salubris oct - dec 2013

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RECOGNISING TALENTS AN NCCS QUARTERLY PUBLICATION October – December 2013 Issue No. 27 • MICA (P) 061/10/2010 Salubris is a Latin word which means healthy, in good condition (body) and wholesome. ...HELPING READERS TO ACHIEVE GOOD HEALTH

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Salubris is a quarterly publication by the National Cancer Centre Singapore (NCCS).

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Page 1: Salubris Oct - Dec 2013

RECOGNISING TALENTS

AN NCCS QUARTERLY PUBLICATION October – December 2013

Issue No. 27 • MICA (P) 061/10/2010

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

...HELPING R EADERS TO ACHIEVE GOOD HEALTH

Page 2: Salubris Oct - Dec 2013

CLINICAL TRIALS AT NCCSAs a leading academic cancer centre, NCCS is actively involved in clinical research such as investigator-initiated trials and international trials which give patients access to new cutting-edge therapies. In this issue, we speak to Dr Daniel Tan, Consultant, Division of Medical Oncology and Co-Principal Investigator, Cancer Therapeutics Research Laboratory, Division of Medical Sciences on his work for clinical trials. He is also the lead clinician in phase 1 clinical trials.

Q: WHAT DOES THE EXPERIMENTAL CANCER THERAPEUTICS UNIT DO?

The Experimental Cancer Therapeutics Unit (ECRU) is a collaborative multidisciplinary service in NCCS that draws on expertise across Outram Campus. This Unit is closely associated with the Investigational Medicine Unit at SingHealth, which is the inpatient facility for clinical trials. Our primary mission is to bring new and novel therapeutic agents into the clinic and at the same time advance our understanding of the biology of cancer.

Q: HOW LONG HAS THIS UNIT BEEN SET UP? HOW BIG IS YOUR UNIT?

This unit was established in 2009. There are currently about eight coordinators and four oncologists who look after the patients on the trials. A few more oncologists will be back from overseas to join ECRU.

Q: HOW MANY TRIALS ARE OPENED AT ANY ONE TIME?

The unit has approximately 15-20 trials open at any one time and the number of patients who choose to participate in phase I trials has been steadily increasing.

Q: WHEN DOES A PATIENT USUALLY CONSIDER CLINICAL TRIALS?

Clinical trials are often used when the patients have exhausted the standard treatments and have no other treatment options.

2 SALUBRIS OCTOBER – DECEMBER 2013

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Q: ARE THERE ANY SIGNIFICANT CLINICAL TRIALS SO FAR?

Yes. There are trials that were done on other sites where our patients have had remarkable responses in the early stages. For example, we worked with second generation ALK Inhibitor LDK 378 where we recruited the eighth patient in the world for the trial and even at the early stage, we saw good response. Since then, this drug has become very successful.

Q: WHAT IS THE ULTIMATE IMPACT OF CLINICAL TRIALS ON PATIENTS?

The phase 1 clinical trials are the point at which new drugs are introduced into medical practice and we hope that this will provide patients early access to the new drugs.

There are a little bit of risks involved as the drugs are new. But the reassuring thing is that safety measures are in place. If the patients run into problems, they can always contact our coordinators.

Q: WHAT IS THE MESSAGE YOU WANT TO BRING ACROSS TO OUR COLLEAGUES IN THE INSTITUTIONS?

The nature of the patients we see and the nature of the drugs side effects do mean that many of our colleagues are also involved in these trials. For example, we involve eye centre colleagues and cardiology colleagues if there are complications that arise from these trials. One of the challenges with these trials is that you may not know what to expect. Hence, we work closely with all our colleagues in the campus to address some of these potential complications.

The team involved in the Experimental Cancer Therapeutics Unit:

PARTICIPATING IN CLINICAL TRIALS

If you wish to participate in a clinical trial at the National Cancer Centre, you can consult your attending physician. If there is a trial that is suitable for you, your physician will be able to refer you to the appropriate clinical investigator responsible for that study. Our clinical investigator will discuss with you what participation in the trial entails and provide details to help you make an informed decision.

