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Cancer: Healing the Modern Day Leper

Jukes Namm

Description

Cancer is the second leading cause of death in the United States and there is growing scientific evidence regarding its link to lifestyle. By better understanding the nature of cancer as well as the prevalent misconceptions on the treatment of this disease, clinicians can better help cancer patients to wholeness.


Objectives:

1. Identify the risk factors associated with the most common cancers
2. Demonstrate knowledge of updated cancer screening guidelines
3. Identify patient and physician factors that affect cancer-related outcomes

4. Appreciate the physician’s eternal impact on a cancer patient 

Presenter

Jukes Namm

Surgical Oncologist and Clinical Ethicist at LLUH

Conference

Recorded

  • October 27, 2017
    4:15 PM
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So a few objectives also list in the program so number one is to identify risk factors that are associated with the most common cancers number to review updated cancer screening guidelines specifically for colon in breast cancer those are kind of my areas of expertise. In there and also discuss patient and physician factors that that may affect cancer related outcomes and then finally last but not least appreciate the physicians eternal impact on a cancer patient so before we start how many of you in this room know someone who is diagnosed with cancer or your city your self or a cancer survivor if you can raise your hand right now I think most of us in this room and if you haven't raise your hand I pretty sure that you will very soon just because cancer is insidious with cancer is growing so rapidly and so just to go over a little bit of statistics I won't bore you too much as to to sticks but you can see that. The death rates in response to cancer on the rise in heart disease is still number one has been for a long time but cancer has has reached it and probably will surpass it in the next five ten years and you can see here in terms of the incidence of death you can see heart disease kind of went up and then has slowly been coming down with largely because of improved education and on diet and smoking in particular but you can see here the incidence of cancer has steadily risen almost three times from one nine hundred fifty and that looks like it's continuing to rise. So. In the United States the good news is that our I expected lifespan is is increasing and so the average American is expected to live seventy eight point seven years the bad news is that the longer you live the higher the likelihood you'll probably get cancer at some point. And we know that right now almost forty percent of men and women in this country will be diagnosed with cancer at some point in their life OK so that's over one third so if you look to your right and left one of you may be diagnosed with cancer and that's not necessarily a bad thing because a lot of cancers especially that are diagnosed early they do have good outcomes but it's still something that is very serious and that we need to take into consideration. And we know that that that number is growing and in the next ten years we expect that four and a half more four and a half million more people will be living with cancer and by twenty twenty four will be nineteen million people will have cancer and that's that will be almost ten percent of all of our population in the United States and there is a silver lining to that because less people may be dying of cancer overall relatively but there will be more people living with cancer which makes cancer more of a chronic disease and then we'll be faced with the issue and the challenge of managing this chronic disease long term. So brief overview many of you probably already know this but in terms of the most common cancers so the most common leading sites of new cancer in men number one prostate number two long number three color rectal and that hasn't changed in a while for female it's very similar except instead of prostate it's breast cancer then long then colorectal cancer but in terms of the deadliest cancers lung cancer is by far and away the most deadly both in male and female colorectal cancer number two breast cancer number two for women prostate cancer for males and colorectal cancer for females. So. I was you know as I was thinking about what to talk about this today you know there are a lot of parallels between cancer and leprosy. Back in biblical times. Was a very very serious illness a very difficult illness to treat they didn't have any cures and in the Bible only mentions a few times where people are actually cured of leprosy. But there are a couple of examples for example Miriam. Moses sister Ghazi. And the leper that that approach Jesus who the theme of our conference this year is based on and also kept in naming. And if you look at the stories in the Bible of leprosy and if you compare it to cancer in this day and age in two thousand and seventeen we find that. There are some stigmas associated with cancer similar to leprosy and one is that you know maybe a result of you know people's choices or actions but it can isolate people is Miriam was kind of isolated outside that is or like camp after she was struck in with leprosy. Is in the case of Gazi the leprosy was passed it was given to him and it was passed on to his children and their children for generations and we know that there is a genetic component to cancer as well. It causes desperation. Many people still believe that cancer is a fatal diagnosis a lethal diagnosis. But