nccs salubris oct - dec 2015

LIVER CANCER – A COMPLEX AND HETEROGENEOUS DISEASE

A NCCS QUARTERLY PUBLICATION October – December 2015

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

...HELPING R EADERS TO ACHIEVE GOOD HEALTH

Issue No. 35 • MICA (P) 108/03/2015

HEPATOCELLULAR CARCINOMA IN THE MEDICAL ONCOLOGY CLINIC

BY JACK JJ CHAN, JOYCELYN JX LEE, DAVID WM TAI Division of Medical Oncology

This article provides a synopsis of the patterns and causes of disease, and treatment options of the commonest subtype of advanced primary liver cancer, hepatocellular carcinoma (HCC), intercalated with a case vignette.

M r Goh (name changed to protect confidentiality) is an active 43-year-old engineer. He has chronic hepatitis B virus (HBV) infection acquired through

vertical transmission from his mother, and is on anti-viral therapy from the gastroenterologist. Two years ago, he underwent a partial resection of his liver to surgically remove a screen-detected, asymptomatic HCC which measured 3 by 4 centimetres. Unfortunately, on his latest surveillance computed tomography (CT) scan, he was found to have relapsed with stage IV disease, with multiple scattered small liver tumours and enlarged intra-abdominal lymph nodes. The cancer was deemed inoperable, and his liver surgeon referred him to the medical oncologist for further management.

Primary liver cancer is the sixth commonest cancer globally, but ranks second only to lung cancer as a cause of cancer deaths [1]. Locally, liver cancer is the fourth most common cancer among males, with an age-standardised rate of almost 17 per 100,000 male residents. Moreover, the mortality rate of primary liver cancer almost matches its incidence rate with 782,500 new cases and 745,500 deaths reported worldwide in 2012[1, 2].

2 SALUBRIS OCTOBER – DECEMBER 2015

Even with curative treatment, 70% of patients with early-stage HCC relapse at five years. The median survival of advanced or metastatic HCC is a few months.

Only a subset of these patients are eligible for systemic therapy, provided they possess adequate liver reserves and good functional status [5,6].

Treating advanced HCC is fundamentally challenging because many patients concomitantly have deranged liver function which can give rise to complications independent from HCC as well as limit chemotherapy options [6, 7]. Inherently, HCC is also relatively resistant to conventional cytotoxic chemotherapy which is hence not routinely used [6].

The medical oncologist discussed with Mr Goh the treatment options for his advanced HCC. He decided to follow the Oncologist’s recommendation of first-line sorafenib, a type of targeted therapy. He remained positive in his outlook, continued to work, and was relatively symptom-free from his cancer and liver cirrhosis.

Targeted therapies represent a newer form of cancer treatment which works differently from traditional cytotoxic chemotherapy. They “target” the differences distinguishing cancer cells from normal healthy cells. Sorafenib is an orally active targeted therapy, and the only drug approved in the United States and Europe for use in advanced HCC. It works by targeting tumour cell proliferation, and blocking the formation of new blood vessels which supply tumours [7, 8].

The approval of sorafenib for the treatment of HCC was based on the landmark Sorafenib HCC Assessment Randomised Protocol (SHARP) trial in a mainly European cohort of 602 patients [9], and a parallel phase III trial involving 271 patients in the Asia–Pacific region [10]. These trials showed sorafenib conferring a survival advantage over placebo in patients with advanced HCC, with a greater benefit seen in SHARP than the Asia-Pacific trial (10.7 months for sorafenib vs 7.9 months for placebo in SHARP, compared to 6.5 months vs 4.2 months respectively in the Asia-Pacific trial). This difference was postulated to be due to the presence of more unfavourable prognostic factors, including a higher incidence of HBV infection (73% vs 12%) and increased tumour burden, as reflected by a higher proportion of secondary tumours outside of the liver among patients recruited into the Asia-Pacific trial. Both studies were concordant in demonstrating that the major benefit of sorafenib manifested mainly as disease stabilisation rather than tumour shrinkage on scans. Sorafenib was well-tolerated in both trials, with the commonest serious side events being hand-foot syndrome, diarrhoea and fatigue.

Phase IV observational studies, such as GIDEON [11] and SOFIA [12], reported similar survival outcomes and toxicity profiles to the aforementioned phase III studies.

It ranks third and fourth in cancer deaths among Singaporean males and females respectively [3]. These statistics underscore the dismal outcomes of liver cancer. HCC alone accounts for 70-90% of primary liver malignancies in adults [2].

HCC is a complex and heterogeneous disease. It is nearly always preceded by chronic liver damage, with cirrhosis (liver scarring) present in 80-90% of patients. HCC is related to chronic viral hepatitis, with the preponderance of HCC cases in East Asia and sub-Saharan Africa reflecting the endemicity of HBV infection in these regions. The other risk factors for HCC can be classified into toxins (alcohol), metabolic diseases (non-alcoholic fatty liver disease, diabetes mellitus) [4], and other inherited or immune-mediated diseases.