GIVING TO CANCER RESEARCH

Many of these studies are made possible only by adequate funding. Should you wish to make a contribution to our effort to eliminate cancer, you can make a donation through this link. http://www.nccs.com.sg/Giving/WaysofGiving/Pages/Home.aspx

BY RACHEL TAN

Doctors Dr Daniel Shao Weng Tan Dr Matthew CH Ng Dr Tan Eng Huat A/Prof Darren Lim Dr Choo Su Pin Dr Yap Yoon Sim

Functional Imaging Dr Ng Quan Sing Dr Thng Choon Hua

Biomarker Development A/Prof Tony Lim Kiat Hon Dr Angela Takano Dr Alvin Lim Soon Tiong

Principal Pharmacologist Prof Balram Chowbay

Lead Trial Coordinators Ms Wang Lan Ying Ms Low Lishan

3SALUBRIS OCTOBER – DECEMBER 2013

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SWEET SHARING OF GOODNESS BY LIN SHUANGCHUN Executive, Volunteer Management

Recently, I came across an interesting book at the Retail Pharmacy at NCCS. The name and cover of the book attracted me. Named “Sharing Plates”, the book’s cover has a picture of a mouthwatering bowl of apple salad and a delicious plate of briyani rice. As I browsed through the book, I was charmed by the photographs and the potpourri of stories the recipes were connected to. I had to buy it.

Sharing Plates is a recipe book created by a group of students from Nanyang Technological University for their final year project. The book is their tribute to those affected by cancer and shares simple food ideas with those going through the cancer journey.

The delectable and carefully choreographed colourful photos of dishes enticed me to try some of the recipes. I was skeptical at first about how it would turn out but I was very pleasantly surprised. What I had cooked tasted GOOD!

It is an easy to read cook book with simple instructions that make whipping up delicious meals and delectable desserts a breeze for anyone in the kitchen.

Being a busy executive with many commitments to juggle, I finally found time to don my apron and put two recipes to the test on a lazy Sunday afternoon - pumpkin and corn porridge for a light lunch, and red dates, red beans and barley dessert for a sweet ending. I must confess that the kitchen is a restricted zone meant for mummy dearest and not for an amateur cook like me. Looking like a fish out of water, I finally served the porridge and dessert much to the anticipation of those present for the food tasting. Surprisingly, the porridge was light and tasty! What blew everyone away was the all-natural sweetness and fragrance of dessert made from red dates, red beans and barley. This dessert gets all the votes because not only can it be prepared in three easy steps, but it also has all the antioxidants that are good for us, and is surprisingly sweet – a definite thumbs up from a sweet tooth like me.

It is official. Desserts can be full of wholesome goodness without compromising on taste. If a Sunday cook like me can turn chef for a day, so can you. Sharing Plates has created a sweet weekend for me to share with my family.

I recommend this simple unpretentious recipe book to anyone who wants to cook a wholesome meal for their loved ones. I am sharing this experience with you so that you too can be convinced that people affected by cancer do not have to eat bland food.

If you wish to get your copy of ‘Sharing Plates’, it is still available at a very special price of $15 per book at the National Cancer Centre Retail Pharmacy, or you can purchase it online at: http://www.nccs.com.sg/Giving/GettingInvolved/Documents/SharingPlates.htm

Proceeds from the sale of the book go to Community Cancer Fund in aid of patient care initiatives and educational programmes.

I recommend this simple unpretentious recipe book to anyone who wants to cook a wholesome meal for their loved ones.

4 SALUBRIS OCTOBER – DECEMBER 2013

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CONGRATULATIONS! RECIPIENTS OF NATIONAL DAY AWARDS 2013

Ms Chew Pheck GeokDirectorRadiotherapy ServicesDivision of Radiation Oncology

“This award is an affirmation of professional & personal contribution; a milestone achieved as part of the healthcare team. This is only possible through the strong support and close collaboration among fellow colleagues who are committed to healthcare excellence.”

LONG SERVICE MEDAL

Ms Chan Soh HwaAssistant DirectorDivision of Oncologic Imaging

“Surprised - however delighted with the affirmation and extremely grateful to the wonderful friends and supportive colleagues who make this possible.”