now we know that it's more of a chronic disease it can be a chronic disease in many cases. But probably the most fascinating is that you know cancer does not discriminate Yes there are disparities in cancer outcomes but whether you're rich poor old young. You know white black Hispanic Asian It affects all of us and although I'd like to go into some of the factors that may play into that but I want to say that there's really still a lot that we don't understand about cancer and why we get cancer so as humans we like to kind of we we want everything to make sense in our life so we like to have everything kind of fall into a kind of cause and effect and we want an explanation for why things happen why there's suffering why there's cancer and so and that's illustrated in the story when Jesus was walking with his disciples and they saw a blind man on the side of the road and the disciples asked their master they say master who sins was it this blind man or his parents. And basically they were asking was his illness a result of his choices his sin or was it somehow kind of genetic and it's similar in cancer we ask when we hear that someone has cancer I think for me the first thing I tend to think of is well what were their lifestyle choices like or did their parents or their family members have cancer to. We do know that there are risk factors associated with cancer and so I don't want to I want you to leave your very clear on that point I think I'm preaching to the choir here most of us here are very very well versed in that but I think science is catching up to what we have already known for a long time and so tobacco use is still the number one. Risk factor for cancer. But coming in a close second is obesity and I'll talk a little bit about that later there are infections viruses and bacteria that can predispose to cancer not so much in the United States but overseas. But here I like this category is a question mark it's an unknown and there's still many cancers out there we just really don't have a good explanation of why it affected a certain individual we do know that exercise or lack there of plays an important role as there's diet there's occupational exposure such as. This best those for me to feel Yoma some other chemicals. In liver cancer all Kohol obviously plays a role in liver cancer cancer. There are reproductive factors associated with breast and ovarian cancer U.V. lights obviously in skin cancers and melanoma environmental pollutants and even prescription drugs there are some studies that link. Some prescription drugs to cancer and particularly narcotics which we have a huge epidemic in a crisis in this country in terms of narcotic use those patients with cancer they tend to have there's a there's studies that show that there's a worse outcome in those patients who are taking narcotics medications and we still don't understand completely why but like I said we've all known this right so we've known that lifestyle is is important and plays a role in our overall health. And I think again medicine is kind of catching up and and finally validating what what this says to whites has shared with us over hundred years ago. So this is one very fascinating study that was published about two years two and a half years ago in science which is one of the premier. Scientific journals and they basically looked at they try to explain how. You know try to attribute cancer wrist to expects Journal factors or intrinsic factors based on it's kind of complicated and based on you know how tumor cells divide and there are cells in our body that divide more rapidly than others and there's there's cells that divide less and they found a correlation in terms of the incidence of cancer in specific body parts based on the cell division. And basically what they concluded was that they set of third of cancer risk is attributed to environmental factors or inherited predisposition so they said only a third was a result of what they called Bad luck now that seems like a lot but actually it's probably a lot more and there was a lot of controversy in the public health world regarding this study and there was actually a rebuttal study that was done use similar techniques but they said kind of improved on it and they actually found that it's not just thirty percent but it's up to seventy to ninety percent of cancers can be attributed to lifestyle diet environmental factors that are not just bad luck and so that really just open the eyes of a lot of cancer researchers and clinicians in this field so that is really kind of changed as a dramatic shift from kind of what we were practicing before. So we know that in lifestyle exercise plays an important role. And I don't want to go through the New Start with all of you but we know that hypoxia on a cellular level. Increases the risk of cancer progression in cancer metastasis. And so in this study in is actually Nature paper in Nature are good Genesis they found that hypoxia drives malignant progression in cancers resulting in poor survival the resistance of therapy and increased maddest attic potential and in one of the areas of research that I'm interested in is metastasis because patients don't die of the cancer in their breast or in their skin but they die when that tumor has spread to other parts of the body and starts taking over organs and causing organ failure and one of the one of the most interesting mechanisms for cancer metastasis is related to hypoxia. The tumors kind of thrive in kind of a hypoxic environment and it kind of causes the release of tumor cells into the bloodstream