Doctor diagnosed with advanced prostate cancer learns lessons on death, dying and compassion
SINGAPORE — Having dedicated more than three decades of his career to the field of urology focused on prostate cancer, Professor Christopher Cheng was aware of the sobering possibility that he may eventually succumb to the very same disease he knows well as a specialist.
- A senior consultant urologist specialising in prostate cancer was diagnosed with advanced prostate cancer himself
- Professor Christopher Cheng, 66, is among 20 doctors featured in a video series called Doctors’ Die-logues
- The doctors share their diverse experiences and perspectives on death and dying in the series
- The videos produced by Lien Foundation aim to help healthcare professionals get a better understanding of the topic of death and the need for compassionate care
- The professor told of the “humbling” lessons he learnt while battling cancer and his own emotional ups and downs
EQUAL CHANCE OF MIRACLE OR DEATH
Prof Cheng is among 20 eminent doctors featured in a series of video interviews called Doctors’ Die-logues. Produced by the Lien Foundation, it is part of a new focus to help healthcare professionals gain a better understanding of the topic of death and dying, and the need for compassionate care. Lien Foundation, a Singapore-based philanthropic organisation, has been championing training, research and advocacy for end-of-life care for more than a decade. In the video, Prof Cheng said: “Scientifically, based on databases and whatever I tell my patients... (I would also say to myself), 'I think you have a 50-50 chance — 50 per cent chance that you’ll have a miracle and 50 per cent chance you’ll die of the disease.” Last month, the urologist spoke at the 8th Singapore Palliative Care Conference at Marina Bay Sands, alongside other doctors on the Doctors' Die-logues panel to explore experiences and leadership lessons learnt within end-of-life care. The conference was organised by the Singapore Hospice Council, with Lien Foundation as one of the supporting partners. As a nation, Singapore aims to boost palliative care services, including home palliative care, and reduce the proportion of people dying in hospitals. In a past survey by Lien Foundation, 77 per cent of Singaporeans expressed hopes of dying at home but only about a quarter (26 per cent) managed to do so. The lack of awareness of such services, even among healthcare professionals here, had been highlighted as one of the key barriers. In a 2020 survey done by the Singapore Hospice Council, less than half (around 46 per cent) of the respondents — who included doctors, nurses and allied healthcare professionals — were familiar with hospice and palliative care service providers and referral processes in Singapore. The survey also found that a significant number of healthcare professionals had not done any personal anticipatory care planning in case of serious illness, with 7 per cent rejecting hospice and palliative care entirely. Such barriers to palliative and hospice care among healthcare professionals may affect how they promote care planning for the patients and families under their care.A LESSON IN HUMILITY
For Prof Cheng, the cancer diagnosis has been a “humbling” experience, one that he has detailed in his book, titled I Thought I Knew: A Professor Turned Patient, published in 2020. He is married to Associate Professor Brenda Ang, 64, who is a senior consultant with the department of infectious diseases at Tan Tock Seng Hospital and the National Centre for Infectious Diseases. They have a 34-year-old son. On the lessons he has learnt after his initial diagnosis, Prof Cheng said in the video: “I was this arrogant, impatient young surgeon, thinking I’m a godsend for mankind — until I became afflicted with prostate cancer, an area I’m supposed specialise in.”However rich, however powerful (they) are, they’ve all had to face death eventually. They all have to let go.
Despite experiencing symptoms such as waking up at night to pass urine and urinary retention years before his diagnosis, Prof Cheng had not thought that it was prostate cancer. Furthermore, a previous prostate-specific antigen (PSA) blood test done years back indicated that he was within the normal range.
“Also, I’ve had (urinary) symptoms for many years since I was a teenager. So my self-diagnosis was that it is very unlikely that it was cancer,” he said.
In 2017, a time in which Prof Cheng jokingly referred to as “all hell break loose days” when he and his team were up to their neck preparing for the opening of Sengkang General Hospital, a prostate examination revealed a suspicious nodule and likely prostate cancer.
He was the chief executive officer of the new hospital then.
The finding was unexpected because he had attributed his urinary symptoms to an enlarged prostate, a benign condition, and had scheduled surgery during the year-end festive break in 2017 to relieve the symptoms.
He recalled receiving results of his PSA blood test while in the midst of a meeting. It was at a “shockingly high” level of 17.8 nanograms per decilitre (ng/dL), which he knew spelled bad news for anyone with prostate cancer.
The PSA is a substance produced by the prostate, which is the small gland that sits below the bladder in males.
While a small amount is normal, men with prostate cancer tend to have higher levels of PSA in the blood. Other conditions, such as an enlarged prostate, may also raise PSA levels.
“In some (overseas) centres, if you have prostate cancer with a PSA of 17, the top surgeons will not operate on you because it would tarnish their results,” Prof Cheng said.
In his book, he explained that some famous centres do not offer potentially curative treatment to patients with a PSA of more than 10, because poor outcomes may affect their reputations unfavourably.
You can’t go out, do online shopping and buy happiness. You can't go through a checklist and say, ‘Okay, I've done this, I’ve settled my will, I'm going to have a good death'.
Prof Cheng has since gone through many episodes of emotional ups and downs while waiting for his PSA test results.