A/Prof Lita Chew Sui TjienHeadPharmacy

Ms Tamilarasi d/o ArumugamNurse ManagerSpecialist Oncology Clinic

“My greatest satisfaction is: Go home with the thought that I made a difference in someone’s life.”

EFFICIENCY MEDAL

Dr Fan Yoke FunSenior ConsultantDivision of Oncologic Imaging

Dr Chua Eu TiongHead and Senior ConsultantDivision of Radiation Oncology

COMMENDATION MEDAL

PUBLIC ADMINISTRATION MEDAL (BRONZE)

5SALUBRIS OCTOBER – DECEMBER 2013

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H e had in fact nominated another fellow doctor for the award and little did he know that someone else had put his name on the nomination list.

And, when he was given the news that he won the award, he could not believe his ears, and questioned: “What have I done to deserve the award?”

The modest and busy man has overlooked his own contributions, taking whatever he has over the years to make a difference in the life of others as just part of his work.

But Dr Koo who holds several responsibilities, has always been a source of inspiration to his peers and juniors in National Cancer Centre Singapore (NCCS), some of whom affectionately refer to him as “Grand Master”. He is the Deputy Director and Senior Consultant (Department of Medical Oncology) at the NCCS, as well as the Associate Programme Director for SingHealth Internal Medicine Residency and SingHealth Group Director for Education. He holds academic positions in the Duke-NUS Graduate Medical School and the Yong Loo Lin School of Medicine at the National University of Singapore.

Looking back on his 31 years in medicine, he said clinicians these days enjoy ample opportunities for further learning outside their clinical work. Explaining this, he cited his example as a junior doctor who was trying to obtain research experience at the labs. The doors were shut. “I was only a clinician and did not have a research grant, did not have sponsors, and had no research experience. I was not welcomed.” Resourcefully he asked Prof Teh Bin Tean, who heads the NCCS-Van Adel Research Institute laboratory, for assistance and the latter agreed to do it for the doctors. The research laboratory was opened with the support of NCCS to enable junior doctors and trainees to get a taste of research. Thereafter, it was mandated that oncology trainees have to go through a mandatory six-month research stint. The experience is enriching regardless of their interest, to help them understand the concept behind research papers, interpret results, and conduct further exploration on their own.

Although his work as a clinician keeps his schedule hectic, Dr Koo believes this serves as a bonus to his role as educator. “I think being an active clinician gives us plenty of opportunities to do education work. Every encounter with patients can be an opportunity to teach and learn from. Students enjoy being guided through real life contact,” he explained.

THE “GRAND-MASTER” WHO LEADS BY EXAMPLEIt was an unexpected turn of the table for Dr Koo Wen Hsin when he was recently told he has been awarded the National Outstanding Clinician Educator Award 2013.

6 SALUBRIS OCTOBER – DECEMBER 2013

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NURSES’ MERIT AWARD 2013

“To be able to give hope and encouragement in their road to recovery spurs me to always do my very best in nursing; to be able to show empathy, care and encouragement to my patients makes me feel proud of being a nurse.”

– SSN SHIRLEY CHENG BEE HONG

Walking the talk is important but it is a challenge for even the seniors. “We have to watch our behavior, even when students are not around”, he said. The junior doctors often watch and emulate what their seniors do. Being an exemplary doctor is not just about treating patients, it is also about being patient and understanding to those in their care. As such, he strives to be a role model in teaching students to be careful, thorough and patient.

Besides his passion for learning and imparting knowledge, he exhibits another precious characteristic of a bona fide educator, and that is, the willingness to accept criticism and learn from others beneath him in terms of credentials. With information flow becoming more prolific due to wide access to the internet, he agrees that even patients and their families may sometimes discover information that even doctors may not be aware of.

“We have to engage in constant learning activities to keep abreast. However, we must be prepared to learn from patients. There are many things which we don’t know that we are unaware of. Patients can accept the fact that we do not know. We just have to be humble to admit our ignorance.”

