Wilfredo Liangco, MD, had finished medical school in Manila, the capital of the Philippines, and was in the process of choosing a residency training program – it was a toss-up between hepatology and oncology – when his father was diagnosed with liver cancer. “I was a freshly minted general physician and then had to take a year off so I could attend to him,” Dr. Liangco explained. He hoped that specializing in oncology would grant him access to expert opinions and clinical trials. It did. And it also supplied plenty of material for his book of essays, Even Ducks Get Liver Cancer, which was published in late 2022.
Dr. Liangco’s father died in 2012, but his memory lives on through Dr. Liangco’s writing and in his day-to-day practice. He spoke with OBR about what his oncology peers may gain from reading the book, which chronicles his experiences providing cancer care in a country that can’t always afford the treatments that patients need. Despite the often-serious subject matter, Dr. Liangco says he hopes everyone has “fun reading it from start to finish.”
The following interview has been edited and condensed for space and clarity.
OBR: How would you describe Even Ducks Get Liver Cancer?
Dr. Liangco: The book is a collection of 49 essays about my experiences in medical school, residency, fellowship training, and a few years into private practice. It’s about some of my experiences when I was training and some of my experiences with patients, but most of all, it is about my experiences with the people around me: my friends, family, patients, and mentors.
The essays aren’t meant to be academic or educational, just personal essays that fall along three themes. The first one is about the coming of age of someone who started out not really liking medicine but eventually got into the field. The second follows my father as he’s diagnosed, has a son for his oncologist, and eventually dies from cancer. And the third, because the pandemic was raging as I was writing, is about what it was like to have a clinical practice during the first few years of the pandemic.
OBR: The title is intriguing. Can you tell us where it came from?
Dr. Liangco: When I was in residency, our textbook was Harrison’s Principles of Internal Medicine. It was the bible textbook for most internal medicine training programs all over the world. And in the liver cancer chapter, there was a throwaway line – the author just wanted to mention that hepatocellular carcinoma is so common in China, so endemic in that part of the world, that even ducks would get it. That really stuck with me.
Later, I was just starting my fellowship training and did not have a lot of experience with patients yet. I didn’t know how to disclose diagnoses to them and so many would be heartbroken whenever their cancer would recur or progress. Of course they would ask me, “Why is this happening?” I was not yet very well-experienced in talking to patients and being empathetic and caring. And at some point, I ran out of things to say. I don’t know why I did it, but I just said, “You know what? In China, even ducks get liver cancer.”
I was beating myself up over saying something so insensitive. Who would derive comfort from that? And that became the book’s title. I wanted to show the evolution of someone who, at the start of his training, did not have very good bedside manners but who, after two years of experience and talking to many patients, has evolved to have more empathy and to care for them.
OBR: Is there anything in particular you hope your oncology peers might take away from this book?
Dr. Liangco: There are some essays in here that illustrate what oncology is like in the Philippines. We’re a third-world country, funding isn’t good, and oncology needs a lot more attention from the healthcare system. Most of the treatments – things like monoclonal antibodies and cellular and immunotherapies – are just unreachable for our patients.
We’re using the same guidelines as our first-world counterparts, but even if the drugs are available here, very few patients can afford them because they have to pay out-of-pocket. We have a government health insurance, called Philhealth, that only partially covers medical expenses – quite a small percentage of the total cost of care. With the cost of the chemotherapy drugs, most of the expenses end up being shouldered by the patient out of pocket. Very few Filipinos buy private insurance. And if patients are supposed to stay on these very expensive drugs for over a year, they very quickly run out of money.
OBR: How often do patients go into debt for these medications?
Dr. Liangco: It’s very common. Some people don’t have a lot of money, but they have a lot of land. So they sell their properties and use the money to finance their treatments. Eventually, either the money runs out or the patient dies. But, slowly, the Department of Health policies are getting better.
OBR: What are you hoping readers take away from your book?
Dr. Liangco: I wrote this book with the primary goal of providing enjoyment. I did not have lofty goals for it. Mostly, I wanted someone to have fun reading it from start to finish, like you’re watching a sitcom or listening to a good album. I think that’s what a book should be: something readers can pick up and just have fun with.
