Although it only affects 15 to 20 per cent of breast cancer patients, the HER2-positive type is one of the most aggressive as it causes cancer cells to reproduce uncontrollably.

On the brighter side, it is one of the cancers for which scientists have developed a targeted therapy known as trastuzumab that can prolong life and allow victims of the disease to enjoy more time with their families.

Developed by a team of scientists with Roche’s Genentech Company in the US, trastuzumab was approved by the US Food and Drug Administration for HER2-positive metastatic breast cancer in 1998 and is available as a treatment of choice in Thailand.

One of the Genentech team who worked on the drug Dr Mark Sliwkowski was recently on a visit to Bangkok and explained to oncologists and selected members of the press how it works.

The HER2 (Human Epidermal Growth Factor Receptor 2) proteins are receptors on breast cells. Normally, HER2 receptors help control how a healthy breast cell grows, divides, and repairs itself. Once it doesn’t work correctly, HER2 will copy of itself and make the breast cells grow and divide in an uncontrolled way. Sliwkowski and his team believed that the only way to stop this HER2 amplification was by using monoclonal antibodies – man-made copies of proteins that the body’s immune system creates to fight off bacteria and viruses in the hope that these antibodies would not only stop tumours from growing but also shrink them.

Using laboratory mice as their subjects, the team developed a mouse antibody that was later refined into to a humanised antibody that wouldn’t be rejected when injected into the human body.

There were several challenges along the way, not least because no previous work had been done on humanised antibodies. “As scientists and drug developers, we fail frequently, which I think is something people don’t appreciate. If your ego or personality can’t accept failure, you don’t learn from the failures. You can’t move on from the failure and so you are not going to be successful,” says Sliwkowski who has been working on the HER2 therapy for decades.

Trastuzumab was initially approved by the US FDA for use in the advanced stage of cancer but is now also used in early stage HER2-positive breast cancer.

Genetech has continued its research into treatments for the disease and has developed the second and third generation of trastuzumab for advance stage treatments. These are Pertuzumab and the latest TDM-1.

In Thailand, trastuzumab is used for early stage HER2-positive breast cancer after the patient has already received chemotherapy or surgery A trastuzumab injection is given every three weeks for 12 months and can prevent the cancer from returning.

However here, as in some other countries, price is a major factor. Each injection costs Bt40,000, which translates to more than Bt1 million for the entire treatment. Patients under the universal Bt30 healthcare scheme and social security are covered for the treatment.

However that cover is no longer applicable for treatment with Trastuzumab, Pertuzumab or |TDM-1 should the cancer return |at a later date.

The cause of the inflammation of the tendon on the outside of the elbow is due to injury in the tendon and muscle which is attached to the bones on the outside the elbow. This may be caused by an acute injury, such as an accident, or by repetitive use over a long period of time, causing degeneration of the tendon. This includes using sports equipment that has incorrectly been designed for the individual player, incorrectly playing sports, or being involved in jobs that require frequent lifting and dragging of heavy objects, such as that of a cleaner whose daily activities include sweeping, wringing clothes, and kitchen work.

When the tendons and muscles are injured, the patient’s muscles are not at its optimal strength. Often, the torn tendons have not been given time to heal completely before they are subject to being used again. This results in repetitive tear in tendons, causing inflammation and swelling, and the repair mechanism in the body slows down by six to 12 weeks.

The inflammation of the elbow can just be a result of tendonitis but the inflammation often includes the area in the body where the muscles and tendons are attached to the bone or joint at the elbow (epicondylitis).

Signs and symptoms of tennis elbow include:

• Recurring pain on the outside of the elbow
• Pain at the back of the hand that extends to the wrist
• Pain that intensifies when lifting objects, especially when the hand is facing down while, for example, washing dishes or stir-frying food.
• Some people may experience severe pain and are unable to |completely extend their hands or brush their teeth

A diagnosis can easily be made by history and physical examination as well as from the symptoms mentioned above. However, there are some symptoms that are often mistaken for tennis elbow, such as pain in the inside of the elbow joint, also known as Golfer’s Elbow. Another condition is pain at the back of the elbow, called Bursitis, which is caused by a cyst. Since the pain is caused by an injury to the tendon in the specified area, the best treatment is to relax and stop the use of the hand that is in pain. When the pain alleviates, begin exercising your hand to strengthen the muscle. If you are required to return to work, the pain in your hand may aggravate or recur. Spend at least 5-10 minutes exercising your hand muscles before using it again.