Indeed, Dr Koo’s work revolves tightly around his patients. He is known to have shared his email and phone with his patients. He advises oncologists not to be hung up on scientific aspects like survival statistic and chemotherapy responses, but to consider how the disease affects patients.

From his personal experience, the best way to do so is to visit the patient at home to understand the overall impact of the disease on him. Having worked initially as a volunteer doctor and later as a staff in the Hospice Care Association, visiting patients and having discussions with the home care team had helped him greatly in empathising with patients’ needs. The compassionate man also volunteered as chairman to the Singapore Cancer Society for many years.

With so much of his time dedicated to his work at NCCS and his patients, Dr Koo tries his best to make time for dinner at home, and to show interest in what his three children do. His wife is a trained pharmacist, eldest son a medical officer, youngest daughter a third year medical student and another son a law student.

In whatever available free time, he would try to catch up on reading, and like most Singaporeans, he loves food and going out with friends to try different types of delicacies.

BY SUNNY WEE

7SALUBRIS OCTOBER – DECEMBER 2013

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Ms Chua Gek Phin receiving the President’s Nurse Award 2013 from President Tony Tan Keng Yam.

AFTER 40 YEARS, SHE STILL SHOULDERS THE CALL FOR DUTYFor almost four decades, Ms Chua Gek Phin, the Director of Nursing at the National Cancer Centre Singapore (NCCS) has been responding to the call for duty as a nurse. While she may not be at the frontline, she is very much in tune with the ground, overseeing the nursing operations, formulating new training programmes and procedures among others.

F or a job that gets a notorious reputation for being “unglamourous” and “arduous”, one may ask how did she remain steadfast in her self-chosen career path. But she explained the “pains” are more an exception rather than the norm. She explained, “Most of the time,

patients and their relatives are very appreciative. It can also be very gratifying because we can make a difference and touch lives,” said Ms Chua.

Candidly she added, “I took up nursing because it is a meaningful and fulfilling career where we can help and care for the sick and make a difference in their lives.” And, this passion has won her this year’s President’s Award for Nurses.

For the family, it will be the second President award. Elder sister Mdm Chua Gek Choo, who is the Deputy Director of Khoo Teck Puat Hospital and the Director Nursing designate of Yishun Community Hospital, won the President’s Nurse Award in 2008.

Humbly, she attributed her award to her colleagues, indicating that it was an acknowledgement and recognition of all the good and hard work that the NCCS Nursing team has put in.

8 SALUBRIS OCTOBER – DECEMBER 2013

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Till this day, Ms Chua strives incessantly for the enhancement of patient care services and the quality of nursing, going far beyond the call of duty in the clinical settings. Over the years, she has pioneered various significant changes in nursing protocols and education.

One of her key contributions is the abolition of the system of double-checking by staff who have worked for more than a year in the Ambulatory Treatment Unit (ATU). Based on an analysis of data collected, she found that double-checking often result in a false sense of security. The staff was inclined to rely on his/her fellow nurse to look out for any error and to correct the mistake. There was the likelihood that the junior would dare query the work done by the senior staff. On the other hand, with the new system, the staff is required to be more vigilant, knowing that they are solely responsible for whatever they have checked.

And, responsibility for the patient welfare is something which Ms Chua has always been a strong advocate of. She said, “Our policies and procedures must be in-place and easily accessible to all staff. We need to ensure an honest and transparent system of reporting incidents so that improvements can be made. We owe it to our patients to learn from our mistakes and make sure that the same mistake should not happen again.”

As such, she has, together with her team, established a system of using flowcharts in the administration of clinical trial protocols to ensure strict adherence, which is crucial in evaluating the success or failure of clinical trials. She also implemented initiatives such as staff training, staff empowerment, and checklists to improve work processes.

Her perseverance helped to raise the standards and the profile of Oncology Nursing in Singapore, contributing to the achievement of 99.99% accuracy in medication administration in the ATU.

As part of her contribution in training for her nurses, she helped develop the NCCS Chemotherapy Course to enable nurses to effectively manage patients undergoing chemotherapy, and educate them in self-care. The course was been developed into e-learning in 2009. She also mentors the nurses in collaboration with external institutions to conduct research to gain a better understanding of patients and their caregivers.

