salubris jan - march 2015

COLORECTAL CANCER: PREVENTION, DETECTION

AND TREATMENT

A NCCS QUARTERLY PUBLICATION January – March 2015

Salubris is a Latin word which means healthy, in good condition (body) and wholesome.

...HELPING R EADERS TO ACHIEVE GOOD HEALTH

Issue No. 32 • MICA (P) 140/03/2014

SYMPTOMSThere are some common symptoms that you should take note of:

• a change in bowel habits, such as persistent diarrhoea or constipation or a feeling that your bowel doesn’t empty completely;

• passing blood mixed with stools which is always a sign that one requires prompt medical attention;

• unexplained weight loss.

Your doctor may, after examining you recommend you to go for more tests or procedures, such as:

• Colonoscopy which uses a long, flexible and slender tube, with a video camera attached, to view your entire colon and rectum. Where necessary, your doctor can pass surgical tools through the tube to take tissue samples (biopsies) for analysis.

• Multiple CT scan to create a detailed picture of the inside of your colon if you’re unable to undergo colonoscopy.

In the course of the medical examination, if polyps are detected, they will be removed by the doctor. This reduces the risk of colon cancer over time because most colon cancers develop from polyps. Thus you remove these polyps by snipping them off; you remove the risk that the polyps will become cancer.

COLORECTAL CANCER: WHY WAIT WHEN IT’S EASY TO PREVENT, DETECT AND TREATBY SUNNY WEE Corporate Communications

VETTED BY DR THAM CHEE KIAN Medical Director, NCCS Oncology Clinic @ CGH Consultant, Division of Medical Oncology, NCCS

Colorectal cancer is one of the top cancers in Singapore, statistically. This cancer is now the most common cancer here affecting both males and females. And for those who just can’t resist numbers, well here they are: about 8,929 cases diagnosed from 2009-2013 in Singapore¹.

DETECTIONThe National Cancer Centre Singapore (NCCS) has pointed out that if you detect the disease early, the odds of survival is close to 90 per cent. But if you find it after the tumour has metastasised, and the treatment requires dosage of toxic drugs and radiation, then the prognosis for the patient is a different picture.

“There are now reliable ways to detect several cancers early enough to prevent the disease from taking a hold,” said Dr Tham Chee Kian, Medical Director of NCCS Oncology Clinic @ CGH, and Consultant in the Division of Medical Oncology, NCCS. “However, many people are either ignorant, or just ignore these life-saving actions.”

Screening for colorectal cancer is recommended for people with no symptoms but are 50 years and older. The simple test is the stool blood test. You may use this Faecal Immunochemical Test (FIT) kit, which is a preliminary screening test for colorectal cancer. The purpose of the test is to look for the presence of blood in the stools. If blood is found in your stool, then you will be asked to go for a more thorough check up by the doctor.

PREVENTIONThere is no need to wait for a “yellow card” before you begin to think about colorectal cancer. There are steps you can take to reduce your risk of colorectal cancer namely:

1 Eat plenty of fruits, vegetables and whole grains which contain fibre and antioxidants;

2 Limit fat, particularly saturated fat such as red meat, milk, cheese and ice cream;

3 Limit alcohol consumption;

4 Quit smoking;

5 Stay physically active and maintaining a healthy body weight.

Each year, March is designated as the Colorectal Cancer Awareness Month. So why wait? Go get your screening now!

REFERENCE:1 Singapore Cancer Registry, Interim Annual Registry Report,

Trends in Cancer Incidence in Singapore 2009-2013

2 SALUBRIS JANUARY – MARCH 2015

FARRAH FAWCETT(FEB 2, 1947 – JUNE 25, 2009)

An American actress and artist, Farrah

Fawcett was a four-time Emmy Award nominee and six-time Golden Globe Award nominee. She catapulted to international fame when she posed in her iconic red swimsuit poster starring as private investigator Jill Munroe in the first season of the television series Charlie’s Angels (1976–77).

Her appearance in the TV show boosted sales of her poster, and she reportedly raked in far more in royalties from poster sales than from her salary for appearing in Charlie’s Angels. She is also famously known for her hairstyle to become an international trend, with women sporting a “Farrah Fawcett flip”.

ROBIN GIBB(22 DEC 1949 – 20 MAY 2012)

A British singer, songwriter and record

producer, Robin Gibb is best known as a member of the famous Bee Gees. He was the fraternal twin of Maurice Gibb – was the older of the two by 35 minutes. He primarily played a variety of keyboards, such as piano, organ and the Mellotron. In 1994, he was inducted into the Songwriters Hall of Fame at the Grammy Museum in Los Angeles, California. Three years later, he was inducted into the Rock and Roll Hall of Fame in Cleveland, Ohio, US as a member of the Bee Gees. In an interview published in The Mail on Sunday on 22 January 2012, he spoke for the first time of the cancer:

“For more than 18 months, I had lived with an inflammation of the colon; then I was diagnosed with colon cancer, which spread to the liver. I have undergone chemotherapy, however, and the results – to quote my doctor – have been ‘spectacular’. It’s taken a toll, naturally, but the strange thing is that I’ve never felt seriously ill.”

CHARLES M. SCHULTZ(NOV 26, 1922 – FEB 12, 2000)

This American cartoonist is best known

for the comic strip Peanuts (which featured the characters Snoopy and Charlie Brown, among others). Charles Schultz is widely recognised as one of the most influential cartoonists of all time. Peanuts was reportedly published daily in 2,600 papers in 75 countries, in 21 languages when it was at its height. Schultz drew nearly 18,000 strips over the nearly 50 years that Peanuts was published. The strips plus the merchandise and product endorsements produced annual revenues of more than US$1 billion, with Charles Schultz earning an estimated US$30 million to US$40 million annually. He received many awards in his lifetime and in 1996 was honoured with a star on the Hollywood Walk of Fame.

CHET ATKINS(JUNE 20, 1924 – JUNE 30, 2001)

An American guitarist, occasional

vocalist and record producer who helped create the smoother country music style known as the Nashville sound. Chet Atkins‘ signature picking style [using the thumb and first two – sometimes three fingers of the right hand] expanded the appeal of country music to adult pop music fans.