Physicians generally prescribe anti-inflammatory medicines to patients in the first stage, when they are not experiencing great pain. If these medications are not effective in the treatment, the physicians will recommend steroid injections into the site of the inflamed tendon. This can alleviate the pain and inflammation but should not be used continuously over a long period of time, as it may cause side effects such as whitening of the skin around the injection site, fat atrophy, or rupture of the tendons.

If the above treatment is not effective, then surgery should be considered to remove the damaged tissue and to repair and tighten the tendons. As with everything, prevention is better than cure. Here are some suggestions for preventing the injury.

• Lift objects with palm facing up
• Exercise by regularly stretching your hand muscles
• Always do warm up exercises by stretching your hands before the start of any activity
• Stop engaging in any activity that causes pain in your elbow. If you must work, then do some warm up exercises to stretch your elbow muscles, at least 5-10 minutes before using your elbow and then immediately apply a cold compress after you have finished your work. Take short breaks between work.
• Use a stretchable cloth or a ready-made fabric as an elbow wrap or support. This will help reduce and protect against any force or impact with the elbow. Use this support while playing sports or lifting heavy objects.
• If your condition and pain persists for several days, consult a physician. If you allow the pain to continue and become chronic, you may lose the ability to move the elbow permanently, or the pain may be caused by other factors, such as gout, infection, inflammation or a nerve compression in the neck.

ASSOCIATE PROFESSOR CHATHCHAI POOKARNJANAMORAKOT, MD |is an orthopaedic surgeon specialising in sports medicine and arthroscopy at Samitivej Sukhumvit Hospital. Call (02) 711 8494-6

The word photoageing refers to premature ageing of the skin caused by radiation from ultraviolet (UV) rays (or light, that is, phos in Greek, which is the root of photo, and hence the name photoageing). Most of our UV exposure comes from the sun. In fact, the Canadian Dermatology Association attributes 90 per cent of skin ageing to the harmful effects of sun exposure. Artificial UV sources include tanning booths, mercury vapour lamps, and halogen lights.

Signs of photoageing include wrinkles around the eyes, mouth, and forehead; spider veins on the face and neck; paler and thinner lips; frown lines that are visible even when you are not frowning; leathery and loose skin; age or liver spots (solar lentigines in medical terminology); easy bruising of skin; and red and scaly spots (referred to as actinic keratoses).

Our skin has three layers: the epidermis which is the outermost, the dermis which is the next, and the subcutis which is the deepest. UV rays, specifically UVA rays make their way through the epidermis and into the dermis. Here, they damage collagen, one of the fibres responsible for skin structure. Our body is not entirely helpless, so it deploys enzymes that help rebuild this collagen.

However, repeated exposure and damage could cause the enzymes to malfunction. This would lead to incorrectly rebuilt skin, which eventually appears as wrinkles and leathery skin. Similarly, age or liver spots are the result of a congregation of melanocytes on a particular patch of skin. Melanocytes are the cells that create melanin, which gives our skin its colour. Reacting to excessive sun exposure, melanocytes proliferate in a particular location. For instance, among men, liver spots are usually found on the hands, arms, face, and back, which are more exposed to the sun than other parts of the body.

What makes photoageing dangerous is the fact that any one of its symptoms could be an indicator of skin cancer. Actinic keratoses are particularly dangerous. These usually red, scaly or crusty, rough growths that appear on sun-exposed skin could, if left untreated, morph into squamous cell carcinoma (SCC), one of the three most common types of skin cancer.

Photoageing is very easy to guard against. Avoid tanning booths, for one and limit sun exposure. The harmful UVA rays are at their strongest from 11am to 3pm. So, it is best to avoid stepping out into the sun during this time.

If you cannot do this, remember not to leave home without adequate protection for your skin. Doctors recommend liberal use of sunscreen that has a sun-protection factor (SPF) of 30 or higher and offers broad spectrum protection from UVA and UVB rays. Ensure that all exposed skin is treated with sunscreen. If possible, wear sunglasses that offer UV protection, long-sleeved clothes, and a wide-brimmed hat (or carry an umbrella).

Much has been written about our need for Vitamin D and how the sun is the best source for it According to doctors, lighter-skinned people need only a few minutes of sun exposure per day to meet their quota of Vitamin D, while darker-skinned or Asian people would need 20 minutes.

Remember that lighter-skinned people with lesser melanin in their skin are more at risk of photoageing than darker-skinned individuals.

However, all is not lost if you think you have developed symptoms of photoageing. The first step is a comprehensive self-examination to detect such signs. Then, consult a doctor, ideally a dermatologist, to ascertain if any of these are causes for concern. If you are light-skinned, have a history of sunburn, have relatives who suffer from melanoma (another common type of skin cancer), then doctors advise regular self-examinations to detect skin abnormalities and annual medical examinations to determine if you are at risk of skin cancer.