“After treatment, every blood test becomes that lying-in-wait to know what the result is,” he said.
“As someone who is supposed to be an expert and knowledgeable in this, I know about all the bad things that can happen.
“It’s either relief or disappointment, multiple (times of) fear, anxiety, anticipation.
His experience has changed the way he informs patients of their progress. Previously, for patients with a good PSA test result, he would print out the result and congratulate them.
“Now I do an extra step,” he said. “If I see an undetectable PSA after surgery, I give the patient a hug and I may have tears in my eyes. Because I think they are free.”
While being on the receiving end of cancer treatment has given him better insights into what his patients go through and greater empathy, Prof Cheng pointed out that no one can claim to truly walk in another person’s shoes.
Even when experiences may seem similar, every individual would have a different perception of their lived experience.
“After the surgery and treatment, I also thought that, okay, I've been through all these complications, all these experiences, I can show my patients the (surgical) scars and tell them ‘I know how you feel’.
“But no, even after you've been through it, everybody who goes through the same journey takes away different things,” he said, adding that this is why it is important to retain humility and openness, and not be judgemental towards others.
‘COMPASSION FATIGUE OVERRATED’
During the interview, Prof Cheng brought up the topic of compassion, which is also a recurring theme in his book.
Experiencing what it is like to be a patient has made him more mindful of the importance of connecting with patients at a deeper “heart” level as a medical practitioner.
This is something he hopes that young doctors would be more aware of and put into practice as well, even when facing seemingly challenging patients.
His personal take on “compassion fatigue” — which some may consider controversial — is that it is “overrated”.
“I think that in giving compassion and care, you receive double the amount,” he said in the video interview.
The term “compassion fatigue” describes the physical, emotional and psychological impact resulting from repeated exposure to traumatised individuals or adverse traumatic events.
It is commonly reported among people who work in a helping profession, such as in healthcare, and can desensitise healthcare professionals to the needs of their patients, causing them to lack empathy.
Prof Cheng’s take is that when it is a good day’s worth of work, “you go home dead tired but you’ve had a fulfilling day”.
“If our heart is true, I don’t think that compassion, by itself, can lead to fatigue.”
Recounting a talk he gave earlier this year on compassion for a group of first-year medical students, Prof Cheng told TODAY that he extended an offer to the students to visit his clinic.
“I said, when you guys are tired and burned out, come to my clinic and connect with the patients. What burnout is there when you can connect with a human being?
“When you touch them at the ‘heart’ level, and you are authentic (and) genuine, people know.”
ON HAVING A 'GOOD DEATH’
As a doctor who has seen patients at death’s door, Prof Cheng came to the realisation that death is an experience that everyone faces alone.
“However rich, however powerful (they) are, they’ve all had to face death eventually. They all have to let go,” he said.
The difference, however, lies in how one faces death.
Once, he asked a patient whose disease had worsened how he was coping, to which he replied, “I have no complaint. I can eat, I can urinate, I can pass motion. I’m okay”.
“I thought, wow, this was really contentment with very little. And he had no angst.”
Then, there are also patients who are full of anger and resentment, and are unable to reach “peaceful acceptance”.
To Prof Cheng, the concept of a “good” death is similar to that of happiness: It is not something that one can achieve by simply checking off a list.
“You can’t go out, do online shopping and buy happiness. You can't go through a checklist and say, ‘Okay, I've done this, I’ve settled my will, I'm going to have a good death’,” he said.
“But I know what's not a good death — being full of anger, rejection and loneliness, etc.
“I think the path to a near-good death is to try to remove as many obstacles, as much clinging (to attachments), disappointments and resolve as many regrets that you can.”
No more postponing meeting the people I really like to catch up with; no more procrastinating on things I would like to complete. Every task is taken as though it is the last chance.
Prof Cheng said that after his cancer recurred, the oncologist proposed an “all-in, kitchen sink” approach, which meant giving maximum treatment available.
“I opted out of it and decided to have very focal, localised (treatment). After a long, long discussion, I didn’t want an all-out treatment that would most likely give me many side effects,” he added.
“People ask me, 'So, how are you?', they are concerned. (I tell them) I'm as good as could be, nothing to panic.
“I’ve everything I need to be happy, and more. I don't think that being at the receiving end of the kitchen sink is going to make me any happier.”
Prof Cheng is considering writing “season two” of his experience but expressed some hesitation over it.
“Part of the reason is because one man's experience is a drop in the ocean. When you write something, you need to basically present a scientific account because people will hang on to those little things.”
For now, he is doubling up his efforts to live life to the fullest, and to be fully present in all that he does.
“No more postponing meeting the people I really like to catch up with; no more procrastinating on things I would like to complete. Every task is taken as though it is the last chance,” he said.
“For the first time, I have a cycling coach and I am winning races for the first time in my life. My paintings are now exhibited, good enough to be sold for charity. Most of all, I make peace with things I accept as being beyond me.
“Every moment is precious. Every encounter is ‘here and now’, like this (interview), at 100 per cent attention,” he added.
“And I’m not in a hurry to go anywhere.”
The Lien Foundation's Doctors' Die-logues video series can be found online.