He reportedly became an accomplished guitarist while he was in high school. He would use the restroom in the school to practice, because it gave better acoustics. He received 14 Grammy Awards as well as the Grammy Lifetime Achievement Award and nine Country Music Association Instrumentalist of the Year awards, among many others. He was inducted into the Rock & Roll Hall of Fame, Country Music Hall of Fame and Museum and the Musicians Hall of Fame and Museum.

PHOTOS FROM WIKIPEDIA PUBLIC DOMAIN.

AUDREY HEPBURN(MAY 1929 – 20 JAN, 1993)

British actress and recognised as a film and fashion icon.

Audrey Hepburn was active during Hollywood’s Golden Age.

The American Film Institute billed her as the third greatest female screen legend in the history of American cinema. She has also been placed in the International Best Dressed List Hall of Fame. She is also regarded by some to be the most naturally beautiful woman of all time. She is best remembered as the naïve, eccentric café society girl in the movie Breakfast at Tiffany’s – a 1961 American romantic comedy film.

DID YOU KNOW?Some well-known celebrities that had been diagnosed with colorectal cancer included Audrey Hepburn (actress), Farah Fawcett (actress), Robin Gibb (singer), Charles M. Schultz (cartoonist/writer), and Chet Atkins (guitarist) among other luminaries.

3SALUBRIS JANUARY – MARCH 2015

EARLY DIAGNOSIS & CANCER SCREENING While assisting in the NCCS outpatient clinic, I was impressed by an experienced GP who referred two newly diagnosed cancer patients without histology directly to the oncologists. One was a senior lady with a persistent cough and a new onset hemiparesis. He sent her for a chest X-ray which showed a shadow, and a CT-Brain which showed intracranial space occupying lesions. At the NCCS clinic, the oncologists scheduled her for bronchoscopic biopsy and staging and she was diagnosed with Adenocarcinoma of the lung with brain metastases.

Another equally impressive referral was an elderly gentleman with persistent back pain and symptoms of prostatism. The GP ordered a Prostate Specific Antigen which was 200 times higher than the upper limit of normal, and a lumbar spine X-ray showed osteoblastic lesions. Further investigations at NCCS revealed the GP’s initial diagnosis of prostate cancer with bone metastases to be correct.

Yet another meticulous GP noted anaemia and presence of stool occult blood in a senior gentleman on health screening and strongly advised a colonoscopy. The patient was promptly diagnosed to have a stenosing sigmoid colon cancer.

Such cases illustrate how a knowledgeable and competent GP can do a lot more for the patients by ordering the right tests to arrive at an accurate diagnosis early. This not only has the potential to provide a better chance of cure for the patient diagnosed at an earlier stage of disease, but also leads to significant savings, both in direct costs of investigations and treatment, as well as opportunity costs to the patient and family by reducing time taken off to accompany the patient for procedures and therapy.

Evidence based cancer screening, like for Hepatitis B Carriers are routinely carried out by GPs. With improved understanding of genomics, familial cancer screening is gaining importance. GPs can help to identify at risk familial patterns and refer patients with polyps or early cancers for further evaluation.

A PRESSING NEED: FORGING CLOSER LINKS IN CANCER CARE BETWEEN PRIMARY AND TERTIARY PRACTICE BY DR ROSE FOK Division of Medical Oncology

During our 2nd National Cancer Centre Singapore – General Practitioner (NCCS-GP) symposium in July last year, I was invited to share my experiences as a GP working in NCCS. One of the aims of this session was to encourage more GPs to come forward for training and education, as well as to contribute more towards continuity of cancer care.

B efore coming to NCCS, my impression was that family physicians ceased to have a role in patient care once cancer was diagnosed, as the oncologist would take over for the entirety of the patient’s care trajectory. I also had the misconception that it was unsafe to treat cancer survivors as

they were high risk patients constantly in imminent danger of relapse. I have realised that this is not always true.

Contrary to popular opinion, the family physician has an important role throughout a patient’s cancer journey, by virtue of having built a long-term relationship with the patient in the setting of primary care. In particular, it became evident to me that GPs would be of great value in negotiating several key areas in cancer care.

NURSING HOMES

NATIONAL CANCER CENTRE

SINGAPORE

COMMUNITY HOSPITALS

POLYCLINIC

SCREENING & PREVENTION PALLIATIVE

CENTRES

FAMILY PHYSICIAN

REHAB CENTRES


CANCER PREVENTION, EDUCATION & GUIDANCE GPs generally place a greater emphasis on health promotion. This focus, coupled with their close relationship to the patients built over many years, places them in a unique position to effect lifestyle changes that can help prevent cancer. These include smoking cessation, decreased consumption of red meat, exercise, as well as obesity and stress management.

In our IT-savvy era, there is often information overload in the internet. In addition, patients can be misled by social media. GPs can provide the guidance and help them to interpret these materials.

GP INVOLVEMENT IN SURVIVORSHIP CARE With the increasing numbers of cancer survivors as a result of improvements in cancer diagnostics and therapeutics, there is no doubt that the family doctor will have more encounters with cancer survivors in the clinic.

Two randomised controlled trials – one conducted in the UK and one in Canada, published in the British Medical Journal, compared family physician versus hospital-based specialist care of patients with cancer. The study revealed no statistically significant differences in cancer recurrence rates, survival, patient well-being or patient satisfaction, suggesting that the primary care setting could be just as effective in managing cancer.

Cancer survivors stand to benefit if their family doctor is also part of the team following them up to monitor for recurrence, manage adverse effects of treatment, detect and address psychosocial problems, and continue the management of comorbid conditions. With proper training, family doctors can give reliable and up-to-date advice on matters like cancer screening and basic genetic counselling for family members of the cancer survivor. Potential barriers to the successful incorporation of GPs into the cancer care team include patient perceptions of incompetency amongst GPs, and gaps in knowledge, skills and communication in cancer care amongst GPs. These will certainly need to be addressed, through training and engagement of all parties, to ensure effective delivery of care.