and to various parts of the body. So we know that smoking also plays a role but the good news is that smoking actually is on the decline thanks to you know concerted public health efforts government efforts and lung cancer as a result is also dropping. And you can see here this is a nice graph kind of illustrating the rate of cigarette consumption in our country and how the rate of male and female lung cancer. Is very very symmetric to the rate of of cigarette consumption and you can see here there's actually about a twenty year lag between the peak of cigarette consumption and the peak of lung cancer and so you know there are obviously patients that smoke for their whole life and they never will get lung cancer but it's especially important in the younger years in your twenty's and thirty's that smoking will affect them that when they're young but when they're older and so that progression can take about twenty to thirty years on average we know that diet is important. And. Especially there's been a lot of research in red meat and processed meats. And just two years ago the World Health Organization published their findings they did a very very exhaustive study looking at the effect of meat on cancer risk. And they found that eating fifty grams of processed meat every day such as hot dogs bacon and cetera increased the risk of colorful cancer by eighteen percent. And also for red meat in general there was increased risk of color rectal pancreatic and prostate cancer and they went even as far as labeling processed meat as a carcinogen. And so it is now officially carcinogen so that's something to consider and finally like I said it's taken has many many years this this should've been you know hopefully you know well known by now but finally we're catching up to we've known and in our evidence health study obviously done at Loma Linda and other sites that crowd rates that fact we know that those who consume more fruits and vegetables they have decreased risk of colon cancer prostate cancer pancreatic cancer and other cancers those who eat meat frequently in their meals there is a significant higher risk of colon cancers bladder cancers and ovarian cancers and that's just in this study other studies have shown links to other cancers as well. But now probably the biggest problem that we have in our country is the obesity epidemic and you can see here that. Overweight you know B.M.I. from you know twenty five to thirty has essentially stayed the same. But if you look at obesity B.M.I. of thirty five to forty that has dramatically increased in the past forty or fifty years and then extreme obesity B.M.I. above forty is slowly on the climb. And why does that matter because we know that there are at least thirteen cancers that have been shown to be linked to obesity. Namely esophageal cancer breast cancer and that's typically after menopause pancreas cancer liver cancer kidney cancer. Colon cancer and uterine cancer as among others and so finally I also wanted to touch a little bit on genetics and the environment. And you know the Bible talks about the sins of the parents and how it gets passed on to to their children to the third and fourth generation and so you know that that verse is kind of stuck in my mind and there is so much truth in that. Here we know that there are some cancer genes that have been identified and you know obviously those are fairly rare those account for maybe less than ten percent of cancers. But there are a lot of things that we still don't understand about genetics and what we call epi genetics basically the genes themselves may not change but there's the body has ways to modulator the expression of certain genes and that can alter the ability of the genes to be passed down to the children and over time the genes can change and they can develop a lot of these mutations that can predispose to cancer and saw you know there are people who may do everything right they may eat right exercise do everything that they're supposed to but because of these genetic predispositions they're still at increased risk of getting cancer. And there are many different genes many that we still don't really know for sure their significance the cancer but we label genes based on the variance and its penetrance basically how strongly it's able to. Become or express cancer in any undo any specific individual and so majority of the mutations that we find in the genome of humans or in these tumors we find there are a lot of common variants but a majority of them don't become cancer which is the good news. There are a kind of variance with modern penetrance where a little bit. More of them may become cancer. But really the ones that you've probably heard of are the high penetrance genes such is the breast cancer mutations gene the B.R.C.A. mutation genes or or the P fifty three mutation genes or the P. ten and those are much more rare but of a significant number of patients with those gene mutations will end up getting cancer and like I said they only they only make up about ten percent of cancers this is breast cancer in particular but we know that patients with a B.R.C.A. mutation gene they can they have about eighty percent risk sixty eight percent risk of developing breast or ovarian cancer in their lifetime and so those are things to keep in mind as we counsel these patients. So now we know all this information so what do we do about it and I think for me I like to talk to patients and kind of break these risk factors up into what I call non modifiable and modifiable risk factors and not modifiable are things that