At diagnosis, a significant proportion of patients with HCC already have advanced disease. Approximately 60% of all patients have disease that is not amenable to curative strategies (e.g. resection, liver transplantation, radiofrequency ablation), nor to palliative locoregional modalities (e.g. trans-arterial chemoembolisation, selective internal radiotherapy).

Continued on page 4.

3SALUBRIS OCTOBER – DECEMBER 2015

Table 1: Ongoing NCCS clinical trials in HCC

INDICATION TITLE OF STUDY

First-line only

Locally advanced/metastatic A Phase II, open-label, Single Arm, multicentre study of INC280 administered orally in adult patients with advanced hepatocellular carcinoma

Locally advanced/metastatic A Phase II trial of Oxaliplatin/Adriamycin/5 Fluorouracil in continuous infusion/Interferon a-2b (OXAFI) combination in metastatic and unresectable non-metastatic hepatocellular carcinoma

Locally advanced only Phase III multicentre open-label randomised controlled trial of Selective Internal Radiation Therapy (SIRT) versus sorafenib in locally advanced hepatocellular carcinoma (SIRveNIB)

Second-line and beyond

Locally advanced/metastatic A Phase 3, randomised, double-blind, controlled study of cabozantinib (XL184) vs placebo in subjects with hepatocellular carcinoma who have received prior sorafenib

Locally advanced/metastatic Phase Ib/2, multicentre, dose escalation trial to determine the safety, tolerance, maximum tolerated dose and recommended phase II dose of DCR-MYC a lipid nanoparticle (LNP) formulated small inhibitor RNA (siRNA) oligonucleotide targeting MYC, in patient with HCC

Any line

Locally advanced/metastatic A phase I/II, multicentre, open-label study of oral FGF401 in adult patients with hepatocellular carcinoma or solid malignancies characterised by positive FGFR4 and KLB expression

Mr Goh took sorafenib for eight months with few side effects before he developed lower back pain. Scans confirmed that his cancer had progressed with new bony metastases. His pain was controlled with oral non-opioid painkillers. His liver function remained adequate, and he was still fit enough to work from home. As such, his oncologist asked him to consider enrolment into a clinical trial.

A significant proportion of patients with advanced HCC experience disease progression, or are intolerant of sorafenib. Beyond sorafenib, there is a dearth of effective systemic therapies for advanced HCC. Current practice guidelines recommend either best supportive care or clinical trial enrolment for these patients.

Researchers have examined other targeted agents as monotherapy head-to-head against sorafenib or in combination with sorafenib in the frontline setting, or as second-line therapy post-sorafenib. Early evidence of anti-tumour activity of several agents in phase I/II studies was followed by disappointingly negative phase III efforts, highlighting the challenges of new drug development in HCC.

More recently, comprehensive genome analyses have identified core pathways and candidate driver genes in the pathogenesis of HCC, thereby offering fresh potential molecular targets. Immunotherapy, which harnesses the body’s intrinsic immune system to fight against cancer, is also gaining traction in the treatment of several solid tumours, as promising phase II/III data emerge, and offers an attractive and potentially tolerable treatment option for advanced HCC.

The clinical trials which NCCS is currently participating in are summarised in Table 1 below.

Continued from page 3.


Table 2: Potential trials in 2016

INDICATION TITLE OF STUDY

Locally advanced/metastatic – first-line only

A randomised, multicenter phase III Study of Nivolumab versus Sorafenib as first-line treatment in patients with advanced HCC

Locally advanced/metastatic – first-line only

A phase III randomised, open-label study comparing Pexa-Vec (Vaccinia GM-CSF / Thymidine Kinase-Deactivated Virus) followed by Sorafenib versus Sorafenib in patients with Advanced HCC without prior systemic therapy

Locally advanced/metastatic – any line

A study of safety, tolerability, and clinical activity of MEDI4736 and Tremelimumab administered as monotherapy and in combination to subjects with unresectable HCC

REFERENCES:

1 The global and regional burden of cancer. In: World Cancer Report 2014. Stewart BW, Wild CP, eds. Lyon: IARC Press, 2014; pp. 16-53.

2 Torre LA, Bray F, Siegel RL, et al. Global cancer statistics, 2012. CA Cancer J Clin 2015; 65:87-108.

3 Ten most frequent cancers, 2010-2014. In: Singapore Cancer Registry Interim Annual Report Trends in Cancer Incidence in Singapore 2010-2014. National Registry of Diseases Office. Singapore: Health Promotion Board, 2015; pp. 7-8.