HOME & PALLIATIVE CARE Following acute cancer treatment, many cancer survivors have significant unmet needs, especially with regards to psychosocial care. Being readily accessible, and having an intimate knowledge of the context of a cancer diagnosis in the patient’s life and overall health, the GP is well placed to integrate cancer care, particularly at the end of life.

This patient-GP relationship often extends to the family, who often turn to their family doctors to seek support, clarification and advice. Some hospice teams like Hospice Care Association (HCA) have a programme to bring GPs into the palliative care network with the patient’s consent. They keep the GPs in the loop on the patient’s care and progress, provide the necessary help and training, develop a clinical management plan, and maintain an open channel of communication with the GPs.

During cancer treatment, home care teams can co-manage patients who may experience complications from blocked tubes and drains, skin reactions and rashes. Such endeavours certainly go a long way towards realising the vision of seamless care for patients.

As we move on to our next stage of GP development and training in Oncology, NCCS will be developing a structured programme to enhance knowledge and skills in oncology. We welcome all interested Primary Care Physicians to walk this journey with us.


W ith the current network of over 30 participating sites, the AHCC network not only facilitates support between members, but also allows broader collaborations between members within participating institutions and beyond. It provides access to key opinion leaders of various disciplines

in different countries and with different expertise within the network.

The National Cancer Centre Singapore (NCCS) provides scientific leadership in the Trials Group while the Singapore Clinical Research Institute (SCRI) is a repository for its database and scientific partner in protocol development.

In October last year, the AHCC Trials Group conducted its first of six monthly meetings including a scientific forum. There was a good line-up of speakers including NCCS’s translational science collaborators from Genome Institute of Singapore (GIS) and Nanyang Technological University (NTU), and clinical collaborators from Australia and Myanmar. The forum was opened to all doctors, researchers and members of the pharmaceutical industry.

The AHCC Trials Group also initiated a proposal for a closer working collaboration with industry partners for clinical projects to allow more patients to have access to treatment. Some of the benefits of collaboration with the group include having access to an experienced network of investigators with a demonstrated track record of success in the field of HCC research, opportunities for face-to-face meetings with key opinion leaders in this field and getting new therapeutic area updates.

Prof Soo Khee Chee, Group Chair of the AHCC Trials Group and Director of NCCS said, “The future of HCC patients looks promising as the AHCC Trials Group hopes to leverage on its experience from previous and existing trials, the expert opinions of its members, together with resources from industry, to develop new therapies for HCC.”

ASIA-PACIFIC HEPATOCELLULAR CARCINOMA (AHCC) TRIALS GROUP INITIATES PARTNERSHIP TO DEVELOP NEW HCC THERAPIES

The AHCC Trials Group comprises a clinical research network of medical experts and key opinion leaders in the management of hepatocellular carcinoma from more than 18 countries in the Asia-Pacific. With 17 years of experience in conducting multi-centre, multi-national clinical trials, the AHCC network is an established and highly reputable platform for high quality clinical studies.

STORIES BY SITI ZAWIYAH, Corporate Communications


CLCC plans to roll out a pilot programme that allows patients with suspected or confirmed Hepato-pancreato-biliary (HPB) cancers to have easy access to NCCS in a timely and seamless manner. In turn, CLCC will refer patients back to GPs for joint care after diagnosis and treatment. Such collaborations are aligned with NCCS’s larger academic medicine mission of improving patient care.

NCCS, GPs LINK UP FOR LIVER CANCER PATIENTS

The aim of NCCS – Comprehensive Liver Cancer Clinic (CLCC) is to provide patients with timely and appropriate therapy in a seamless manner, while ensuring their continued care.

I n November last year, Prof Pierce Chow and Dr Choo Su Pin, co-directors of the CLCC, invited Family Medicine Physicians (FMP) for a sharing session to update them on the evidence-based treatment of liver cancer and introduce NCCS’s

multi-disciplinary management guidelines on liver cancer. At the session, the CLCC team gathered feedback on the FMP’s needs when patients with liver cancer are referred to them, and on how best to develop a collaborative model between FMP and the CLCC.

SECOND RIDE FOR A TOBACCO-FREE SINGAPORE

The second Ride for Tobacco-Free Generation 2000 (TFG2000) saw more than 60 riders comprising a cross-section of society from the man-in-the-street, to professionals from the healthcare and education sectors riding 100 kilometers around the island in support of a tobacco-free millennium generation. Another 70 community riders joined the round island riders for the last 5km ride.

A t the closing ceremony, 55 scouts – all millennium generation children aged 8 to 11 and born after 1 January 2000, from Henry Park Primary School’s Pelican Scout troop pledged to be tobacco-free forever.

They are the first and the youngest uniform group in Singapore to take this stand.

Founded in 2012, the Tobacco-Free Generation is a notion to discourage the young from taking up smoking. It proposes that children born after 1 January 2000 be denied the use of tobacco even after they have reached 18 years old. Many in Singapore now support the notion that smoking should be eliminated. To learn more about Tobacco-Free Singapore, visit www.tobaccofreesingapore.info.

The TFG2000 movement is funded by the Community Cancer Fund of the National Cancer Centre Singapore (NCCS). You can support the goal of protecting our future generations from the harm of tobacco by making a donation to the movement.

To find out how you can make a donation, please write to [email protected].


G uest-of-Honour, Dr Lam Pin Min, Minister of State for Health, kick-started the event with possibly Singapore’s largest ‘Wefie’ and flagged off the 10km runners before joining participants for the 3.5km family run/walk. Into its 22nd consecutive year, Run For

Hope 2014 raised more than $449,000.00 on 16 November. The money raised is for the NCC Research Fund to provide seeding, bridging and advancement funds for an array of collaborative clinical research projects.

Run For Hope’s success cannot be measured entirely on the funds raised. The astounding support from celebrity ambassadors, cancer survivors, family members and participants pieced up the image perfectly with cancer awareness and community support in mind.

NCCS acknowledges the support from participants, donors like AIA Singapore, Far East Organisation, Natixis, as well as key sponsors including All Nippon Airways, Nature Valley, Kopiko L.A. Coffee, Wonder Wheat, Shaw Theatres, Tee Hai Chem Pte Ltd, City Gas Pte Ltd, Marina Bay and Urban Redevelopment Authority (URA), who have made the event possible.