they really can't do anything about and this is pretty specifically in breast cancer there's a lie see a lot of breast cancer patients and obviously female age race family or personal history you can't really do anything about so there's really no use worrying about you know what to do about that. However if they do have you know a genetic predisposition if they had a history of radiation therapy to the chest those are patients that I counsel to you know they may require more frequent screening or closer follow up because the may be at increased risk of breast cancer. But these are the modifiable or quasi modifiable risk factors so the one is you know Breast feeding has been associated with decreased risk of breast cancer. Early childbirth has been associated with the increased risk of breast cancer but that's probably not very modifiable. But hormone therapy there are links of hormone therapy with breast cancer but studies show that if you stop hormone replacement therapy or all contraceptive therapy within three years your risk goes back down to normal but the big three that I really you know counsel patients on and talk to them about are obesity exercise and limiting all go now ideally you know I don't tell patients you have to stop drinking completely I do recommend it but studies have shown that if you drink less than three drinks a week then your risk of cancer breast cancer significantly decreases and there was an exercise of three four times a week about an hour thirty minutes to an hour of good vigorous aerobic exercise in obesity if you can get down to kind of normal B.M.I. between twenty and twenty for those three in combination probably will do much more for decreasing breast cancer risk and breast cancer mortality than any of the treatments out there. And what about colon cancer so the same so there's non modifiable unmodifiable risks and again personal family history race inflammatory bowel disease is a big one and I see the incidence of that has been increasing significantly. In diabetes also has been linked to colon cancer and also a prior radiation soap specifically patients who've had radiation treatment for prostate cancer there is a slightly increased risk of developing rectal cancer because of the radiation in that area again that's usually about ten twenty years down the road. But those are modifiable smoking. Limiting red meat or just a little eliminating eliminating completely and again the same three obesity exercise and alcohol intake but again you know you will see patients and there maybe even some people here in the room who do all these things yet still get cancer and so what do we do about those patients. And you know I tell them. I don't know. And they're sometimes we don't have good answers for that. And going back to the story about Jesus and His disciples. You know they said you know what happened why did this man become blind. And I love Jesus answer he says you know neither did this man sin or his parents but that the works of God should be made manifest in him. And so what I take away from that is when I see patients with cancer you know whether or not they're smokers or drinkers or they're overweight or what have you I think first and foremost as physicians we need to show compassion. In meet them where they are. Use a lot of the times they already feel guilty they already know a lot of times they'll ask me you know why did this happen was it because you know I didn't exercise or because I smoked you know and they're already being themselves up enough and I don't think as physicians we need to do anymore you know bludgeoning them at that time I think there's a time for education but I think first and foremost we need to be compassionate and then treat and I'm not going to go too much into treatment today but there are very good treatments for cancer. And I think there's a role for you know using both. The kind of conventional medical therapies as well as the alternative lifestyle therapies out there but I have seen patients who decided they want to go slowly with you know lifestyle therapy and I've heard of some good outcomes and I've also heard of you know many bad outcomes as well and so I think first and foremost we need to understand that you know really God is the ultimate healer and me as a surgical oncologist I'm the first to tell you that I know that there are limitations in the medical treatments especially in cancer therapy and it's not a perfect it's not a perfect solution that we have. I want to shift gears a little bit and go on to screening because I think first and foremost prevention risk reduction is where we should be I think focusing most of our energy but after that really should be advocating for screening because if cancer is caught early it can be treated and patients will have a very very good outcome specially in breast and colon cancer. But when I talk about screening you know I think there's a lot of us who are heroes of the word but not do are right and a lot of our patients the Likewise the same and you can you have to do it there's no shortcut you can't just think about doing it you have to do it. And in terms of breast cancer. There are updated guidelines from the American Cancer Society and so used to be all women forty and above to get mammograms but now studies have shown that in between the age of forty and forty four if you don't have any increased risk if you get what we call average risk of breast cancer you can kind of have a discussion with your physician but you don't have to start annual mammogram screening. But once you become forty