4 Nordenstedt H, White DL, El-Seragb HB. The changing pattern of epidemiology in hepatocellular carcinoma. Dig Liver Dis 2010; 42: S206-S214.

5 Chong DQ, Tan IB, Choo SP, Toh HC. The evolving landscape of therapeutic drug development for hepatocellular carcinoma. Contemp Clin Trials 2013; 36: 605-615.

6 Chua CW, Choo SP. Targeted therapy in hepatocellular carcinoma. Int J Hepatol 2011; 2011:348297.

7 Liu L, Cao Y, Chen C, et al. Sorafenib blocks the RAF/MEK/ERK pathway, inhibits tumor angiogenesis, and induces tumor cell apoptosis in hepatocellular carcinoma model PLC/PRF/5. Cancer Res 2006; 66:11851-11858.

Drugs such as sorafenib for advanced HCC became standard of care in cancer treatment through properly conducted, large-scale clinical trials in the past. It is hoped that new effective and safe drugs will be discovered from clinical trials in the near future to address an unmet need in advanced HCC. Please contact Dr David Tai at

[email protected] for enquiries regarding clinical trials options.

8 Wilhelm SM, Carter C, Tang L, et al. BAY 43-9006 exhibits broad spectrum oral antitumor activity and targets the RAF/MEK/ERK pathway and receptor tyrosine kinases involved in tumor progression and angiogenesis. Cancer Res 2004; 64:7099-7109.

9 Llovet JM, Ricci S, Mazzaferro V, et al. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med 2008; 359:378-390.

10 Cheng AL, Kang YK, Chen Z, et al. Efficacy and safety of sorafenib in patients in the Asia-Pacific region with advanced hepatocellular carcinoma: a phase III randomised, double-blind, placebo-controlled trial. Lancet Oncol 2009; 10:25-34.

11 Marrero JA, Lencioni R, Ye SL, et al. Final analysis of GIDEON (Global Investigation of Therapeutic Decisions in Hepatocellular Carcinoma [HCC] and of its treatment with Sorafenib [Sor]) in >3000 Sor-treated patients (pts): clinical findings in pts with liver dysfunction. J Clin Oncol 2013; 31(15 Suppl):abstr 4126.

12 Iavarone M, Cabibbo G, Piscaglia F, et al. SOFIA (SOraFenib Italian Assessment) study group. Field-practice study of sorafenib therapy for hepatocellular carcinoma: a prospective multicenter study in Italy. Hepatology 2011; 54: 2055-2063.


SIGNS AND SYMPTOMS OF HEAD AND NECK CANCERHead and neck cancer can be treated effectively if discovered at an early stage, thus it is important to be aware and to recognise early signs and symptoms of head and neck cancers. Below are some of the signs and symptoms of head and neck cancers.

ORAL CAVITY CANCERS• Mouth/Oral ulcers that don’t heal• Whitish or reddish patches in the mouth• Loosening of teeth• Dentures that suddenly don’t fit properly• Foul-smelling breath

NASOPHARYNGEAL CANCERS• Lumps in the neck• New-onset hearing loss• Recurrent ear-infections• Nose-bleeds• Blurring of vision / double-vision• Facial pain or numbness• Persistent headaches

OROPHARYNX• Pain on swallowing• Difficulty swallowing or breathing• Foul-smelling breath• Lumps in the neck

LARYNX AND HYPOPHARYNX• Changes in voice / hoarseness of voice• A sore throat that does not get better• Difficulty or Pain on swallowing• Pain in the ear• Difficulty breathing• Lumps in the neck

SIGNS AND SYMPTOMS ASSOCIATED WITH HEAD AND NECK CANCER

BY DR GERALD TAY Department of General Surgery Singapore General Hospital

THESE INCLUDE CANCERS OF THE:

WHAT ARE THE RISK FACTORS FOR HEAD AND NECK CANCERS?The 2 most important risk factors for head and neck cancers arising from the aerodigestive tract are tobacco smoking and alcohol consumption. The duration and intensity of smoking is directly related to the risk of cancer. Likewise, the chronic intake of alcohol also appears to increase the risk of upper aerodigestive tract tumours by 2 to 3 times. There appears to be an additive effect of tobacco smoking and alcohol consumption. People who both smoke and consume alcohol regularly appear to have a risk which is 10 to 20 times higher than that of non-smokers and non-drinkers.

Other risks factors also include:

1 Chewing of Betel Nut Betel nut is the seed of the

oriental palm Areca catechu. Betel nut chewing is a common habit in many Asian countries. Betel nut chewers have a higher incidence of developing oral cancers as well as submucosal fibrosis, a condition in the inner lining of the mouth becomes hardened.

2 Human papilloma virus (HPV) infection

Infection with HPV, especially HPV-16, has been shown to be a risk factor for developing cancers of the oropharynx, especially cancers of the tonsils and the base of tongue.

