Comment on: Fasting among Muslim cancer patients during the holy month of Ramadan

To the Editor: We have read the article by Ahmed et al¹ with great interest. We thank our colleagues for highlighting this issue that turns into a conscientious responsibility for physicians who are esteemed to be “decision maker” during the holy month of Ramadan. They have presented the rates of fasting among cancer patients and also reported which cancer patients are more likely to be fasting. Additionally, the impact of advices by either physicians or religious persons (Imam) on the decision of fasting has also been expressed in a good way. This novel study hopefully will stimulate more detailed clinical trials on this topic. However, there is still no standardized criteria for defining medically compromised patients in terms of fasting. Physicians will continue to experience this dilemma, as they will continue to be exposed to the question “Doctor, can I fast?”. The present study would have been more illuminative if: (1) the non-fasting patients who started to fast on physicians’ advice were followed up for symptoms or at least were asked whether they experienced clinical deterioration with the commencement of fasting and (2) the fasting patients who were exempted from fasting with the physician’s advice were asked whether they experienced improvement in the clinical status. This is not the case of just oncologists to decide; rather physicians should be able to reply such questions about fasting. These two questions in the questionnaire of this study might have been better for clinicians to find more evidence-based replies and satisfy patients’ concerns. We, as cardiologists in Turkey as a Muslim country, have often faced these questions in the holy month of Ramadan. We also use our personal experience and judgment because there is no clear criteria laid down dealing with this issue in the field of cardiology as in other clinical branches. Most of stable cardiac patients can fast, and this case usually does not constitute a dilemma for physicians. This point of view is also supported by relatively small clinical trials.^2,3 However, evidence-based decision on this issue still seems to be infeasible because studies are not yet enough in number and scope to follow a common pattern of approach for physicians. The existing trials may also sometimes reveal conflicting results.⁴ Besides, the status of patients who are free of symptoms but have the potential to worsen based on the stage of the disease is also controversial. In all clinical fields, encouraging stable patients about fasting and maybe a close follow-up with more frequent intervals to monitor a possible clinical deterioration will be a logical approach.