DO YOU KNOW? “I was inspired to work with the idea of every individual lending their support to the cause, hence the graphic of two thumbprints that form

a heart. I hope every race participant will run with hope and their participation shows their approval and thumbs up for the cause,” she added.

Local fashion designer, Mae Pang lending her support to the cause with her artistic touch.

TODAY’S RUN FOR TOMORROW’S CURE BY EDWIN YONG Corporate Communications

For love, for friends, for Hope…for various reasons, 11,000 participants ran with us supporting a meaningful cause – paving the way for a Cancer Free Tomorrow – by helping NCCS raise much needed awareness and support towards cancer research.

Largest ‘Wefie’? GOH Dr Lam Pin Min orchestrates possibly Singapore’s largest ‘Wefie’ to date.

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EXECUTIVE CHALLENGE WINNERS

Congratulations to (1) Mr Daniel Gibson, Managing Director, Havas Worldwide Singapore for topping the Executive Challenge. 1st runner-up goes to (2) Mr Tan Hak Leh, CEO, AIA Singapore and 2nd runner-up to (3) Ms Lim Sok Bee, Country Manager, Asiaworks Training (S) Pte Ltd.


UP CLOSE & PERSONAL WITH A LEGENDBY FLORA YONG Community Partnership

Martina Navratilova, tennis player extraordinaire was in Singapore recently for the BNP Paribas Women’s Tennis Association (WTA) Finals held from 20th October to 26th October. National Cancer Centre Singapore (NCCS) had the privilege to invite Ms Navratilova for lunch where she shared with guests her triumphs and tears in tennis, her cancer experience as well as other personal challenges which made her a better and stronger person today.

Sharing her personal story

M artina dominated the four Grand Slams; US Open, French Open, Australian Open and the most elite and coveted, The Wimbledon for more than 30 years from 1975 to 2006. She took women’s tennis to a

new level with her speed, determination and agility. She won the Wimbledon single’s title a record 9 times and won 18 Grand Slam singles titles, 31 Grand Slam women’s doubles titles and 10 Grand Slam mixed doubles titles. Some experts call Martina the best tennis player of the modern era, maybe even in the history of the world.

Standing at 174cm is a tennis legend, untouchable. Or at least she seemed untouchable until she was diagnosed with breast cancer in 2010. In her own words, Martina said “The news literally knocked the wind out of me. There is the “Why me?” too, but more than that, “Why now?” I wasn’t ready for it. It’s like the great comedian George Burns once said: “I can’t die. I’m booked.” It all just goes to show that cancer can show up at any time, and it’s never the right time.”

Martina has been described as feisty, self-deprecating, courageous and controversial. The same determination which had brought such remarkable achievements on court has helped her through her battle against breast cancer. Martina admitted that a cancer diagnosis is a terrifying experience. She said she was in denial for about two seconds but realised that she had to immediately find a solution as she has a lot more life left in her.

She focused her energy on her treatment, on getting a group of supportive people around to help and on what she had to do to get well. Two weeks after her cancer surgery, Martina took part in a triathlon. She said “It was rough but now I’m happy to say I’m cancer-free.”

Martina likened her job as a tennis player to running her own business. She is the employer, employee and shareholder all at once. She had to be accountable for every action and consequences for the decisions she has made. As a tennis player, she found it can be very challenging. However, she believes that a lot of the same attributes that allowed her to break through barriers and become a champion on and off the tennis courts can be applied to business and in life. She shared four tips for success with the audience and hopes that the audience can apply these principles to their own lives when they do not feel their best.

1 Think BIG and TAP into your Talent 2 Be BOLD

and PLAY to WIN 3 Stay FOCUSED 4 Be RESILIENT

At the end of her candid speech, the guests rewarded Martina with thunderous applause. As a parting quote, Martina said “People who succeed take chances. They don’t listen to negative comments along the way. You have to ignore the naysayers, not let them sabotage you, and go after what is in your heart.”

A memorable moment for Professor Kanaga Sabapathy (Head of Cellular & Molecular Research) with Martina Navratilova


You are the first Cancer Genetic Counsellor working in National Cancer Centre Singapore (NCCS). Could you tell us more about your qualifications and your trainings?

Genetic counsellors are health professionals working with a geneticist. They can work in two main fields: general genetics or cancer genetics, as well as in some organ-specialised genetic diseases services.

Genetic counsellors come from diverse backgrounds. Most like myself already have a firm grounding in science. I have an undergraduate science degree and a master degree in Biology. I wished to work in a setting where I have face to face time with patients, so I undertook further training specifically in genetic counselling.

A huge part of the training is in understanding the science and genetics of many disparate disease processes, ranging from pre-natal diagnosis to general genetics and cancers genetics. Another purpose of the training is to be able to manage a consultation with a patient – we have a lot of psychological courses as well as scenarios trainings to determine if genetics testing is appropriate for the patient. This is an important component and one which many people not familiar with the field understand poorly. Since genetic testing has significant implications for the patient, their families and society at large, bioethics, legal and social implications of what we do are compulsory core components of the training.

What is your role with the patient?

Genetic Counsellors work hand in hand with the clinical geneticist. In NCCS, I work with Dr Joanne Ngeow who heads the Cancer Genetics Service, as well as Dr Tan Min-Han and Dr Peter Ang who are visiting consultants. The first consultation in the Cancer Genetics Service is really important. We spend time to understand why the patient has come to see us. Often, we may encounter patients who do not understand why he was referred to see us. We will go over with him/her the whole genetic process starting from the basics. Our team sees it as our duty to firstly educate patients as well as their referring physicians, on how genetic testing can help his/her care. It may not be appropriate for all patients and that is why we see them to understand and assess which patients this is relevant for.

To do this, we have to gather the patient’s personal health history as well as his/her family’s health history. We say health history and not disease history as many times the clues are not often obvious to patients or their families and can be as subtle as “my dad has hypertension but it was really hard to control” or “my uncle had difficulty with classes in school”. The whole familial history is presented on a family tree. We go back three to four generations and like a detective, we look for clues that may suggest if there is any risk that runs in the family. For some suspected syndromes, we use risk calculator’s models in order to score the likeliness of a patient having a genetic basis causing the disease.