Looking back at the advances in nursing, she said the profession has become more sophisticated. “For a start, education in nursing has become more recognised and there’s greater specialisation.”

“There is plenty of theory in the learning process and nurses can go into research and clinical postings, aside from administration and education, which used to be the only career choices for nursing. They can even present their papers at international conferences and publish their works, and pursue degree courses.” Ms Chua herself received several education awards and WHO scholarships in the past years, and graduated with a Bachelor of Nursing (with Distinction) in 1995, and Graduate Diploma in Oncology Nursing (with Distinction) in 1996 from Queensland University of Technology. In 2007, she completed her Master of Nursing.

“We used to wash and boil our syringes, make bottled feeds for the paediatric patients as well as make feeds for our adult patients etc. There was no plug in oxygen, suction, as well as infusion pumps. We had to manually calculate the drips, invert the bottles to create suction for our intra-gastric suction etc… I still remember that when I was on night duty in KKH as a Unit Staff Nurse, I had to manually pump the paediatric patient using the air viva, the whole night!” she reminisced.

Indeed, nursing is a demanding profession. Nurses have to cope with the occasional demanding patients and their caregivers. And, the job comes with health risks, like the SARS.

Today, one of her challenges includes the management of staff. While matrons in the old days were privileged with showing austerity towards the junior nurses, this has changed. “Nowadays, we have to deal with the strawberry generation. You need to handle them gently or they’ll resign or take sick leave,” she lamented. The only “fear” that the seniors can instil in the nurses is that if they deviate from the standards of practice and indulge in unsafe practices, they will have to face the brunt of the associated consequences.

Despite the complexities of her job, Ms Chua’s anticipations remain simple. Her best moments are “seeing the patients recover, and getting acknowledgement from patients that the nurses are doing a good job.” From a professional standpoint, she hopes that nursing will eventually become a career of choice for Singaporeans, and that a cure for cancer could be found one day.

BY SUNNY WEE

9SALUBRIS OCTOBER – DECEMBER 2013

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THE PROSTATE CANCER DILEMMA: TO SCREEN OR NOT?BY DR RAVINDRAN KANESVARAN Consultant Division of Medical Oncology

Prostate cancer is the third most common cause of cancer and the sixth leading cause of cancer death among men in Singapore.1

The disease however has a remarkably diverse natural history. It may commonly present itself as a benign tumour with a long natural history or as metastatic disease which has an average survival of just about two years. Strategies for managing prostate cancer as such have been aimed at early detection, using a tailored management method.

WHAT IS PROSTATE CANCER SCREENING?

The test consists of both a prostate specific

antigen (PSA) test and a digital rectal examination

(DRE). Studies have shown that conclusive results

can be drawn upon when both tests are used in

combination.2 PSA is a substance made by the

prostate gland. The test measures the PSA level

in the blood and a raised level can be an early

indication of prostate cancer. Unfortunately, a

raised PSA may not exactly point to prostate cancer

and may lead to overdiagnosis and overtreatment.3

MORE RISKS THAN BENEFIT

Intuitively it would seem that early detection and treatment should translate to an overall survival benefit for all men in general. Though in a study involving 162,000 European men, they found 1,410 men needed to be screened and 48 men were treated to prevent one cancer death over a period of 10 years. That means that 47 men were treated in futility. These men would have unnecessarily suffered from the side effects of overdiagnosis.3

PSA screening carries minor biopsy risks which include pain, bleeding, infection, haematuria and haematospermia.4 The major side effect of screening is overdiagnosis – which may lead to unnecessary treatments like surgery and radiation therapy. These treatments may have inherent risks such as operative mortality, urinary problems and sexual dysfunction.

10 SALUBRIS OCTOBER – DECEMBER 2013

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REFERENCES: 1 Trends in Cancer Incidence in Singapore 2006-2010. Singapore Cancer Registry, 2010: p 1-15.

