Monday, April 29, 2019

Reading backlog

For the past years, I've been reading books in my Kindle. It saves me space. I've been particularly drawn to printed books, however, and can't seem to get over them. Whenever I come across book stores, I am drawn to spend a few minutes to browse through the novels, short story collections, and works of non-fiction. Like any bibliophile, I smell the pages and read a few passages. It is hard to ignore this compulsion, and I almost always end up buying one or two. My threshold for a purchase has grown rather high as I've grown up, but I can't pass the chance to buy an Elena Ferrante, James Salter, or Mavis Gallant, among many, many authors I turn to when I want to daydream. How I will ever find time to read them, given my massive backlog of readings in oncology, remains a mystery to me, but I somehow squeeze non-academic reading in my life. These books end up on my bedside table, or, for this stack, on the dining table. My brother, whom I live with, often protests and chides my behavior, but he devours some of these books and forgives me anyway. A huge pile of backlog is something I am grateful for.


Praise be to God for human friendships

1 Samuel 18:1, written with Pilot Custom 74, broad nib, with Pilot black ink. I thank my friends, whether I see them every day or hardly ever.

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Friday, April 26, 2019

Coffee and the Christian

The reason why I identify myself as a Christian is that the Christian worldview makes so much sense. It appeals both to reason and emotion. It offers a logical, comprehensive, and satisfying explanation as to why things happen the way they do. It does not shy away from miscellany—consider coffee and other caffeinated drinks, for example.

My morning reading was David Matthis's interesting essay on the Christian and caffeine.

The Scriptures do not mention caffeine, but they do give us all we need to observe, learn, and wisely decide how we, as Christians, can faithfully use (or abstain from) caffeine for the glory of Christ — namely, for our pursuit of Christ-exalting joy for ourselves and others. As with other powerful substances, whether naturally occurring in creation or stemming from human cultivation, God made us to search out the prudent, life-giving (rather than life-diminishing) use of his created world.

My first cup today was a kapeng barako given by a patient. I might have another cup during the day. Ma'am Cherith, who works at the Onco office, brews delicious coffee all day!

Thursday, April 18, 2019

Not lifting hands

Funniest thing I read in the internet today:

According to multiple sources at Sovereign Redeemer Church this past Sunday, a man who didn't raise his hands a single time during the regular time of worship obviously doesn't love Jesus at all.

Read to the last sentence. I love Babylon Bee.


Wednesday, April 17, 2019


Random notes on ESMO Annals of Oncology editorial by Drs. Cartwright and Chau on ATTRACTION-4 trial in advanced gastric cancer. Colophon: Diamine chromium ink, using Sailor 1911 fountain pen with a broad nib.

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Tuesday, April 16, 2019

Grateful to work with these men

UP-PGH Medical Oncology fellows at the first round table discussion on papillary thyroid carcinoma at The Medical City. Missing were Mervyn Leones and Karen Mondragon, who had to attend to an intraoperative chemo. Photo credit: Rich King (his real name).


Thursday, April 11, 2019

On National Siblings Day

Eight days after Tatay passed away, my brothers and I tried to make sense of our grief by visiting the fruit stands along the highway, where Tatay loved to buy pineapples, papayas, mangoes, and watermelons for Nanay. I see so much of my father in my brothers, Manong Ralph (@arveecee) and Sean (@seancatedral)—his pot-bellied tummy, self-deprecating humor, extreme adherence to punctuality. I am grateful to have grown up with them.

Tuesday, April 9, 2019

Genes turned on

The field of developmental biology answers the fundamental question of how cells make decisions about what kind of cells they will become.

Scientists from the Sloan Kettering Institute studied the mouse endoderm, the germ layer that forms majority of our internal organs. This paper is published in Nature. Using single-cell RNA sequencing (scRNA-seq), where single cells are isolated and the messenger RNAs in them are fully sequenced, scientists could see a snapshot of the actual genes that are turned on during development.

Their findings were as follows:

Trajectories of endoderm cells were mapped as they acquired embryonic versus extra-embryonic fates, and as they spatially converged within the nascent gut endoderm; revealing them to be globally similar but retaining aspects of their lineage history.

From the MSK website:

They found that cells that come from extra-embryonic tissues and those that come from the embryo are 99% identical regardless of origin, yet there is a set of genes whose activity is different between them. What’s more, the investigators were able to decipher some of the signals that help cells make their earliest fate decision: whether to become part of the embryo or part of the extra-embryonic structures. The team also pinpointed the earliest time when cells with organ-specific endoderm can be identified. It is far earlier than previously believed.

What does this mean?

The study adds to our current understanding of how cells develop. It shows that certain genes are crucial in determining the fate of a cell. This research inevitably leads to more investigations: how are those genes activated, for instance? How do those genes affect the cells, the organ, and the body, in all stages of development? The answers may be useful to our understanding of developmental biology and, hopefully, of cancer.


Nowotschin S, et al. The emergent landscape of the mouse gut endoderm at single-cell resolution. Nature (2019). Link here.


Monday, April 8, 2019

Father and son


This young father took his son with him to the coffee shop. The son felt quite at home.


Sunday, April 7, 2019

Spirituality and cancer

Puchalski et al (2019) reviewed the scientific literature on spiritual care in oncology.