Could you tell us more about the Cancer Genetics Service in NCCS? Who are the patients referred to this service? What can you do for them?

The National Cancer Genetics Service welcomes patients who are first identified by their doctors – either their surgeons, general practitioners (GP) or their oncologists, as to a possibility of a hereditary condition.

Patients are usually referred either because they have been diagnosed with cancer at a young age, or because many individuals in the family have suffered from cancers, or because a particular cancer is known to be caused by an underlying genetic cause.

Cancers are common diseases. Most of the time, they happen by chance, because of many factors. But a small part of cancers (10%) can be linked to a hereditary condition which can be passed down from one generation to the next. These are changes in some genes that increase the risk of getting a cancer. We call these changes in the genes germline mutations.

A gene can be considered as a very long sentence. A mutation would be a misspelling in that long sentence. Because of this misspelling, the message cannot be understood anymore and a tumour may develop.

Having such a change in a gene does not mean that it will lead to cancer, but the risk is higher than in general population. How high the risk is will depend on the type of gene involved, the type of mutation as well as other factors such as a patient’s age. We can perform clinical genetic testing for patients who need the testing to be done, and in whom there are management guidelines available for how this may affect the patient’s care.

CANCER GENETICS SERVICE

An interview with MARIE MET-DOMESTICI (MSc), a Cancer Genetic Counsellor

Marie explaining the Cancer Genetics Service


For the patient, is this a one-time visit to the Cancer Genetics Service?

If the genetic risk assessment does not point out a likeliness of possible underlying genetic cause to the disease, it can be, and patients will be advised to return if personal or familial history changes.

However most times, patients have several visits. All patients have very personal reasons as to why they come to see us and how testing can help them. Many come to us for answers as to why they or their family members have cancers. We may be able to help them understand this in 10% of cases but for the majority, research is still ongoing. Part of my job is to help patients understand this.

The first consultation can be very long, around one hour most of the time. Many patients are surprised by the details we go into and often comment that they felt like they have just gone to a science class! I will see the patients first before discussing with Dr Ngeow and other doctors in the team the appropriate plan of investigation. If genetic testing is needed, some patients go for genetic testing at the end of this first session but most of the time – and this is common, they need time to think about it.

Firstly, not everyone wants the burden of genetic information and secondly, patients have to be prepared to make some decisions if the test result is positive. These decisions involve increased screening to detect early cancer and in some very select cases, to consider surgery as a prevention.

This is the reason why, most of the time, genetic testing is not done in the first visit. Usually, patients go home with some brochures to read and think about the test and the possible test results implications.

Some patients may ask for another consultation in order to ask more questions about the procedure. Some would return with details about their family members’ health. A lot of the cancer risk assessment is based on information we gather from patients, very similar to how a doctor would normally make a diagnosis based on symptoms. Here, the difference is that we try to understand the patient’s health together and in context with that of his/her family’s and why it is important that patients referred to the service come prepared with “family history homework” done. Or we will send them home with some!

Thereafter, if they are keen to go on for testing, another consultation is booked in order to collect a blood sample and send it for analysis.

When it comes time for the test result consultation, the results are explained to the patients. If the test is positive for a mutation which may predispose to cancer, the risk management options are once again explained to the patients and a letter is sent to the practitioner in charge so that the follow-up can be organised or surgery planned. If the test is negative, patients and their families may not need the screening recommendations which would otherwise have been indicated. Each patient, like each family, is unique and hence, the assessment and recommendations will vary.

Could you summarise the hereditary cancer in a few words?

A subset of cancer patients may have an underlying genetic predisposition, a gene which may predispose them to develop cancers. Knowing this can allow patients and their family members to have a more intensive screening and/or surgery to reduce these risks.

To summarise, I would say that our activity focuses on proactively identifying patients who may have a high risk of getting cancer and making recommendations to help detect cancer early in affected individuals.

The Cancer Genetics Service consultation room is located in NCCS main building, level B2. To make an appointment, please call 6436 8000.

CANCER GENETICS

SERVICE IN NCCS

DR JOANNE NGEOW Head

DR TAN MIN-HAN Visiting Consultant

DR PETER ANG Visiting Consultant

MARIE MET-DOMESTICI (MSc) Genetic Counsellor

Marie explaining the Cancer Genetics Service


癌症遗传学服务作者：遗传学咨询辅导员

MARIE MET-DOMESTICI (MSc)

您是第一位在新加坡国立癌症中心工作的癌症遗传学咨询辅导员。请您告诉我们更多关于您的资历和培训。

遗传学咨询辅导员是和遗传学家一起工作的保健专业人士。他们主要在两个领域内工作：普通遗传学或癌症遗传学，以及一些特殊器官遗传病服务。

遗传学咨询辅导员来自不同的背景。大多数像我一样已经在科学领域具有扎实的基础。我拥有理科学士学位和生物学硕士学位。由于我希望在能够与患者面对面交流的地方工作，因此我接受了遗传咨询的专科培训。

培训的一大部分在于理解许多不相关疾病过程的科学和遗传学，从产前诊断到普通遗传学和癌症遗传学。培训的另一目的是为了能够与患者会诊。我们确实要上很多心理培训课程以及情景培训，以确定患者是否适合进行遗传测试。这是重要的环节，而许多不熟悉该领域的人所知甚少。由于遗传测试对患者、其家庭和全社会影响甚多，其生命伦理、法律和社会影响都是我们培训的核心。

对于患者而言，您扮演什么样的角色？

遗传学咨询辅导员与临床遗传医师携手合作。在新加坡国立癌症中心，我与癌症遗传学服务的主任饶润仪医生以及客卿顾问医生陈民汉医生和翁子祥医生一起工作。癌症遗传学的第一次会诊极其重要。我们会花时间了解患者会诊的目的。我们经常遇到不明白自己为何被转诊到癌症遗传学服务的患者。面对这一类患者，我们会从基础开始解释整个遗传过程。我们的团队认为我们的职责首先是教育患者及其转诊医生遗传检测如何利于患者护理。遗传检测未必适合所有患者，所以我们通过会诊来评估患者的适合性。

