Doctor Diagnosed With Advanced Prostate Cancer Learns Lessons on Death, Dying and Compassion

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.

In 2017, the urologist and trailblazer in the use of robots for surgery found himself on the other side of the treatment room after becoming a patient himself.

He was diagnosed with advanced prostate cancer and underwent treatment. However, the disease recurred.

In an interview with TODAY, Prof Cheng, who completed radiation therapy in December 2021 for the recurrence, offered his perspective on death and dying as a doctor who battled a life-threatening disease.

The 66-year-old is a senior consultant urologist with Singapore General Hospital and Sengkang General Hospital.

“I have a 50 per cent chance of being on pal (palliative) care eventually, with the recurrence,” he said candidly.

Palliative care is a patient-centred approach that enhances the quality of life for patients and their families who are coping with life-threatening illnesses such as cancer.

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.”

What can you do when a loved one has cancer? Start by asking some questions and listening 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.

Doctors, nurses cite insufficient training, education in hospice palliative care: Survey 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. Professor Christopher Cheng on what he has gathered from treating dying patients ”

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.

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'. Professor Christopher Cheng likening a good death to happiness ” 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.

Commentary: It takes a village to care for the terminally ill — and here’s how all can help “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.

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.”

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.

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. Professor Christopher Cheng on what he does differently now ” 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.

IMO, if it were possible, every doctor should have to experience for a while, what their patients deal with.

I think it would make them more compassionate.

I knew of a young OB whose wife delivered a month premature. I figured it would make him a better doctor because he had been there and knew what it was like to have a child having been born in that situation.

Of course, she was treated like royalty by the nursing staff, like the rest of us weren’t.

His ongoing, firsthand experience with cancer is very likely to make him a more thoughtful and compassionate doctor to his cancer patients. There are Pros and Cons to that.
One possible “Con”: If I am about to be told a have a soon to be fatal disease or condition, I don’t want my Doctor making a bad thing even worse by delivering this news ‘with tears in his eyes’. No, thank you.

Then, I would really feel like the floor had just dropped out from beneath me. That there is absolutely no hope. He may be too close to that particular kind of misery to do this. Delegate that part of the Office Visit to your Nurse Practitioner. Personally, my own misery does not love company.

There was a movie some years back called “The Doctor” with William Hurt that is based on Dr. Edward Rosenbaum’s 1988 memoir “A Taste Of My Own Medicine” in which he described his experience being a physician who is dignosed with lung cancer.

I don’t recall if the movie was any good-it has been nearly thirty years now, but as anyone who has ever worked in healthcare knows, there are positive things you can take from going from being a healthcare provider to being a healthcare recipient, and compassion is one of them.

Many healthcare providers opt to get healthcare at other hospitals than the one they work at, and you are treated pretty much the same as any other patient there where few, if any people know you.

Personally, I have never had a problem with understanding and feeling compassion for patients, but there are people who, for a variety of reason, seem to have lost that.

When I was a student, I remember our instructor showing us a brain death study on a young automobile accident patient. As we clustered around, she put the films up, and after going over it, she said “This patient is DED...” and I found myself searching my mind for a syndrome with the acronym of DED. I was thinking “What is that? “DiEncephlographic Dysfunction” or...” and I raised my hand to ask “Excuse me, what is DED?” and she said “Dead”.

She was not a mean person, was excellent and caring for her patients, and was great at what she did, but it struck me as totally hard and unfeeling. I was very young. It was only after I had worked for a while and seen things, that I realized that people who work in an environment where they come into close contact with human suffering and tragedy over a long period of time cope with stress and terrible things they see in very different ways. She would never have treated a patient in any way other than fully respectfully and compassionately, but this was probably some way of coping for her.

My wife underwent cancer treatment at the facility where she worked. She “hob nobs” with the Senior Executive team. She was, as most would suggest, “connected.”

Having stood next to her through the entire process, I can tell you that it got us recommendations as to who to see. The hospital presidents would say, “Go to this guy.” That was nice.

Once in the system...we were in line with everyone else. She suffered the same indignities as everyone else. She received the same outstanding compassion and care from the infusion nurses as anyone else. The billing system drained our savings...like everyone else.

On the rare occasion we were treated by someone she “knew”, the attention was slightly closer. But that would be true if we were the nurses next door neighbors. That is just human nature.

The ONLY time we witnessed any “special” treatment was when I was getting rotator cuff surgery. My wife was high school friends with the PACU nurse. She gave me warm blankets when everyone else was given cold ones. LOL

Hospitals are like any other “factory” or “retail” environment in the world. Personal relationships will always get you a little bit more. People are not robots.

Your point to metmom is well made but part of her point was that the physicians don’t see it from our end as well and that is correct.

My wife had a serious cardiac event that put her in the hospital and cathlab for 23 hours and the insurance paid in full 34k. Our cardiologist (top guy in his late thirties) was surprised as to the total.

Likewise, I was in the Phoenix valley MD Anderson hospital for stomach removal due to stomach cancer and the surgeons, other Docs and Nurses were outstanding but the hospital facility was way below par and they were somewhat unaware of the deficiencies because it was their everyday workplace. I know the issues as my company built hospitals and medical facilities. For example, some rooms were terribly cold at night due to poor HVAC control systems — I wore a woolen stocking cap I was smart enough to bring.

I will add for clarity, if you have serious Cancer, MD Anderson or Sloan Kettering are the two top places in the US. Don’t avoid them due to my opinion on their facility issues.

My surgeon was the BEST in the western US in my opinion and my wife was in Medical management for over 40 years. My Oncologist was not from MD Anderson and I still feel he was excellent and I was very lucky to be referred to him.

Nevertheless, having experienced something gives you new insight to what others are struggling with.

And yes, my main point was about the doctors having been there. The wife getting better treatment was just an aside. It was a very small local hospital but she did get her own room and the nurses were constantly in and out. I could see her door from my room.

Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.