If your doctor finds evidence of photoageing, he or she will recommend an appropriate course of treatment. Photoageing treatments are also anti-ageing treatments, including those that we have all heard about at some time — botox and fillers. Laser, chemical peels, and the administration of retinoids (synthetic derivatives of Vitamin A) are some other popular treatments prescribed for photoageing. In fact, recent studies have found that some treatments for photoageing, such as chemical peel, laser and retinoid, could prevent skin cancer as well. However, this is not true for all treatments. Botox, for instance, is merely a cosmetic treatment.

Given the link between photoageing and cancer, it is important to take treatment advice seriously. It is foolish to dismiss the signs of photoageing as part of the natural process of growing old. You could opt to avoid anti-ageing treatments if your situation is not considered medically threatening but to ensure that it isn’t, consult your dermatologist at the earliest.

DR SAROJ SUVANASUTHIP is a Dermatologist at Samitivej Sukhumvit Hospital. Call (02) 711 8700-2.

Scientists and researchers around the world are constantly working on ways to more efficiently treat this potentially fatal illness while simultaneously reducing the nasty side effects and one of the most promising to date is immunotherapy, which uses the body’s own immune system to help fight cancer cells.

Research into immunotherapy, specifically Cytokine-induced killer (CIK) cells therapy, is also underway in Thailand. Like all other research, it costs a lot of money and a cell therapy research fund for cancer treatment has recently been launched under the umbrella of the Siriraj Foundation. It will support of efforts of Dr Kittipong Soontrapa who is working on CIK Cells research at the hospital’s Department of Pharmacology, part of Mahidol University.

Since Cytokine-induced killer cells were first discovered in the 1990s by Prof Robert Negrin at Standford University, research into their efficacy, along with that of Natural Killer Cells, TIL cells and CAR-T cells, in curing disease has been ongoing in many corners of the world.

Cytokines are chemicals crucial to controlling the growth and activity of other immune system cells and blood cells. White cells, it will be remembered, are involved in protecting the body against both infectious disease and foreign invaders including cancer.

Dr Kittipong chose to focus on CIK Cells because of earlier work undertaken by respected doctors Dr Suradej Hongeng and Dr Adisak Wongkajornsilp, which focused on healing cholangiocarcinoma, malignancies of the biliary duct, which are commonly found in South East Asia.

The CIK Cells are prepared by taking blood from the patient and then culturing it in the control lab to avoid infection. After being cultured with the cytokines chemical for around three weeks, the cells are strong enough to be reintroduced to the patient’s body. By this time, the cells are capable of detecting alien invasions of cancer cells and killing them.

While it is acknowledged that CIK Cells probably benefit early-stage cancer patients rather than late-stage tumours, the Thai team is working on healing final-stage cancer and also opting to use blood from siblings or the patient’s children instead of the patient’s blood.

“As they are sick, their blood cells are obviously not as strong as those of healthy and younger people,” Dr Kittipong says.

He adds that theoretically, the therapy should help heal every type of cancer, but as each cancer has a different strength, the level of response varies.

However, what’s clear from the team’s discoveries so far is that cell therapy has a positive response with only very minor side effects compared to the traditional treatments of surgery, chemotherapy or radiotherapy.

“But this is an expensive process and we only have the capacity to work with one or two patients at a time. If even one minor mistake is made during the culturing process, we are throwing away hundreds of thousands of Baht and have to begin all over again,” Dr Kittipong says.

The CIK Cells are cultured in the sterile lab for about three weeks – the same cycle age of white blood cells in the human body – then injected into patient’s body. Patients need between three and six injections per course of treatment.

While many countries have already approved cell therapy, here it remains in the research stage. Dr Kittipong and his team are working in clinical research with selected patients joining the project.

A graduate of the Faculty of Medicine, Ramathibodhi Hospital, Mahidol University, the Thai-Japanese doctor chose to pursue his dream by going on to study pharmacology at Kyoto University. He has so far been unable to devote all his time to his research and is also teaching in the hospital’s Pharmacology Department at the medical faculty.

To date the CIK Cells research centre at Siriraj Hospital is small and working with just one or two patients.

“Our dream is to be a cell therapy centre that gathers all parts of the process together. For that reason, we are in need of financial support not only to purchase the equipment we need but also the chemicals. We can’t afford any mistakes if we are to avoid infection in the cultured cells that are injected back into the patient,” he says.

Donations from the public are now being invited so that this important work can continue.