five to fifty four that's really the highest yield and that's when I really advocate for women to get mammograms yearly. And then fifty five and older studies have shown that it's safe to switch to every other year instead of once a year but with the caveat that you know you it's you shouldn't really miss a year because if you miss the screening and it becomes four years then you may you may run into trouble. But there's also been some controversy in terms of how long should we you know screen for and some people say after Stage seventy five it's probably not worth it to screen but I kind of individualize it based on my patient and if they're healthy seventy five are healthy eighteen you think they're going to live you know ten more years and I think it's worthwhile to continue screening with them but if they're frail if they're bed bound or if they're just sitting at home and they're not you don't dissipate them surviving longer than five ten years and you probably don't need to worry about screening and they may develop a breast cancer but they probably won't die of breast cancer they'll die with the breast cancer and it won't it won't cause them any problems. So in terms of colon cancer so colon cancer is a little bit more complex but overall they recommend starting screening at age fifty and really the gold standard for screening is colonoscopy Yes I know it's not fun. But if you're clear then it's you're good for ten years that's the good news right but if you find anything abnormal then if you have a polyp a small pile up then then you may they may recommends repeat colonoscopy in a shorter interval maybe five years or three years. However there are what's called high risk patients so again patients that had previous cancer before or who had large polyps or who has a strong family history they really should start screening earlier and the recommendation is starting at age forty or ten years before the first relative that had. Breast cancer colon cancer and the recommendation is every five years in those in those patients. There are some genetic. Syndromes that's significant increase the risk of colon cancer such as the familiar and no poly poses or Lynch syndrome and those really are fairly rare but if you have patients with that the really the recommend screening as early as ten to twelve years of age or twenty to twenty five years of age for the Lynch syndrome for inflammatory bowel disease. Really there is no clear consensus in terms of when to start screening but typically about eight to ten years after their first diagnosis or their symptoms of inflammatory disease they should start screening because we know that the longer they go the risk of cancer significantly increases. And they should get colonoscopies with random biopsies every one to two years to make sure that there isn't any dysplasia or changes that may predispose to cancer so one of the two I mentioned call and ask people for those patients who don't really you know want to get a corner Skippy probably the next best thing is what's called a FIT test basically it's a immuno chemical test it's a stool test and it's relatively new or we used to recommend just doing fecal occult blood tests but that has kind of fallen out of favor you can see the the major kind of societies of have nots recommended that anymore just because the sensitivity and specificity is is so low but the FIT test is more sensitive and more accurate and so. In addition to call and ask me you can recommend a yearly fit tests so what is the fit tests basically it's. It's a test they collect stool sample the they mix it in a vial with solution and then they drop it into this this monitor and the good news is that it's very specific for human blood and for lower G.I. bleed it's not affected by the food that they eat. Or animal products that they eat usually requires only a few store specimens it's better more sensitive then the older fecal called Blood tests false positive rate is low and slightly more costly but it's not that much more cost it's about twenty five dollars or so for this test. So that's kind of the overview for screening and I want to just in the final few minutes I want to talk about cancer therapy and just the overall. Overall how I approach cancer. You know when I was growing up and starting about cancer I used to think that cancer was you know one cell that got mutated and they just started to proliferate out of control and they used the picture it kind of just it's a local phenomenon and at some point it develops mutations and then it starts to spread in metastasized to distant organs but now we you know modern research is showing that that's not entirely true and yes it is it does start with one cell that's requires one two maybe three mutations. And eventually loses its ability to auto regulate and it grows but what it does is it starts to incorporate the body's normal. Support system to help it to grow it starts acquiring blood vessels it starts using the immune system to its advantage to kind of block the immune system so it's it's. So that it suppresses the immune system and we also know that cancers we used to think that it grows and grows and grows eventually it kind of grows too big for its britches in and starts to spread but we know that cancer actually spreads far earlier than we thought specially in pink We had a cancer very early in the course of pancreatic cancer there are cancer cells already circulating throughout the bloodstream and other parts of the body Now the good news is that most of these cells that are circulating never end up kind