3 Epstein-Barr Virus (EBV) infection

EBV infection has been shown to be a risk factor for developing cancer of the nasopharynx.

4 Exposure to occupational carcinogens

Exposure to wood and leather dust has been shown to be a risk factor for developing cancers of the nasal cavity, paranasal sinuses and nasopharynx. Workers exposed to certain chemicals such as formaldehyde may also increase the risk of developing cancers of the paranasal sinuses and nasopharynx.

5 Chronic irritation Poorly fitting dentures or sources

of chronic irritation that cause repeated trauma in the oral cavity is thought to increase the risk of oral cancers.

Head and neck cancers refer to cancers that arise from the mucus linings inside the head and neck (also known as the upper aero-digestive tract) the skin of the head and neck, salivary glands and thyroid gland.

• Lips and Oral Cavity (Mouth)• Nasal cavity (nose) and Paranasal sinuses• Nasopharynx (back of the nose)• Oropharynx (back of the throat)• Hypopharynx• Larynx (voicebox)• Cervical oesophagus

• Thyroid gland• Salivary glands• Skin and Subcutaneous tissues


THYROID CANCERS• A lump in the neck, sometimes

growing quickly• Neck swelling• Pain in the neck• Voice hoarseness / Changes in voice• Difficulty breathing• Persistent cough

SALIVARY GLAND CANCERS• A new lump in the area just in front

of or below the ear, below the jaw, lip, or inside the mouth

• Trouble swallowing or opening the mouth widely

• Numbness or weakness in the face• Persistent face pain

NASAL AND PARANASAL SINUS CANCERS• Persistent blocked nose• Nosebleeds / Nasal discharge• Blockage of one side of the nose• Loss of smell• Numbness or pain in parts of

the face• Growth or mass on the face,

nose or palate• Constant watery eyes

SKIN CANCERS• A sore or skin ulcer that does

not heal• Spread of pigment from the border

of a mole into the surrounding skin• Redness or a new swelling beyond

the border of a mole• A change in sensation of a mole –

itchiness, tenderness or pain• Change in the surface of a mole –

scaliness, oozing, bleeding.

UPPER AERODIGESTIVE

TRACT

WHEN SHOULD I SEEK MEDICAL ATTENTION?Many of the signs and symptoms of head and neck cancer are non-specific and you may experience them at one time or another (e.g. ulcers in the mouth, nosebleeds). However, if the symptoms are persistent and last longer than two to three weeks or are more severe than usual, early medical attention is warranted. Patients who have risk factors for head and neck cancer should also pay more attention to these signs and symptoms and have a lower threshold to seek a medical opinion.

WHAT CAN I DO TO AVOID HEAD AND NECK CANCERMany of the risk factors for head and neck cancer are things that are in our control. You may not be able to change the genes that you inherited from your parents, but you can minimise your risk of head and neck cancer by following some simple steps:

1. Avoid Cigarette Smoking

2. Minimise the intake of Alcohol

3. Eat a diet rich in fruits and vegetables

4. Avoid Betel Nut/ Tobacco chewing

5. Visit your dentist every 6 – 12 months for a regular check-up.

Figure 4. Tumours of the salivary glands (parotid gland) can present as lumps in front of the ear or at the angle of the jaw.

Figure 3. Thyroid cancers can present as lumps in the neck.

Figure 2. Cancers of the gums can present with swelling or growths.

Figure 1. Tongue cancers can present with ulcers or growths in the mouth.


PATIENTS:

A message of Hope

Majority of patients attending NCCS Specialist Outpatient Clinic (SOC) look healthy on the outside and can go about their daily lives. Many have survived more than five years cancer-free, others have survived over two years following treatment for metastatic disease.

Much assistance are provided for advanced cancer patients in the wards to find peace and comfort. If needed, arrangements are made for home support or hospice care.

At all stages, the oncology team provides hope, and works hard to prolong the amount of quality time for the patient and family to make their days meaningful.

Some patients may have cancer since young, some faced three cancers in a lifetime, and others have family histories with three or more cancers. All these highlight the relevance of cancer genetics and the available interventions.

Don’t lose the patient, don’t lose hope. “Can I see you in 1 to 2 weeks?”

In the wards, a consultant squats to talk to the patient sitting on the low chair. He holds the elderly lady’s hand for minutes, and he takes his time to ask about the patient’s insight and wishes for the last days: “What can we do for you? Yes, we should be able to do that; we’ll do our best, record that wish down in the case records.”

THE INSTITUTION:

NCCS has great teams of doctors. The consultants share their years of experience and wisdom with the juniors; they would consult other consultants who possess greater expertise on the less common cancers.