The fund code is D-003658 – and must be quoted to differentiate it from the Siriraj Foundation’s other funds, which are used for different purposes.

To donate or receive more information, visit Dr Kittipong’s Facebook page at http://www.facebook.com/Dr.Aki, call the foundation at (02) 419 7658-60 extensions 101 and 104 or email donate_siriraj@hotmail.com.

“I left the stall immediately, telling myself I would rather hold it in and risk getting a urinary tract syndrome than use that bathroom,” she recalls.

On the door of the stall was a sign asking users not to flush toilet paper down the toilet.

This is a common sight in Korea where public restrooms often have such signs, along with waste bins piled high with soiled toilet paper.

It is an occurrence that has peeved American expat Michael Hurt for a long time. The research professor at Korea University has been living in South Korea since 1994. “The practice of putting one’s wastepaper into a basket is completely unhygienic and unsanitary,” he says.

“And it’s interesting that during the MERS (Middle East respiratory syndrome) scare recently and the SARS (severe acute respiratory syndrome) outbreak before that, one of the points of emphasis became that of hygiene and reducing transmission of viruses and bacteria. But little thought was given to the fact that faeces smeared all over paper sitting out in open-air containers is also pretty problematic.”

Many signs in bathroom stalls explain that the water pressure of the flushing system is low. Hence patrons are asked to toss wastepaper into a bin instead. However, according to Pyo Hye-ryeong, who heads a non-governmental organisation that advocates sanitary public bathroom facilities, water pressure is rarely a cause of clogging in public bathrooms in South Korea.

“According to our research findings, most clogging cases in public bathrooms occur because people flush random objects down the toilet, including food garbage,” says Pyo, who represents the Citizens’ Coalition for Restroom Culture.

“Toilet paper manufactured nowadays rarely makes toilets clog because it dissolves in water in about 30 seconds.”

Random items clogging up the pipes include socks, leggings, used baby diapers and sanitary napkins.

The practice of throwing out used toilet paper into trash cans began here in the late 1980s, after the 1988 Seoul Summer Olympics, according to Baek Chung-yeop, an official at the Ministry of the Interior.

Before the Olympics here, nearly 70 percent of all public bathrooms in Seoul had squat toilets without plumbing systems, he explains.

“The government replaced as many squat toilets with flush toilets as possible in 1988, because they didn’t want to give a bad impression to visitors during the games,” says Baek, who oversees public bathroom policies at the ministry.

Pyo from the CCRC claims the practice can be a threat to public health. She has been advocating for public bathrooms that do not have such trash cans since the 1990s.

“Very often the trash cans are not emptied frequently enough,” she says. “Sometimes they remain piled up in a closed space for more than 10 hours. No one with any common sense can think such an environment is in any way hygienic.”

When asked by The Korea Herald about the potential health risks of such trash bins, physicians at the Samsung Medical Centre said that one’s chance of contracting an infectious disease is low, unless a person directly touches the used toilet paper.

While Cho Eun-hee, a high-ranking official at the Korea Centers for Disease Control and Prevention, agrees with these doctors, she also notes that children are particularly vulnerable in public bathrooms with piled-up wastepaper.

“Kids are curious and you never know what they might touch in stalls of public bathrooms,” says the director of infectious disease surveillance division of the KCDC.

Lee Jang-hoon, professor at Kwangwoon University’s environmental engineering program, says trash cans are also one of the major causes of bad odours.

Lee explained that Korean bathrooms are already vulnerable to bad odours, as more than 80 per cent of properties in Seoul use septic tanks, small-scale sewage systems that treat and dispose of household wastewater on site. In North America, only about 25 per cent of the population relies on septic tanks, mostly in rural areas that lack connection to public sewage pipes.

The South Korean government has only started taking notice of the problem in recent years. It is gradually making changes to public bathrooms nationwide.

In 2013, the Ministry of the Interior began removing wastepaper bins from bathroom stalls in state-run facilities. This included all Seoul subway stations along lines 5 to 9.

The government has also begun switching its campaign from telling people not to flush anything down the toilet to telling them to only discard toilet paper.

Seoul City Hall, the building of the Gyeonggi Provincial government and Suwon City Hall have removed all trash cans from their bathrooms. “Our ultimate goal is to remove trash cans from all public bathrooms across Seoul,” said Kim Woo-gyeom, who works in the Seoul Metropolitan Government’s public health bureau.

Above all, Pyo from CCRC said that what South Korea needs is public decency. “The thing is, people wouldn’t flush their socks down the toilet at home, because once it clogs, they’ll have to fix it on their own,” she says.