Looking at Cancer up Close
by Marika Azzopardi
A Nuclear Medicine physician with a special interest in the imaging of tumours, Dr Mark Anthony Aquilina recently returned back to Malta after a stint of specialising and working up north in Milan’s prestigious San Raffaele Hospital. From his north Italian posting he went into depths in his field of Nuclear Medicine, becoming an expert at PET-CT scanning, a sub-specialty of this imaging technique. With the introduction of PET/CT scanning in Malta, Dr Aquilina has brought to fruition his long-term intention of returning to island living, carrying on practicing his specialisation here and serving the Maltese people.
He speaks openly of his experience in Italy. “I graduated from the University of Malta in 2001 and finished housemanship in 2003. Malta was still not an EU member and the post-graduate exams to get into specialisation in Italy were extremely difficult. In fact many years had passed since the last Maltese doctor specialised in Italy. But I was determined to specialise in Italy and at age 25 I had to take a bank loan to do what I had set my heart on doing, and I also had to rely on my family for financial support. Then I suddenly found myself at the largest Nuclear Medicine centre in Europe with great exposure and the best tutors around. The fact that I graduated with distinction when I finished specialisation allowed me the luxury of choosing between a consultant post in San Raffaele, another hospital in Milan, Bergamo, and later on another important hospital in London. However I immediately opted to take up an opportunity to work at the San Raffaele.”
His first boss was Italy’s famous politician Prof. Ferruccio Fazio, now Italian Minister for Health. As director at the San Raffaele Nuclear Medicine Department, Fazio voiced an instant gut feeling that the Maltese doctor would stay on once a specialist post was opened purposely for him. And Dr Aquilina did … stay on and learn that with today’s high technology methods, some cases of cancer have become more like a chronic disease rather than a fatal one.
The going was not easy. In Italy he had few connections initially, had to relinquish some of his sporting activities and could not keep a pet nor really live comfortably in his 40-metres-square of apartment space. “My social network changed but I still found that Milan is an easy place to integrate in and make buddy pals. However, it was an uphill struggle, breaking into a system that required for instance, writing reports in perfect Italian, and working in a system somewhat alien to the British methods used here in Malta. Each and every report had to be on the dot because our assessors would take random samples of our writings and expect them to be perfect every time. So there was no chance of skiving. After all, San Raffaele is considered a centre of excellence in the field (Nuclear Medicine), and a top notch product is expected from the specialists working there.”
He also learnt more about dealing with people, as opposed to dealing with patients. People who arrive at hospital are generally very scared with many misgivings as to the outcome of their tests, whether they already have a diagnosis or merely a suspicion of one. “Many a-time, people from Malta would arrive at San Raffaele and link immediately with me because they feel more attached to a fellow national than to a foreign Italian one even because of the language barrier which, where medical terms are concerned, can be quite non-plussing to foreigners. You learn to interact with people and address their fears rather than merely scan and test ‘cases’. Patients bring with them a fear of the unknown and it is our responsibility to help them rather than just give them a pill to tranquillise them.”
Dr Aquilina states the fact that as medical doctors most are very good at diagnosing and managing illnesses, and there are absolutely no problems with standards. But he bemoans how one limitation stands out particularly… very much like a sore thumb…
“We are not trained to give out bad news”.
“PET/CT is an essential tool to the oncologist, but a person who reads a scan is also the one facing the patient when a high level of tension is palpable. Besides reporting thousands of conventional nuclear medicine scans and seeing to hundreds of patients undergoing radionuclide therapies, I have done on average some 1000 PET/CT scans a year for more than five years in a centre where 10,000 PET/CT scans are performed annually, but I am never prepared enough to deal with people’s fears. It is never easy telling somebody about their terminal illness, nor telling somebody that their child or loved one has something of the sort.”
He feels that PET-CT scanning positively alters the picture of cancer and a considerable percentage of patients have their management changed or optimised. Through PET-CT, most cancers can be imaged. This new method offers essential complementary information to the stand-alone CT scan since functional data is added to structural imaging and the physician can also see all organs within an extensive field of view. “For example we know that in many instances a PET-CT can remove the necessity of a biopsy completely; by characterising lesions the scan helps one to make a better and sharper decision during diagnosis, and optimise management thereafter. It is also essential in evaluating a response to therapy appropriately and in the follow-up of patients. Many Maltese patients came to Milan for PET-CT scans because this extremely expensive apparatus was not previously available in Malta. Scans do not come cheap however as is the case with all new applied technology; the tracer is also bought from abroad.”
For the moment, Dr Aquilina is relishing his time back in Malta, helping establish the new scanning system together with San Raffaele Hospital and returning to a life here. He plans to return to scouting and to playing football with his Maltese buddies, something which he never stopped doing in Italy, even going so far as fracturing his cheekbone on the field. “I also play table tennis when the opportunity arises and did judo in the past …. Am looking forward to having a pet again…. I can never get over the loss of the dog which I had from age five months till 16 years.”