Each new case would have a personal consultation with a consultant and that includes subsidised patients. Many follow-up cases are attended to by the same consultant for years. NCCS is able to arrange for early first consultations, urgent tests and diagnostic procedures efficiently, thanks to having their own dedicated imaging facilities and support personnel.

NCCS has numerous resources and funding programmes for subsidised treatment and research.

DOCTORING CANCER PATIENTS:

Professional and Personal Care: A General in Charge, Open hands and Holding hands:

Cancer is a huge label and psychological burden for the patient and family. The consultation atmosphere can be intense.

With each new case, the consultants patiently lay out the battle scenario, and then provide a clear explanation of the condition, the prognosis, and the treatment resources available with evidence-based medicine. Honest, open communication, presenting scientific evidence with humility, the possible benefits versus the risks and the appropriate dose of hope for cure or at least palliation. The consultants acknowledge the unknown, respecting the patient and family’s choice and autonomy. The patient is reassured with all necessary support in the course of treatment.

I get the impression of a general taking charge of a serious battle, a very experienced down-to-earth ground leader exuding some measure of calmness and confidence. There will be patients and families who are not ready to make a decision. The doctor patiently explains again, beyond the duty hours, and continues to extend an open hand to take them on board the rescue helicopter when ready.

GPsC@N – GPs Caring for Cancer at NCCS

DR CHAN CHEOW JU PIONEERS OUR 1ST GP CLINICAL ATTACHMENT

BY DR ROSE FOK Division of Medical Oncology

Dr Chan shares his memories of a wonderful attachment which he found to be a privileged learning experience. He is now more confident that he can better engage his patients and families with cancer.


Cancer medicines, unsubsidised, are generally very expensive. The doctors’ efforts to find funds to help defray treatment costs for the “needy patients” at a low threshold of means testing are laudable.

Cancer medication costs stretching over half a year can easily match up to more than 10 years’ worth of common chronic disease treatments. GPs would hope to emulate the successes of NCCS in sourcing for funds to promote primary care management and prevention of diseases (cancer included).

FOR THE GENERAL PRACTITIONERS (GP):

At the end of an intensive experience, we chilled out with Italian ice cream, courtesy of the consultant! Topping up with a run along the old railway Green Corridor at nearby Kampong Bahru, and you’ll be all refreshed and recharged to re-engage patients back at the GP clinic.

General Practitioners who are interested in having clinical attachments at National Cancer Centre Singapore may contact the following executive in-charge at [email protected] for more information.

Industry Collaborative News

COLLABORATION TO RESEARCH AND DEVELOP THERAPIES FOR ASIA-PREVALENT TUMOUR TYPES16 July 2015 – ASLAN Pharmaceuticals (ASLAN), an oncology focused biotechnology company, and National Cancer Centre Singapore (NCCS) announced the signing of a Memorandum of Understanding (MOU) that will further enhance the study of novel therapeutic agents for the treatment of gastric cancer, hepatocellular carcinoma (liver) and cholangiocarcinoma (bile duct), three common forms of gastrointestinal (GI) cancers that are particularly prevalent in Asia.

The collaboration will encourage a broader clinical understanding of gastric cancers which account for more deaths than any other cancer types in the region.

CLOSER TIES TO RESEARCH FOR NEW TREATMENTS BENEFITING CANCER PATIENTS

31 August 2015 – National Cancer Centre Singapore (NCCS) and A*STAR’s Institute of Molecular and Cell Biology (IMCB) have entered into a partnership to enable closer collaboration and networking among researchers between the two institutions.

Under this collaboration, four Principal Investigators (PIs) from each institution will hold joint appointments at the respective institutions. This move will benefit both parties through the sharing of knowledge among the scientists. The ultimate aim is to develop new therapeutic treatments for cancer patients. To commemorate the momentous event, an inaugural Joint Oncology Symposium was held on the same day to set the vision of the two institutions.

(Left to right) Prof Soo Khee Chee, NCCS Director and Prof Hong Wan Jin, Executive Director of IMCB delivering their welcome speeches at the symposium.


EXPRESSING GRATITUDE LEADS TO WELL-BEINGBY FLORA YONG Community Partnership

The landscape of healthcare philanthropy continues to change rapidly. Confronted with the challenging economic conditions, healthcare institutions have increasingly turned to philanthropy. Grateful Patient Philanthropy Programmes have become a crucial source and pipeline of philanthropic revenue for many healthcare institutions in US. While many still view these programmes as a rising trend, grateful patient fundraising is already a standard practice for many hospitals with comprehensive fundraising programmes, including those in Singapore.