The authors recommend that "all clinicians who develop assessment and treatment plans should assess patients for spiritual or existential distress and for spiritual resources of strength and integrate that assessment into the assessment and treatment or care plan." Another take-home message from the paper is that "clinicians are responsible for attending to the suffering of their patients." This is a tall, albeit reasonable, order.

The authors also put forth recommendations for integrating spiritual care in medical training:

  • All oncologists and clinicians practicing in oncology settings should be trained in spiritual care. This training should be required as part of continuing education.
  • Clinicians should be trained in spiritual care, commensurate with their scope of practice in regard to the spiritual care model.
  • Healthcare professionals should be trained in doing a spiritual history or screening.
  • Healthcare professionals who are involved in the diagnosis and treatment of clinical problems should be trained in the basics of spiritual distress diagnosis and treatment.
  • As part of cultural competency, all clinicians should have training in spiritual and religious values and beliefs that may influence clinical decision-making.
  • Training should also include opportunities for all members of the clinical teams to reflect on the role of their own spirituality and how it impacts their professional call and their own self-care.

Spirituality is "an important component of health and general well-being of patients with cancer, and that spiritual distress has a negative impact on quality of life of patients with cancer. This makes the implementation of spirituality-based interventions essential in order to support the spiritual well-being of patients with cancer. Spirituality and spiritual well-being have been proven to have a positive effect on patients with cancer."

I am interested in doing a study on whether Filipino oncologists are able to integrate spirituality into their practice. I wonder if similar studies have been done locally. Given the massive patient load and the myriad physical problems that cancer patients have, it is a challenge for physicians to look beyond the physical aspects of malignancies and view the patient as a person with a body and soul.


Puchalski CM, Sbrana A, Ferrell B, et al. Interprofessional spiritual care in oncology: a literature review.  ESMO Open 2019;4:e000465. doi: 10.1136/esmoopen-2018-000465


Mount Matutum


In Mandaluyong, I enjoy the view of Mount Matutum, sans the massive Dole pineapple plantation.


The waters of baptism

When I attended water baptism on Saturday morning, I was refreshed. Men and women from various ages and backgrounds spoke of lives changed, hearts softened, priorities altered. No wonder why, in his exhortation that morning, Pastor Bob called water baptism one of his favorite duties in the ministry. It is not that baptism saves any one; it is a declaration of one's faith in Jesus Christ.

Stephen Charnock, in his comprehensive and voluminous treatise, The Doctrine of Regeneration, wrote, "What am I now? Here is a new light in my understanding, new inclinations in my will; I can now look upon God with pleasure and run his ways with delight. Christ is my only joy, and Christ is my only gain. My old nature is wearing away, my new nature is rising higher and clearer; now I am freed by the blood of Christ from my filth."

That a Puritan preacher from the 1600s and modern-day Filipinos speak of the same personal spiritual experiences and truths is nothing short of a miracle. It is the supernatural work of God alone: this change in the very nature of men and women who were once lost but now found (Ephesians 2).


Saturday, April 6, 2019

Breast surgery in patients with stage IV disease may increase survival

The ASCO Post, explaining the results of a study by Ross Mudgway (a medical student!) and colleagues:

To assess the impact of primary tumor resection on survival in patients with HER2-positive stage IV breast cancer, they conducted a retrospective cohort study of 3,231 women with the disease, using records from the National Cancer Database from 2010 to 2012.


The researchers found that surgery was associated with a 44% increased chance of survival, assuming the majority of patients also had systemic treatment.

Read the abstract here, first presented at the AACR Annual Meeting in the USA.

Few things I find interesting:

1. The primary author is a medical student. How cool is that!

2. There's a working database that's a minefield of research possibilities, even for those who are in their early stages of their medical careers. In the Philippines, there's an urgent need for a   comprehensive cancer registry.

3. Patients who have metastatic breast cancer I'm meeting for the first time would invariably ask me if they, too, can have surgery. Unless the patient's breast mass has secondary infection, I would refer to surgery for toilet mastectomy or debridement. This study shows that there is surgical benefit for those whose breast cancer profile is Her2 positive. I hope this makes its way to our guidelines eventually.

(HT: Dr. Dennis Lee Sacadlan for sharing the link, via Facebook)


Why critics are important

A.O. Scott, writing for the NY Times:

No reader will agree with a critic all the time, and no critic requires obedience or assent from readers. What we do hope for is trust. We try to earn it through the quality of our writing and the clarity of our thought, and by telling the truth. The truth, in this case, about what we thought about what we saw, read or heard.

That's true.

I turn to critics I trust to help me sift through the many options of films, movies, plays, and books. I also ask my close friends and family for such advice. I don't take all of them seriously. I leave room for experimentation and discovery.


Wednesday, April 3, 2019


The title comes from a comment by my friend, Racquel Bruno, when I posted the photo on Instagram.

My good friend, Roger Velasco, the brilliant and compassionate oncologist who holds clinics next to my cubicle, gave me the olive-green bag. Some of Mari Kondo's philosophy rubbed off on him. The bag did not spark joy in him, apparently.

I've been using this bag daily. My laptop, phone charger, ink bottle, a hardbound novel (in this case, a short story collection lent to me by my mentor, Dr. Ding Fernando), and a few sheets of paper, fit inside.

Thanks, Raj!