Singapore oncologist shares journey in treating patients with virus-related cancers

Dr Richard Quek's path to becoming an oncologist was paved in part due to the positive change he experienced under the care of doctors in his childhood.

He recounted how as a young child, a dermatologist managed to relieve his pain from an open sore due to eczema. The memory and impact stayed even decades after.

"He put a gauze bandage around it and immediately, the simple act of it completely took away my pain," said Dr Quek, Senior Consultant, Medical Oncologist at Parkway Cancer Centre.

Aside from some level of prestige, being a doctor also involves "doing good" and "self-sacrifice", themes that appealed to Dr Quek as a young boy. And now, "these qualities are even more clearly evident in the Covid-19 pandemic."

As the battle against the coronavirus rages across the globe at present, patients under Dr Quek's care are often fighting against other serious illnesses caused by viruses as well.

As an oncologist, Dr Quek is all too familiar with how viruses play in the formation of cancers. In particular, the Human Immunodeficiency Virus (HIV), which leads to Acquired Immune Deficiency Syndrome (AIDS) in its advanced stages.

While HIV does not directly cause cancers, it weakens the immune system such that viruses may infiltrate. 

Dr Quek explained: "Once HIV takes root in a person, it damages the immune system. Without a normal functioning immune system, the patient becomes prone to infections.

"Many of these infections are uncommon infections, also known as opportunistic infections, which are not normally present in someone with a normal immune system."

These include fungal infections, tuberculosis (especially in non-endemic countries, for example, Western nations), and certain viral infections such as cytomegalovirus infections.

Said Dr Quek: "These unusual illnesses are part of the AIDS-defining illness. When present, it defines AIDS in a HIV patient."

Few may know that HIV is also related to three types of cancers -- lymphoma, cervical cancer and Kaposi sarcoma -- which are linked to and driven by viruses.

Lymphoma is linked to the Epstein Barr Virus (EBV), cervical cancer with the Human papillomavirus (HPV), and Kaposi sarcoma (KS) with the Human Herpes Virus-8 (HHV8)

"We now recognise that these cancers are also AIDS-defining illnesses," said Dr Quek.

"When HIV strikes, the immune system goes down, these viruses flare up and drive cancer development.

"As such, when we see these cancers in new patients, we check for HIV status," Dr Quek added.

Virus and Kaposi Sarcoma

Touching on the types of cancers that are related to HIV, Dr Quek shared that Kaposi sarcoma is the rarest.

"It is a cancer that grows under the skin (subcutaneous) or can affect the lining of the mouth, nose, and throat, in lymph nodes, or in other organs. These patches are usually reddish or purplish in colour", said Dr Quek.

The signs of this slow-growing cancer are oftentimes mistaken for rashes and pigmentation.

And while a weakened immune system may lead to the development of KS, HIV is often the culprit.

It may be an "insidious" disease, perhaps one positive aspect is that not many, especially in Singapore, will have it.

Outside of the HIV population, there are people who may be genetically predisposed to developing KS, but it has been found to afflict mainly middle-aged or elderly men of Mediterranean or Ashkenazi Jewish descent.

"A subspecialist who sees sarcomas like myself, may see only a few cases in a year. So this is a very, very rare disease," shared Dr Quek.

In patients with AIDS and cancers, HAART, also known as highly active anti-retroviral therapy, is a key cornerstone of treatment, said Dr Quek. The treatment has to be started in a timely fashion, either concurrent with or prior to cancer treatment, to be effective. Oftentimes, once the immune system recovers, KS may go into spontaneous remission without need for additional treatment. With HIV under control, the patient's immune system will improve, rendering patients less likely to catch any opportunistic infections during treatment as well.

Treatment

In treating HIV-related cancers, the challenge is that both HIV and cancer have to be dealt with at the same time.

“When dealing with a HIV patient with cancer, we are essentially dealing with two diseases. Namely, the cancer and HIV or AIDS,” said Dr Quek.

He explained that often, by the time the HIV patient seeks medical treatment for the three AIDS-defining cancers, especially lymphoma, “his or her immune system may be in tatters”.

“Not only do we have to treat the cancer with chemotherapy, we are dealing with fragile patients with a much weakened immune system. And these drugs further reduce an already weakened immune system, resulting in high risks of severe and life-threatening infections,” Dr Quek explained.

“The risks of these high risk infections also impact how we can or should treat our patients. If we give the same standard treatment as we would in non-AIDS patients, we run the risk of patients developing severe infections and dying from infections.”

Building a relationship with patients

As treatment for cancer tends to stretch over a period of time, Dr Quek gets to build rapport with his patients, which is one aspect of being an oncologist that drew him to the discipline in the first place.

He shared: "There’s a deep sense of humanity that grows out of the continued interaction between patient and doctor. To this day, it continues to inspire me to do my very best every day."

Victories and losses in the medical battlefield inevitably comes with the territory -- both equally powerful moments which stick with him, said Dr Quek. But they serve to spur him on to "do better" and push forwards.

"You know, as of today we still cannot cure many patients with Stage 4 cancer. It just tells us we need to work harder and do better in our field.”

This article was brought to you in partnership with Parkway Cancer Centre.