为此，我们必须收集患者的个人病历以及家属的病历。我们问诊时，线索经常不明显，甚至可能微乎其乎，譬如“我爸爸患有难以控制的高血压病”或者“我叔叔有学习障碍”。我们将整个家族史呈现于家谱上。我们追溯三到四代，并且像侦探一样，寻找任何可能暗示遗传风险的线索。对于一些疑似症状，我们采用风险评估模式来判断患者具有引发疾病的遗传基础的可能性。

请介绍新加坡国立癌症中心(NCCS)癌症遗传学服务。哪些患者会被转诊到癌症遗传学服务？您能为他们做些什么？

国家癌症遗传学服务欢迎首次由医生确诊疑似遗传性疾病的患者。向我们转诊的医生包括外科医生、家庭医生和肿瘤科医生。

通常，患者被转诊是因为他们年轻时被诊断患有癌症，或因多名家人患有癌症，又或因被认为其癌症是由潜在的遗传因素所造成。

癌症是常见的疾病。大多数时候，癌症是偶然发生，并涉及多种因素。但一小部分的癌症（10%）可以与遗传性疾病有联系，而遗传性疾病可以从一代传到下一代。某些基因变化增加了患癌症的风险。我们称这些基因的变化为基因种系突变。

一个基因可以被视为一个长句。突变则是这个长句中的拼写错误。因为这个拼写错误，导致消息不能被理解，而且可以导致肿瘤形成。

这样的基因突变并不意味着它会导致癌症，但患癌症的风险高于一般人群。风险的高低取决于突变部分的基因类型、突变的类型以及其他因素，如患者年龄。只要有相关的治疗指南能够引导患者的护理，我们可以为有需要检测的患者进行临床基因检测。


请您能概述一下遗传性癌症。

一小部分的癌症患者可能具有潜在的遗传性倾向，即可能使其身体患癌症的基因。了解了这一点，就可对患者及其家属进行更深入的筛查或手术，以降低患癌风险。

最后我想说的是，我们团队的工作集中于主动识别具有患癌高风险的患者，并提供建议帮助他们检测出早期癌症。

癌症遗传服务询诊室

位于新加坡国立癌症

中心主楼地下二楼。

若需预约会诊，

请拨电6436 8000。

新加坡国

立癌症中

心癌症遗

传学服务

饶润仪医生主任

陈民汉医生客卿顾问医生

翁子祥医生客卿顾问医生

MARIE MET-DOMESTICI (MSc) 遗传学咨询辅导员

癌症遗传学的会诊是一次性的吗？

如果患者的遗传风险被我们评估为低，会诊也许是一次性的。如果个人病历或家族病历有所变化，我们会建议这类患者返回癌症遗传学服务求诊。

然而，多数患者会多次前来会诊。所有患者都有他们的个人疑问，例如：“我为何来到此就诊？”、“检测如何能够帮助我？”。许多询诊的患者是为了了解为何他们或他们的家庭成员患有癌症。只有在十分之一的病例，我们可以帮助他们理解原因，但大部分病例仍处于研究之中。我工作中的一部分就是帮助患者理解这一点。

首次会诊的时间较长，大多为一小时左右。很多患者对我们的调查细节感到惊讶，常常会说自己好像参加了科学试验班。我会先观察患者，然后再与饶医生和团队的其他医生探讨出适当的调查方案。如果需要遗传检测，一些患者会在首次会诊答应接受基因检测。但多数患者都需要时间考虑。

首先，并不是每个人都想接纳遗传信息的负担。其次，如果检测结果是阳性的，患者必须准备采取一些决定。这些决定包括：进行更多筛查试验以确定是否属于早期癌，甚至某些特殊患者得考虑是否通过手术来防癌。

这就是多数患者首次会诊不会进行遗传检测的原因。通常，患者会带着说明册子回家阅读，并考虑是否接受检测以及检测结果的潜在后果。

为了对检测程序有更深了

解，一些患者可能会要求复

诊。也有某些患者在得知其

家庭成员的健康详情后会

回来会诊。癌症风险评估依

赖我们从患者收集的资料

为根据，就如医生通常根据

症状进行诊断。不同之处在

于，我们不仅试图了解患者

的健康状况，也要了解其家

属的健康背景。所以，接受

该服务的患者需携带完整

的家族病历资料。否则我们

就会要求患者去查明。

之后，如果他们想要接受检测，需再次预约复诊，收集血液样本并送交进行分析。

我们会向患者解释检测的结果。如果具癌变倾向的突变检查结果为阳性，我们需再次向患者解释应对风险的选项，并通知负责医生，以安排复诊或手术。如果检查结果为阴性，我们则不需要建议患者及其家属进行筛查测试。每位患者如同每个家族一样，都是独一无二的。因此，我们的评估与建议也会是定制的。


WHERE THE WORLD IS HIS CLASSROOM...BY SUNNY WEE Corporate Communications

An interview with PROF IAN F. TANNOCK, Canada’s best-known oncologist and a leading international figure in cancer research.

N ot many of us can look back at our career and have the satisfaction of seeing how our contributions are being put to good use for

mankind. But that’s the satisfaction that one man enjoys when he reflects on his life in the field of medicine.

Prof Ian F. Tannock, 70, retired from active practice at Princess Margaret Hospital in Canada in June last year after some 40 years, has made a name for himself in the field of oncology. He started his higher education not in medicine but in Mathematics and went to medical school in the US at the age of 27.

“I was in Houston, I saw people doing clinical research and I liked what they were doing,” he said in an interview at the National Cancer Centre Singapore (NCCS) where he delivered the Humphrey Oei Distinguished Lecture in November. His lecture was titled “Whither the Randomised Controlled Trial”.

He joined medical school at 27 years and today there’s no looking back. Two of the textbooks he edited are essential references for trainees in most oncology training centres in Canada and the US. Prof Tannock is Canada’s best-known oncologist and a leading international figure in cancer research.