G ratitude is the appreciation of what is valuable and meaningful to oneself; it is a general state of thankfulness and/or appreciation. Reported in

the “Grateful Patient Programmes: A Nationwide Healthcare Report” in US last year, 85 percent of the USD$8.6 billion raised by healthcare institutions came from individuals. In 2011, that number grew to USD$8.9 billion. Patients represented 21 percent of those individuals in 2008, and have been the only group of individuals to increase their share of giving over this time. This has positioned patients as the focal point of healthcare institutions’ fundraising programmes, motivating many hospital foundations to adopt or strengthen grateful patient programmes.

Statistics for healthcare philanthropy in Singapore are limited, but many local healthcare institutions are embarking on Grateful Patient Philanthropy Programmes as a source to increase their philanthropic income to support the various patient care, education and research initiatives which are often partially or not funded by the government. Beyond clinical care, philanthropy in healthcare institutions often serves as the “margin of excellence” that sets each institution apart.


REFERENCES:

1. Gobel, C., “Best Practices in Clinician Engagement, Building a Culture of Gratitude to Enable Philanthropy”, Gobel Group White Paper (2014).

2. Grant AM, et al. “A Little Thanks Goes a Long Way: Explaining Why Gratitude Expressions Motivate Prosocial Behavior,” Journal of Personality and Social Psychology (June 2010): Vol. 98, No. 6, pp. 946–55.

3. Harvard Mental Health Letter, “In Praise of Gratitude”, (November 2011)

4. Wood, A. M., et al., Gratitude and well-being: A review and theoretical integration, Clinical Psychology Review (2010), doi:10.1016/j.cpr.2010.03.005

WHAT IS A GRATEFUL PATIENT PHILANTHROPY PROGRAMME?

At one time or another, each of us will need to trust our lives or the life of a loved one to a team of healthcare professionals. The Grateful Patient Philanthropy Programme provides an opportunity for a patient, their friends and family to say “Thank you” for the care received by making a financial contribution to the hospital.

It is thus a meaningful way to say thank you. It enables patients to pay tribute to someone at the hospital who has made a significant difference in their care – someone who went well beyond what was expected and played meaningful roles in their care.

At NCCS, this is a special programme for many reasons. Firstly, it was started by grateful and generous patients. Not only that, this gesture also spreads warm feelings of gratitude and appreciation throughout the centre, both from patients wanting to say thank you, and from the caregivers or staff members who receive the compliment. Finally, patients also get to support the future of their own healthcare, as well as the medical care of others in their communities.

NCCS is a valuable cancer treatment resource in Singapore. NCCS’ programmes and services are available to the more than five million residents. NCCS provides specialised cancer services that may not be available at other hospitals in our community.

Grateful Patient Philanthropy Programmes, as their name suggests, are a way for patients to express their gratitude through philanthropy to the physicians, nurses, and other caregivers.

The donor’s gratitude is in direct response to the high quality, clinical excellence and exceptional experience they have had in the course of their healthcare encounter (Grant AM, et al. 2003).

Philanthropic research studies have also provided compelling evidence that highlights its role in patient encounters. It was also reported that expressions of gratitude, such as those made by a grateful patient, have been linked to an increased ability to cope with stress, a stronger immune function, quicker recovery from illness, lower blood pressure, increased feelings of connectedness which improves relationships and well-being, greater joy, optimism and increased generosity and compassion. In an article published by Harvard Health Publications in November 2011, the authors wrote “expressing thanks may be one of the simplest ways to feel better”. Experiencing gratitude, thankfulness, and appreciation tends to foster positive feelings, which in turn, contribute to one’s overall sense of well-being.

Philanthropy has a unique ability to unlock the power of gratitude to help patients heal. When a patient is grateful for the care they have received, they are motivated to donate. When they make a gift and express their gratitude, they are happier. Gratitude boasts many benefits – including better relationships, better physical health, increased happiness and better coping skills. Patients who experience gratitude, experience more positive emotion and are better equipped to deal with negative situations. Grateful Patient Philanthropy Programmes are a continuation of the clinical experience and an extension of a patient’s healing journey.

If you wish to make a gift for the extraordinary care that you have received from your physician, a nurse or someone in the healthcare team at NCCS, please contact 6236 9440 or email [email protected] to learn more about how you can make a difference to the future of cancer care in the community.


COMMON BREAST PROBLEMS BY TEO LAY CHENG Senior Staff Nurse Cancer Education and Information Service

A woman’s breasts go through multiple changes throughout her life. Most of these changes are normal and are due to the fluctuating levels of reproductive hormones in our bodies. These hormone levels alter during ovulation, menstruation, pregnancy and menopause. As we age, our hormone levels gradually decreases and we may experience various changes in our breasts. These may include unusual pain and/or swelling, a lump or general ‘lumpiness’, nipple retraction, or even a discharge from the nipple. Although most of these changes are benign (non-cancerous), they can make us very anxious and concerned. It is very important that these changes are thoroughly checked by a doctor.