2 Catalona, W.J., et al., Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men. J Urol, 1994. 151(5): p. 1283-90.

3 Schroder, F.H., et al., Screening and prostate-cancer mortality in a randomized European study. N Engl J Med, 2009. 360(13) :p. 1320-8.

4 Rietbergen, J.B., et al., Complications of transrectal ultrasound-guided systematic sextant biopsies of the prostate: evaluation of complication rates and risk factors within a population-based screening program. Urology, 1997. 49(6): p. 875-81.

5 Fowler, F.J., Jr., et al., The impact of a suspicious prostate biopsy on patients’ psychological, socio-behavioral, and medical care outcomes. J Gen Intern Med, 2006. 21(7): p. 715-21.

6 Lim, L.S. and K. Sherin, Screening for prostate cancer in U.S. men ACPM position statement on preventive practice. Am J Prev Med, 2008. 34(2): p. 164-70.

WHO SHOULD THEN BE SCREENED AND HOW FREQUENTLY SHOULD IT BE DONE?

Based on evidence by expert opinion, the Ministry of Health (MOH) Singapore Clinical Practice Guidelines on Cancer Screening 1/2010 suggest the following groups (after having counselled about the risks and benefits of prostate cancer screening) could consider getting screened:

• Menwhoarebetween50and75yearsofagewithanestimated life expectancy of more than 10 years.

• High-riskmen–AfricanAmericanmen,menwith a strong history of prostate cancer (one or more first-degree relatives diagnosed before age 65 years) may be offered screening earlier.

• Routinescreeningofmenyoungerthan50yearsofageshould not be offered. Men with life expectancy of less than 10 to 15 years should be informed that testing and treatment is unlikely to be beneficial.6

The PSA screening frequency as recommended by the above guidelines recommends it should be repeated annually. However the screening may be performed every two years in low risk men with a baseline PSA of less than 1.0ng/ml (recommended best practice by the guideline development group).

In conclusion, the decision to use PSA for the early detection of prostate cancer should be individualised. Physicians should continue to provide men with all the information about the risks and benefits of screening for prostate cancer before coming to a shared decision. Routine screening without proper counselling should be discouraged.

Finally like any other screening test, PSA may yield a false positive result as well. This may cause patients intense anxiety which may not resolve even with a negative biopsy thereafter.5

11SALUBRIS OCTOBER – DECEMBER 2013

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前列腺癌的窘境:是否应进行检查拉文詹医生 咨询顾问 肿瘤内科部门

前列腺癌是新加坡男性第三常见癌症,第六主要癌症死亡病因1。

不过,此疾病有着多种截然不同的自然史。它可能是具有很长自然史的良性肿瘤,也可能是平均只有两年存活期的转移性疾病。因此,治疗前列腺癌的策略着重于及早确诊,并采用按需定制的管理方案。

何为前列腺癌检查?

检查方法包括前列腺特异抗原(PSA)测试及直肠指检(DRE)。研究显示,结合这两项测试的结果,将能确诊病患是否患有前列腺癌2。前列腺特异抗原是前列腺分泌的一种物质,该测试测量病患血液中的前列腺特异抗原水平,如果水平上升,即可能是前列腺癌的初期迹象。不过,前列腺特异抗原水平上升,并不意味着罹患前列腺癌,因此可能导致病患过度诊断和治疗3。

风险大于益处

直觉上,及早诊断和治疗应能普遍提高所有男性的整体存活率。然而,在一项长达10年、以16万2000名欧洲男性为对象的研究显示,在1410名男性必须进行检查当中,有48人接受治疗,但其实只有1人患有前列腺癌。这意味着,47人白白接受治疗,并可能经历过度诊断的不必要痛苦。3

前列腺特异抗原检查具备的轻微活检风险包括疼痛、出血、感染、尿血和血精症4,而主要副作用是过度诊断,这可能导致病患必须经历手术和放射治疗等不必要的治疗程序。这些治疗程序都具备固有的风险,可能导致病患因手术而死亡、面对排尿问题和性功能障碍。

12 SALUBRIS OCTOBER – DECEMBER 2013

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参考资料: 1 Trends in Cancer Incidence in Singapore 2006-2010. Singapore Cancer Registry, 2010: p 1-15.