In fact, the latest book – the fifth edition of ‘The Basic Science of Oncology’, has been translated into Japanese, Italian and Greek and about 20,000 copies of the textbook have been sold. The book is used every year by incoming medical and radiation oncology residents at the Princess Margaret Hospital.

He is married to a renowned doctor, Dr Rosemary Tannock who specialises in attention-deficit hyperactivity disorder in children.

For Prof Tannock, he would not have chosen any other path for his career. One of his greatest satisfactions is in seeing the group of Research Fellows he trained and mentored become successful in their own careers. “I am very happy to see several holding senior positions around the world,” he added.

Another, he said, was the international study that he led in the 1990s to determine whether chemotherapy could improve symptom control and quality of life in patients with incurable prostate cancer. Based on the Canadian study, the US Food and Drug Administration eventually gave approval for mitoxantrone for use in treatment of prostate cancer.

If he has free time, he would go hiking. His other hobby is reading.

Among his credits, he has published many scholarly papers and his research work includes a study on tumour biology and cytotoxic drug administration which has improved the quality of cancer care.

Among the recognitions he received for his work was the 2003 O. Harold Warwick Award from the Canadian Cancer Society. He received the M.D. Anderson Outstanding Alumnus award and also an honorary DSc degree from London University, UK. In December 2013, Prof Tannock was made a Member of the Order of Canada, one of the country’s highest civilian honours to recognise outstanding achievement and dedication to the community.

A grandfather and with three grown up children, he said he would continue contributing to the medical work, doing international teaching and advising institutions especially in less developed countries “until their invitations stop coming”.

The slim-built white-haired Professor has an unassuming and warm personality. “I guess from my accent you may know that I was born and grew up in England,” he said. He lived in Britain and the United States before settling in Toronto.


OUTREACH – PUBLIC FORUMS & CANCERWISE WORKSHOPS

Event Date, Time, Venue Registration

Bilingual Public Forum – Colorectal Cancer Awareness Month: Trim Your Risk of Getting Colorectal Cancer

TOPICS:• What is Colorectal Cancer?• Diagnostic procedures and treatment options• Recommended screening and recent advances

7 March 2015, SaturdayMANDARIN SESSION Time: 9.15am to 10.30am (Registration: 9.00am to 9.15am)

ENGLISH SESSION Time: 11.15am to 12.30pm (Registration: 11.00am to 11.15am)

Peter & Mary Fu Auditorium National Cancer Centre Singapore 11 Hospital Drive Singapore 169610

Free Admission Strictly no admission for children below 12 years old. Registration is a MUST as seats are limited.

PHONE REGISTRATION ONLY

Please call: 6225 5655 Monday – Friday: 8.30am to 5.30pm

Bilingual Public Forum – Role of Traditional Chinese Medicine in Cancer Care

TOPICS:• Overview of Traditional Chinese Medicine• How does it complement conventional

cancer treatment?• Potential herb and drug interactions• Understanding the side effects

21 March 2015, SaturdayMANDARIN SESSION Time: 9.15am to 10.30am (Registration: 9.00am to 9.15am)

ENGLISH SESSION Time: 11.15am to 12.30pm (Registration: 11.00am to 11.15am)





CancerWise Workshop – Basics of Cancer

TOPICS:• What is cancer?• What causes cancer?• Risks, signs & symptoms• Prevention & screening• Types of screening tests for men & women• Cancer treatment options • Advances in cancer treatments

21 March 2015, SaturdaySession will be conducted in English.

1.00pm – Registration 1.30pm to 3.30pm – Workshop starts

Peter & Mary Fu Auditorium National Cancer Centre Singapore 11 Hospital Drive, Singapore 169610




The information is correct at press time. NCCS reserves the right to change programmes or speaker without prior notice.


OUTREACH – PUBLIC FORUMS & CANCERWISE WORKSHOPS

Event Date, Time, Venue Registration

CancerWise Workshop – Nasopharyngeal Cancer

TOPICS:• What is Nasopharyngeal Cancer?• What are the risks, signs & symptoms?• What diagnostic tests to detect

Nasopharyngeal cancer?• Preventing Nasopharyngeal Cancer • What are the treatments available?• New developments in nose cancer

21 March 2015, SaturdaySession will be conducted in English.


Level 4 Function Room National Cancer Centre Singapore 11 Hospital Drive Singapore 169610




CancerWise Workshop – Lymphoma

TOPICS:• Overview of Lymphoma• Types of Lymphoma• Risk factors• What are the diagnostic tests to detect

Lymphoma?• What are the treatment options?• New developments in Lymphoma• Targeted therapy

11 April 2015, SaturdaySession will be conducted in English.






The information is correct at press time. NCCS reserves the right to change programmes or speaker without prior notice.


SEMINARS / FORUMS / TUMOUR BOARDS / SMC-CME ACTIVITIES FOR MEDICAL PROFESSIONALS ONLY

FEBRUARY 2015

Date Time Event Information CME Pt Registration Contact

4, 11, 18, 25

4, 11, 18, 25

2, 9, 16, 23

4.30 pm

5.00 pm

5.00 pm

NCCS Tumour Board Meetings:

Sarcoma Tumour Board Meeting

General Surgery Tumour Board Meeting

Head & Neck Tumour Board Meeting

@ NCCS Level 2, Clinic C, Discussion Room

1

1

1

Lim Shufen 6436 8283 [email protected]

Daphne 6436 8592 [email protected]