of metastasizing never end up you know harboring you know Harbor you know finding safe harbor in the lungs or the liver but some of them will eventually and we don't know when and we don't know where but that's kind of the mystery of cancer that we are trying to figure out now how can we limit these cells from metastasizing and establishing a new home in a place where we don't want it to be. We also know that these tumor cells are not just clones of each other and they're very very complex and the have what's called tumour heterogeneity and so it may start with one cancer but that cancer may be what's called a cancer stem cell in a may give rise to kind of projet or cells that are slightly different and those cells will will divide and multiply and we know that's when we treat these cancers with let's say chemotherapy or radiation therapy they may they may respond a majority of them may respond but because they're different they may be some chemo resistant or radio resistant cells that remain behind and those cells will they may kind of be senescent for a little while but eventually they will start growing again and that's when we have difficulty that's why second and third line treatment really is difficult in cancer so we have made a lot of advances in the treatment of cancer therapy and really there are multiple more delegates that we use to treat cancer surgery just one of them and I am happy to say that surgery is becoming less and less important although it still is important but chemotherapy radiation immunotherapy and that's probably the most exciting one that's when these there's newer drugs that help kind of activate the body's own immune system to attack the cancers and so that's has shown some promise but with all of these treatments it's still what I call a very blunt instrument in dealing with cancer because. Yes it does treat some cancer cells but it still affects the normal cells as well there's a lot of toxicity a lot of morbidity associated with it and so we don't have a silver bullets we don't have a miracle cure for cancer. And I think ultimately we as clinicians we can help maybe slow down the progression of cancer maybe even get it to a point where we don't see any evidence of disease but I still firmly believe that there's still so much we don't understand about cancer there's still so much left to chance that we call but really the only one that can truly heal someone from cancer I think is is God our Creator. And so this is a passage that you know Jesus was kind of speaking about that I thought would be relevant for. For this topic and he was kind of talking about. The law in sin in our hearts and I think in a lot of ways leprosy was was associated with sin in Bible times and we can look at cancer through this lens as well too and he said. You know if you look on a woman with lust you overtly committed adultery in your heart. In he goes on to say if you're right I offend the pluck it out you know if your right hand offend thee cut it off in. My interpretation of this and maybe some scholars would agree as well he wasn't advocating for surgery to treat this condition. And we know that because people didn't all of a sudden start plucking their eyes out or cutting off their hands after Jesus said this. But a lot of times we approach cancer the same way we think we just need to cut it out but really cancer is a disease of the entire body it's not just the disease of the breast it's not just the disease of the skin but it's a combination of your whole body your lifestyle choices the your environment your genetics a lot of things that you can control a lot of things that you can't control. And I think it requires surgery on the heart. In Again as I said only God can really treat He's the only physician that can treat and cure that. And so it goes back to the original question why does this happen why is there cancer why do people get cancer and. I don't have the answer for you and I don't know but I do know that God's will for us is not to be sick God's will for us is to be healthy God's will for us is to be cancer free to live prosperous healthy happy lives that we can be a light in a beacon to the rest of the world. But that being said. There will be people in this room who. Will be diagnosed with cancer at some point it may be me hopefully not but I think that's the reality if we look at it and. In God's will ultimate purpose is not that our bodies be saved but that our souls be saved. And I think one of the blessings the silver linings of being able to treat someone and help someone the cancer. In contrast to someone with a heart attack who just so suddenly dies or maybe someone who's dying of dementia and Alzheimer's where you can't really have a lucid conversation with them cancer patients their mind is still intact they know that they may have a finite amount of time left in their life here on Earth. And so it opens up the door for conversations with them they come to you vulnerable they come to you asking for help and. When you treat them with compassion and you treat them with love. Really you can show Christ's character and love to them and you can give them the tools and the education to you know if it's God's will and if they are blessed to. Be given a second chance at life then they can live a fuller and happier life. After after their treatment of cancer. And again this is probably one of my favorite quotes I tell this to my residents all the time and they say and it says you know people don't care how much you know until they know how much you care and again I'm sure I'm speaking