2 Catalona, W.J., et al., Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men. J Urol, 1994. 151(5): p. 1283-90.

3 Schroder, F.H., et al., Screening and prostate-cancer mortality in a randomized European study. N Engl J Med, 2009. 360(13) :p. 1320-8.

4 Rietbergen, J.B., et al., Complications of transrectal ultrasound-guided systematic sextant biopsies of the prostate: evaluation of complication rates and risk factors within a population-based screening program. Urology, 1997. 49(6): p. 875-81.

5 Fowler, F.J., Jr., et al., The impact of a suspicious prostate biopsy on patients’ psychological, socio-behavioral, and medical care outcomes. J Gen Intern Med, 2006. 21(7): p. 715-21.

6 Lim, L.S. and K. Sherin, Screening for prostate cancer in U.S. men ACPM position statement on preventive practice. Am J Prev Med, 2008. 34(2): p. 164-70.

谁应接受检查? 应多频密接受检查?

以专家意见为依据,卫生部的《新加坡癌症检查临床

实践指南1/2010》建议,以下群体(在咨询有关前列

腺癌检查的风险和益处之后)应考虑接受检查:

• 年龄介于50至75岁、预期寿命超过10年的男性。

• 高风险群男性—非洲裔美国男性、具有家族

病史(一个或多个直属亲人在65岁之前确诊罹患

前列腺癌)的男性可能须尽早进行检查。

• 年龄低于50岁的男性不应进行例行检查。医务人

员也应告知预期寿命少于10至15年的男性,检查

与治疗的效益可能不大6。

上述指南建议,应每年进行前列腺特异抗原检查。

不过,低风险群男性若前列腺特异抗原水平少于

1.0ng/ml,则可每两年进行一次检查(由指南制定

小组推荐的最佳做法)。

总而言之,通过前列腺特异抗原检查及早确诊前列腺癌的做法,应视个别情况而定。医生应继续为男性提供所有关于前列腺癌检查风险与益处的资讯,然后再达成共识。病患不应在没有经过适当的辅导之前就进行例常检查。

此外,犹如其他检查,前列腺特异抗原检查可能呈现假

阳性结果,造成病患强烈焦虑,即使之后的活检结果呈

阴性,也无法消除此焦虑感5。

13SALUBRIS OCTOBER – DECEMBER 2013

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SEEKING THE ‘HOLY GRAIL’ – BIOMARKERS TO PREDICT RESPONSES AND TOXICITIES OF RADIOTHERAPYBY VERONICA LEE

In the setting of modern day cancer treatment where drug options are increasingly expansive, radiotherapy remains a very effective non-surgical approach in the management of cancer patients. It is estimated that more than 50% of all cancer patients will require radiotherapy at some point during their treatment, and among these, approximately 60% receive this treatment with a curative intent. Conventionally, radiotherapy is delivered using high energy X-rays, but other sources of radiation include heavy ions and protons. Regardless of the modality, the biological effects of radiotherapy are primarily exerted through the induction of DNA damage and subsequent downstream signalling events leading to lethal cell cycle arrest, genomic instability, and cell death.

W ith the advent of modern techniques like intensity modulated (IMRT) or image-guided adaptive radiotherapy (IGRT), the precision of irradiating tumour tissues has markedly

improved. Nonetheless, an estimated 10-20% of radiotherapy patients still suffer from irreversible late adverse effects, occurring months to years following treatment. This is in part due to the principles of radiotherapy planning where irradiation of adjacent normal tissues is unavoidable.

Modulators of tissue responses to radiotherapy include clinical factors such as total radiation dose received and prescribed radiation dose per day. However, clinical evidence suggests that genetic and epigenetic factors intrinsic to an individual are perhaps the major determinants of late toxicities following radiotherapy. It is on this basis that over the past decades, significant resources have been committed to establishing a highly robust biomarker of intrinsic radiation sensitivity of an individual. On this note, our research in collaboration with investigators from the Royal Marsden Hospital, Institute of Cancer Research, and the Public Health of England primarily focused on the fidelity of DNA repair as a surrogate for normal tissue radiation sensitivity. Specifically, our hypothesis rests on the rationale that repair of DNA double-strand breaks (DSB), an extremely lethal form of DNA damage induced by ionising radiation, correlates with the progression of late adverse effects in radiotherapy patients.

