is hysterectomy. 

So almost all of the patients who develop uterine cancer from the Tamoxifen are all in Stage 1.  And they were all cured by a simple hysterectomy. 

So if you want to weigh the risks and the benefits, I  think the benefits one gets from taking Tamoxifen outweighs the risk of developing uterine cancer. Therefore, do not stop your Tamoxifen.   

(BO):  Okay, next question.  Suzette

. 

SUZETTE:  I’m just wondering how come after the surgery the number of nodes you remove varies.  Does the patient needs radiation after almost all are removed 

(MK):  The question was why does the number of nodes vary?  Bakit meron diyang 10, may 8, may 5 nodes lang ang nakita.  Or none sometimes?  There are one of several reasons.  Marami actually.  There’s patient factors, that some patients are thinner and so it’s more difficult to harvest the nodes when they’re thinner.  And there are also physician factors.  Don’t blame the surgeons lang, pathologists meron ding kasalanan diyan sometimes.  Kasi ganun yan.  The surgeons, we don’t take the nodes. We don’t just, we don’t… like berry picking or calamansi picking or tomato picking. It’s not like that. We harvest them.  They are enveloped or they’re within fat so we pick out the auxiliary fat and then the pathologist goes through it and then harvests the nodes and then counts them.  Now, it’s not a problem naman kung mas konti or mas marami.  Depende pa rin ano?  Ang usual na gusto naming, we aim for at least 10 nodes that are counted, at least.  Kasi then you will have a better picture or a more accurate picture if the nodes really contain cancer or not.  Once you have 10 or more, then the percentage goes about 90% higher.  For example, you have 2 nodes positive.  And how sure are you 2 nodes lang iyan?  Hindi 3, hindi 4, etc?  Kasi it will affect the treatment.  Therefore, the more nodes counted, the higher the chance that it is indeed accurate.   

So it does affect radiation treatment as such… 

(BO):  Ang hirap pala nuon ano?  Iba-iba yung mga nodes. Parang ang feeling ko tuloy, 2 nodes, 3 nodes, 24, 28, 32, BINGO! (laughs) 

Anyway, our next question is going to be from Karina Soriano. 

KARINA SORIANO (KS):  For those who will not be able to take the 5 fruits and vegetables, what is the safe amount of ascorbic acid to take?  500 milligrams okay? 

(FL):  500 milligrams.  

(KS):  500 milligrams. 

(FL):  500 milligrams is safe.  As I’ve said once you get a certain point, you just start urinating all those Vitamin C.

   

(KS):  Just one more question, what is it in Ginseng.. 

(FL):  Ginseng and Soya have estrogen like properties as part of it.  And if you are taking, if you are taking (yes, Ginseng Tea) So if you are taking Tamoxifen, and you are taking these medicines, so there’s a theoretical risk that you can further stimulate those estrogen receptors and compete with your Tamoxifen.   

(KS):  My PR and PR negative and Her2+.   Do we need any medicines to take in lieu of Tamoxifen, like Femara??? 

(MK):  Is this in the Adjuvant setting? Adjuvant ito ano?  Well, studies have shown if your ER/PR are negative, you don’t benefit from these hormonal drugs. So there’s this new study that just came up this June in the American Society by getting Herceptin, which I showed earlier, for 1 year.  It can be given every 3 weeks for a total of 1 year. But again Herceptin is quite expensive.  And it showed, the data showed that there is improvement in survival compared to those who did not receive the drug.  I think that’s the only thing that’s available right now that has evidence. 

(BO):  Doc, how expensive is Herceptin?  Para malaman naming kung magsasanla kami ng asawa. 

(MK):   Roche, the booth of Roche is downstairs.  Perhaps you can ask them  how much Herceptin is… Maybe 2 vials of Herseptin is what, 64, around 64,000 every 3 weeks for a year.  Isangla mo na si Carlitos. 

(BO):  Ha? Buti na lang guwapo asawa ko, marami ang tatanggap ng sangla.  (laughs)  Pero, okay… 

(FL):  These drugs are indeed expensive because they still have patency, that’s number 1.  And they’ve just been developed so and again, they go by international price.  That’s why a lot of patients ask me, “Is it cheaper if you buy the drug in the States?”  Not necessary so, unless it’s given to you from the States then yes.   

(Q):  Follow up question sa Ginseng.  I’m ER/PR negative and I’ve been taking Ginseng concentrate. I’m a 5 1/2 year survivor.   

(MK):  They say, as Dr. Lopez said, that Ginseng has what you call estrogen-like effects.  It may act like an estrogen.  Although a weaker version of Estrogen.  That’s why we’re not very, of course, we’re not very sure really whether it can increase your risk of getting, of having a recurrence.  And especially if you’re ER/PR negative. That means that your tumor does not react or respond very well to hormones anyway.  So maybe, it’s okay but as Dr. Lopez would say, the advice is there’s no real benefit from it anyway. So you might as well take whatever other supplement, pareho lang siguro.. e ito may theoretical ano pa, risk of getting recurrence pa.  So that would be the advice. 

(Q):  Hindi po ata ako mamamatay sa cancer, kundi sa heart attack.  Kasi po sinabi sa akin maganda raw ang Kelation. And I have undergone 15 times ng Kelation which is too expensive.  Now, I would like to know your opinion about it… 

(BO):  Kelation naman iyon.. 

(FL):  Regarding that question of Kelation.  Again, we have to go by evidence based medicine.  What is the scientific basis for this?  What is the proof?  I always tell my patients, if you don’t have a randomized, meaning kukuha tayo ng 1,000 women, mag Kelation tayo ditto, at hindi tayo mag kelation dito, who will live longer?  And if we don’t have that kind of a study to prove that Kelation does working, then I, as a physician, don’t really have any basis for recommending it to my patient. 

But when you go to an alternative medicine, and again, I don’t have anything against that, but if you go to an alternative medicine and they offer you something, they will explain to you and they will make sense.  They will explain what Kelation does, it will take out all the dirt, all the etc, etc, in your body and you will feel better and your cells will be happy, ect, etc.  But again, what is the evidence base?  And again, there is none. 

I hope that answers your question. 

(BO):  May follow up question.  Ano raw ang chances na mag-recur kung 10 years ka ang cancer free? 

(FL):  Well, the chances are very low.  As you go farther from the time of your diagnosis to 2 years, 3, years, 4 years, 10 years, the chances are really low.  But if you’re asking me for a number right now, I don’t that exact number.  It’s suffice to say, the farther you are from your time of diagnosis then the chances of recurrence is very low.  And as mentioned by Dr. Mark Kho, it could now be considered a new primary if it comes back later on, which I have a couple of patients that way.   

(BO):  At this point, we would like to thank our two good looking doctors, Dr. Lopez and Dr. Kho.  (clapping) 

And before I go, one last tip:  We’re all supposed to think positive but we must also learn to think negative about the positive. Pag nagpapa-test  ako, hindi ako maka-think ng positive eh.. Lagi kong iniisip sana negative, sana Negative, sana Negative.. yun okay.. (laughs)