Here are some of the changes which may occur, their features and possible doctor recommendations:

CONDITIONS FEATURES YOUR DOCTOR MAY RECOMMEND:

Benign Fibrocystic Changes

• Develop with age & in women whose breasts appear to be particularly sensitive to the monthly hormone changes

• Usually disappear after menopause

• A mammogram and/or ultrasound may be used to see whether a lump is solid or filled with fluid

• A biopsy may be used for diagnosis

Cyst • Fluid-filled sac• May feel soft or firm• Sometimes may feel painful when touched• Majority of cysts are harmless

• Doctors often observe cysts over some time or use fine-needle aspiration to remove the fluid from the cyst

• Ultrasound may be used to confirm whether the lump is a cyst

Fibroadenoma • Non-cancerous lump of fibrous tissue• Firm & rubbery• Common in younger women between the ages 18 to 30• Can be found in older women above 30 years old

• If the fibroadenoma does not appear normal, the doctor may suggest taking it out to make sure it is benign


Women are at risk of developing breast cancer and the risk increases with age. Keeping Abreast of Change aims to create awareness and encourage regular screening as Breast Cancer is the number one cancer affecting females in Singapore. Women are encouraged to perform monthly breast self-examination to learn about the look and feel of their breasts.

In conjunction with Breast Cancer Awareness Month, the National Cancer Centre Singapore will be organising a roadshow at Woodlands Civic Centre on 17 October 2015, from 10am to 3pm.

Island-wide subsidised mammogram screening vouchers will be given away at the activity booths. Participants will be taught how to do Breast Self- Examination and receive free tokens upon completing cancer-related quiz and games. Journey away from the number one killer and learn more about cancer on board the Cancer Education Bus!

Pledge to screen regularly at our photo-taking booth and bring home a souvenir from this meaningful event.

See you there!


以下是一些可能出现的变化，其特征以及针对这些状况的建议：

常见的乳房问题张丽清

高级护士

癌症教育与资讯服务

在女性的一生中，乳房会出现许多的

变化。大多数的变化是正常的，主要

是受到生育激素水平波动的影响。这

些激素水平会随排卵、经期、怀孕和

更年期而改变。随着年龄的增长，激

素的水平会逐渐减低，乳房也许会出

现多种变化。这些变化可能包括异常

的疼痛、肿胀、肿块、乳头凹陷或乳头

出现分泌物。虽然这些变化大多数是

良性的(非癌性)，但多少会令我们感

到焦虑。出现这些变化时，让医生彻

底检查是非常重要的。

状况特性医生可能会建议

良性纤维囊变化 • 随着年龄增长以及对每月激素变化特别敏感的女性可能

出现的身体状况

• 通常在更年期过后消失

• 乳房X光检查和/或超声波可用于区分

肿块或是充满液体的囊肿

• 可用活组织检查诊断

囊肿 • 充满液体的囊

• 可软可硬

• 有时触摸还会疼痛

• 大多数的囊肿是无害的

• 医生通常会观察囊肿，或使用细针抽取

囊肿的液体

• 超声波可以用来确认是肿块或是囊肿

纤维腺瘤 • 无害的纤维组织肿块

• 通常会感觉坚硬和似橡皮，质感平滑

• 常见于18岁至30岁之间的年轻女性

• 超过30岁以上的妇女，也可能会增长

• 医生可能会建议切除可疑的纤维腺瘤，

以确定它是否是良性的


女性都有患上乳癌的风险，而且这个风险会

随着年龄的增长而增加。掌握变化 (Keeping Abreast of Change) 旨在提高公众的癌症

意识以及鼓励大家定期作筛查。在新加坡的

女性当中，乳癌是最常见的癌症。女士们若每

个月都能定期做乳房自行检查，就会熟悉自己

乳房正常的外观与感觉，并及时察觉出变化。

在乳癌宣传月份，新加坡国立癌症中心将于10月17日，

星期六当天举行乳癌意识月的路演。地点是位于兀兰

的民事服务中心 (Woodlands Civic Centre)。路演

将从上午10点至下午3点举行。

其中一个活动展台将分发乳房X光检测的优惠券。

有了优惠卷，女士们能到新加坡全岛任意一间综合

诊疗所 (Polyclinic) 接受乳房X光检测。乳癌筛查

资讯柜台也会教导女士们如何自行检查乳房。在完

成教育性的活动或游戏后，参与者将获得免费的小

礼物。同时，欢迎公众乘搭癌症教育巴士，了解更

多有关癌症的资讯并驶离本地的头号杀手！

参观了巴士，别忘了到富有主题性的照相台将自己

愿意定期做筛查的承诺拍下，并将这份深具意义的

纪念照带回家！

到时见！


OUTREACH – CANCERWISE WORKSHOP AND UPCOMING EVENTS FOR THE GENERAL PUBLIC

Public Forum

Event Date, Time, Venue Registration

Role of Diet and Supplements in Cancer CareTOPICS:

Influencing cancer risk through • Diet• Supplements

09 January 2016, Saturday

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

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

CancerWise Workshop

Event Date, Time, Venue Registration

CancerWise Workshop – Lung Cancer TOPICS:• What is Lung Cancer?• What are the risks, signs & symptoms?• Prevention• What are the diagnostic tests to detect

Lung Cancer?• What are the treatments available?• New development in Lung Cancer• Targeted therapy

07 November 2015, Saturday

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


Free Admission




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

09 January 2016, Saturday

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


Free Admission





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

NOVEMBER 2015

Date Time Event Information CME Pt Registration Contact

5 5.00 pm

NCCS-SGH Joint Lymphoma Workgroup Meeting

@ NCCS Level 2, Clinic C, Discussion Room

1 Jennie Tan 6436 8280 [email protected]

27 5.00 pm

NCCS Neuro Onco Tumour Board Meeting

@ Academia, Diagnostic Tower, Level 9, Histopathology Microscopy Teaching room

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

26 7.30 am

Endocrine and Rare Tumour Meeting



12, 26 12.30 pm

Upper GI Tumour Board Meeting

@ NCCS Level 4, Peter & Mary Fu Auditorium

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

4, 11, 18, 25

4, 11, 18, 25

2, 9, 16, 23, 30

4.30 pm

5.00 pm

5.00 pm

NCCS Tumour Board Meetings:

Sarcoma Tumour Board Meeting

Surgical Oncology Tumour Board Meeting

Head & Neck Tumour Board Meeting


1

1

1

Lim Shufen / Ella 6436 8723 / 6436 8294 [email protected] / [email protected]

Daphne 6436 8592 [email protected]

5, 12, 19, 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]

4, 11, 18, 25 1.00 pm

S’Health Hepato-Pancreato-Biliary Tumour Board


1 Saratha / Carol Tang 6436 8165 / 6436 8539 [email protected] / [email protected]


mailto::[email protected]

mailto:[email protected]



DECEMBER 2015


3 5.00 pm




18 5.00 pm


@ Academia, Diagnostic Tower, Level 9, Histopathology Microscopy Teaching Room

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

17 7.30 am




10 12.30 pm




2, 9, 16, 23, 30

2, 9, 16, 23, 30

7, 14, 21, 28

4.30 pm

5.00 pm

5.00 pm






1

1

1


Daphne 6436 8592 [email protected]

3, 10, 17, 24, 31 11.30 am




2, 9, 16, 23, 30 1.00 pm

S’Health Hepato-Pancreato-Biliary Tumour Board


1 Saratha / Carol Tang 6436 8165 / 6436 8539 [email protected]


mailto::[email protected]



JANUARY 2016


6, 13, 20, 27 1.00 pm

S’Heath Hepato-Pancreato-Biliary Tumour Board


1 Saratha / Carol Tang 6236 9165 / 6436 8539 [email protected] / [email protected]

6, 13, 20, 27 1.00 pm

Gynae-Oncology Tumour Board Meeting

@ NCCS Level 1, Clinic A, Discussion Room

1 Lim Shufen / Ella 6436 8723 / 6436 8294 [email protected] / [email protected]

6, 13, 20, 27

6, 13, 20, 27

1, 8, 15, 22, 29

4, 11, 18, 25

4.30 pm

5.00 pm

4.30 pm

5.00 pm




Breast Tumour Board Meeting



1

1

1

1


Lalitha / Nora 6436 8236 / 6576 2037 [email protected] /[email protected]

Angela 6576 1731 [email protected]

7, 14, 21, 28 11.30 am




7 5.00 pm



1 Carol Tang 6436 8539 [email protected]

22 1.00 pm

Journal Club

(Topic: To be advised)

@ NCCS Level 1, Mammo Suite Discussion Room

1 Phua Chay Sin 6704 2037 [email protected]

29 5.00 pm


Academia, Diagnostic Tower, Level 9 Histopathology Microscopy Teaching Room

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

7, 14, 21, 28 12.00 pm




29 1.00 pm

Teaching Session

(Topic : To be advised)

@ NCCS Level 1, Mammo Suite Discussion Room

1 Phua Chay Sin 6704 2037 [email protected]

26 7.30am



1 Saratha 6436 8165 [email protected]





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 Mr Edwin Yong

Members, Editorial Board

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

PUBLISHED BY NCCS CORPORATE COMMUNICATIONS

www.nccs.com.sg

www.facebook.com/NationalCancerCentreSingapore

www.linkedin.com/company/NationalCancerCentreSingapore

nccs salubris oct - dec 2015

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