to the choir here I know you guys are all excellent physicians clinicians friends husbands wives but it's what this world needs is not smarter physicians smarter surgeons but it's more Christ like physicians. And so in summary. Number one education regarding cancer risk reduction I think is probably the most important thing and for me as a surgeon I'm not on the you know on the. Front lines it's the primary care physicians preventive medicine physicians many of you in this room who are having that conversation with patients who can really make a difference maybe not on a population level but for the individual patient you may make a huge difference. And again smoking obesity exercise all the whole diets in getting a genetic history a family history those are very very important can go a long way in helping patients to hopefully never get cancer. But again that approach should be with compassion so I say compassion first treat second and then that opens the door to education and when they come with that cancer diagnosis a lot of the times what I tell them goes in one ear and goes out the other and they don't remember anything that I told them all they really remember at the end is these they say thank you you've helped me to feel better about cancer you they that what they want to hear is that you're not going to die right now you have time and we have the tools and we have the ability to treat you. And so that's really all they're looking to hear and so giving them that hope is is probably the most important thing and then once they get through that ordeal then opens a door for education and trust me they will grab onto that education and they'll grab on to the health message and they'll remember how you treated them as a physician and as a friend. So a number two early detection with screening saves lives and studies are shown that it does improve breast cancer mortality and colon cancer mortality. And you just have to you know get it done there's really no shortcuts there's no other way to do it. And I urge all of you in this room also to get screening if you haven't already. Be doers not hearers only and cancer affects the entire body and so I want you to start thinking of cancer as a disease of the whole body it's not just one area it's not just the breast and I think in medicine unfortunately you know in especially the subspecialties we've become physicians of body parts organs and we've lost the ability or the focus of being physicians of the whole body and so I hope that's you know one thing that you can take away is to remember that. Cancer behind the cancer is a human being and a person and I think it's important to. To encourage them that treatment is effective even in stage four cancer there are treatments that allow patients to be alive a long time now the chance for a cure is very very miniscule but in some cases the again they can live with the cancer in they will die with the cancer not of the cancer. But again finally I firmly believe that only God can truly cure. The human condition in the element of cancer it's a disease that affects not just organs but it affects the cells it affects the D.N.A. and that's something that is beyond my comprehension and I think unfortunately because of sin and our condition cancer is here to stay but I think through that we have opportunities to really reach out and help others really see that's you know the eternal eternal perspective. Ans You know even when patients you know maybe aren't cured or when treatments fail. Again it is an opportunity to open the doors to talk about salvation and and broader things of things not of this world but of something greater. Because you know we have a privilege that's in cancer patients again their mind is still usually very very sharp and that's all they need to make a decision for Christ they don't need strong bodies they don't need functioning livers but all they need is just to make that decision and so we can help facilitate that as physicians. And so this is a quote by William O's lawyer famous. Internist. And he says the good physician treats the disease the Great Physician treats the patients who has the disease. I think it's true and leprosy in Jesus' time I think it's true today in cancer. I think we should just remember that we are treating people. And these are some of my friends who lost their lives far too early to cancer. And I think all of you I think you know my experience is not unique and all of you probably have lost loved ones friends. Mothers daughters children and so. I think we can't forget about the human element when we're dealing with patients with this disease. And so I just want to leave you with this quote. I want to thank you for what you do as physicians. It's it is a calling. I have three children and you know I don't know if. I can say for sure if I really want them to go into medicine because I know the sacrifice that entails obviously if they're called to do and they want to do it I would be the first to encourage them to do it but. What you all do as physicians is incredible the sacrifices that you've made no one will truly know maybe until we all get to heaven but know that your. Your efforts. Have eternal ramifications. And so I want to leave you with that and and thank you all for this time this media was brought to you by audio from a website dedicated to spreading God's word through free sermon audio and much more if you would like to know more about audio verse or if you would like to listen to more servant leader Visit W W W. Or.

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