4, 11, 18, 25 1.00 pm Hepatobiliary Conference

@ NCCS Level 4, Peter & Mary Fu Auditorium

1 Lim Shufen 6436 8283 [email protected]

5, 26 5.00 pm NCCS-SGH Joint Lymphoma Workgroup Meeting


1 Jennie Tan 6436 8280 [email protected]

5, 12, 26 11.30 am Lung Tumour Board Combine SGH-NCCS Meeting

@ SGH Blk 2 Level 1, Radiology Conference Room

1 Christina Lee Siok Cheng 6326 6095 [email protected]

PH 1.00 pm Journal Club

Topic: To be advised

@ NCCS Level 1, Mammo Suite Discussion Room

1 Phua Chay Sin 6704 2037 [email protected]

27 1.00 pm Teaching Session




26 7.30 am Endocrine and Rare Tumour Meeting



24 5.00 pm NCCS Neuro Onco Tumour Board Meeting


1 Saratha / Ang Hui Lan 6436 8165 / 6436 8174 [email protected] / [email protected]

12, 26 12.30 pm Upper GI Tumour Board Meeting


1 Carol Tang / Ang Hui Lan 6436 8539 / 6436 8174 [email protected] / [email protected]



MARCH 2015


4, 11, 18, 25

4, 11, 18, 25

2, 9, 16, 23, 30

4.30pm

5.00pm

5.00pm






1

1

1



4, 11, 18, 25 1.00pm Hepatobiliary Conference



5, 19 5.00pm NCCS-SGH Joint Lymphoma Workgroup Meeting



5, 12, 19, 26 11.30am Lung Tumour Board Combine SGH-NCCS Meeting



26 7.30am Endocrine and Rare Tumour Meeting



24 5.00pm NCCS Neuro Onco Tumour Board Meeting


1 Saratha / Ang Hui Lan 6436 8165 / 6436 8174

[email protected] / [email protected]

12, 26 12.30pm Upper GI Tumour Board Meeting


1 Carol Tang / Ang Hui Lan 6436 8539 / 6436 8174 [email protected] / [email protected]

20 1.00pm Journal Club




27 1.00pm Teaching Session






APRIL 2015


1, 8, 15, 22, 29

1, 8, 15, 22, 29

6, 13, 20, 27

4.30pm

5.00pm

5.00pm






1

1

1



1, 8, 15, 22, 29 1.00pm Hepatobiliary Conference



2, 9, 16, 23, 30 11.30am Lung Tumour Board Combine SGH-NCCS Meeting



2, 16 5.00pm NCCS-SGH Joint Lymphoma Workgroup Meeting



17 1.00pm Journal Club




30 7.30 am Endocrine and Rare Tumour Meeting



28 5.00pm NCCS Neuro Onco Tumour Board Meeting


1 Saratha / Ang Hui Lan 6436 8165 / 6436 8174 [email protected] / [email protected]

9, 23 12.30pm Upper GI Tumour Board Meeting


1 Carol Tang / Ang Hui Lang 6436 8539 / 6436 8174 [email protected] / [email protected]

24 1.00pm Teaching Session





WORLD CANCER DAY 2015 – NOT BEYOND USBY RACHEL TAN Corporate Communications

Cancer is on the rise in Singapore. 1 in 3 people will develop cancer in their lifetime. All of us will be affected in some way – as individuals, friends, family and colleagues. According to figures from the Singapore Cancer Registry, the number of cancer notifications per year had increased year on year for the period 2009 to 2013. 12,664 people were diagnosed with cancer, up from 10,824 in 2009. This marks an increase of nearly 17 per cent.

Cancer Prevention and Education

In line with our mission to lead and promote anti-cancer advocacy, the National Cancer Centre Singapore (NCCS) organises cancer awareness roadshows and public education activities such as public forums, workshops and health talks in the heartlands. We believe in empowering and encouraging members of the public with the right knowledge and skills to help themselves and their loved ones. Through exhibits and interactive activities at these public education programmes, cancer information is made more accessible to the public.

Effective outcome to patients through multi-disciplinary approach

At NCCS, we adopt a holistic approach to cancer treatment with our multi-disciplinary approach. This means that patients will be given the best treatment with optimal clinical outcome as recommended by a panel of oncologists in various disciplines, with the highest standards of medical diagnosis, treatment and patient care. As a national and regional centre of excellence, we are committed to excellence in research, education and clinical care.

Research to improve clinical care

As the nation’s resource for integrated cancer care, NCCS is deeply engaged in basic, clinical and translational cancer research. Translational research, which is research that has direct application to everyday life, can potentially be applied to improve clinical care.

Patient Support Programmes

We believe that it is important for patients and family members to be able to make informed and effective decisions, continue to communicate well, bond with their loved ones and “live their best” in the face of the illness. NCCS offers a wide range of psychosocial services to help patients and family members cope and manage the illness. Some of our services include depression counselling, financial assistance, patient support programmes and enrichment programmes.

Taking place under the tagline ‘Not beyond us’, World Cancer Day 2015 will take a positive and proactive approach to the fight against cancer, highlighting that solutions do exist across the continuum of cancer, and that they are within our reach.

For counselling and cancer information, public can call our Cancer Helpline at (65) 6225 5655 or email to [email protected].

Choosing Healthy Lives

Achieving Treatment For All

Delivering Early Detection

Maximising Quality Of Life

T oday, more than half of all patients diagnosed with cancer can be cured. Many others will live long, meaningful lives even with their disease. But getting the right information, correct diagnosis and the

most appropriate treatment right from the start is crucial.

On World Cancer Day on 4 February 2015, we show you that cancer is simply Not Beyond Us.

WORLD CANCER DAY 2015 CAMPAIGN KEY MESSAGES


SALUBRIS is produced with you in mind. If there are other topics related to cancer that you

would like to read about or if you would like to provide some feedback on the articles covered, please email to [email protected].

NATIONAL CANCER CENTRE SINGAPOREReg No 199801562Z

11 Hospital Drive Singapore 169610 Tel: (65) 6436 8000 Fax: (65) 6225 6283www.nccs.com.sg www.facebook.com/NationalCancerCentreSingapore www.linkedin.com/company/NationalCancerCentreSingapore

Editorial Advisors

Prof Kon Oi Lian Prof Soo Khee Chee Dr Tan Hiang Khoon

Editorial Consultant

Mr Sunny Wee

Medical Editor

Dr Richard Yeo

Executive Editors

Ms Rachel Tan Ms Siti Zawiyah

Members, Editorial Board

Ms Lita Chew Dr Mohd Farid Ms Sharon Leow Ms Jenna Teo Dr Melissa Teo Dr Teo Tze Hern Dr Deborah Watkinson

PUBLISHED BY NCCS CORPORATE COMMUNICATIONS

salubris jan - march 2015

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