While adopting radiation-induced late effects in the breast as our clinical model, we reported that in a subset of breast cancer patients who had displayed marked reactions to breast radiotherapy, irradiated skin tissues and blood lymphocytes of these patients exhibited significantly higher levels of residual DSB as opposed to tissues from controls, confirming a mechanistic role of impaired DSB repair in the pathology of late radiation-induced toxicities. Moving on, we were able to further establish correlations between other cellular end-points related to radiation exposure and clinical radiation sensitivity of our breast cancer patients. On the basis of these pilot findings, we proceeded to initiate a large prospective trial, which is currently ongoing, testing the reliability of these cellular markers for predicting late toxicities in breast and prostate radiotherapy patients.

Predictive assays of normal tissue radiation sensitivity have often been referred to as the ‘holy grail of radiotherapy’, which bears a disheartening connotation of something intensely sought but never found. Nonetheless, the benefits of such an assay, if it exists, are extremely appealing. For example, cancer patients identified to be radiation sensitive could be referred for surgery instead or alternatively, receive a lower radiation dose. With the introduction of newer and more robust assays, along with the progression towards multi-centre collaborations and large scale prospective studies, one may be convinced that we are now better equipped in the pursuit of the ‘holy grail’.

14 SALUBRIS OCTOBER – DECEMBER 2013

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PROF RUTH E. MALONE: END GAMES STRATEGIES IN TOBACCO CONTROL Ruth Malone was just like any typical adult working American. In-between her daily work, she would pause, light up a cigarette almost nonchalantly to get her “fix”. A full pack of 20 sticks was what she would burn to satisfy her crave for nicotine. This went on for a good 16 years until one day in the course of carrying out her work she came across bundles of documents originating from the tobacco industry.

A nd, lo and behold, the pages contained information that would be the dream of any

whistle-blower who wants to make a good exposé in the press. Before her were 14 million dossiers, running into 80 million pages. They contained incriminating correspondences between executives in the tobacco industry strategising to get more people to get addicted to tobacco and how to carry out marketing campaigns to promote and encourage more people to take up smoking, ignoring the hazards that it could cause to the public health. This shocked her into giving up smoking and it has been 20 years since she lit up her cigarette.

“I decided that I want to be alive to see my two children grow up, and these disclosures in the dossiers gave me every reason why I should stop smoking. It was very difficult initially and I finally stopped, but it was not the first attempt. I believe many smokers succeeded in cutting the habit after more than one attempt,” said Prof Ruth Malone who is the Professor and Chair in the Department of Social and Behavioural Sciences in the University of California, in San Francisco.

She noted that the tobacco industry is now trying to do a cover up by launching corporate social responsibility activities, supporting anti-smoking activities for youths, and setting up clinics in Africa.

This, she said, was a gimmick and it has the reverse effect of telling the youths that when they are adults it would be alright to take up smoking. “The industry sees WHO, medical institutions and other non-government anti-tobacco groups as their enemies, and they have been penetrating even some of these groups under the pretence of supporting their activities,” said Prof Malone, who is also the Editor-in-Chief of Tobacco Control, an international peer review journal.

“Why should an industry that sells products that have been killing so many innocent people be allowed to continue with their business?” she asked passionately. “Surely under normal circumstances, someone who sells or produces such harmful product would say ‘oh oh let’s stop it as it is killing the customers’ or say ‘let’s take it off the market’?”

Yet, she pointed out that tobacco companies are even now allowed to sell their products just like any other products. “They have promoted the acceptance of cigarettes like any normal product that you can buy off the shelves all over the world,” she lamented.

Today Prof Malone’s work involves looking at the tobacco industry and mass media influence on health risk issue, and her current research focuses on the tobacco industry’s efforts to counter public health among others.

Prof Malone, who was at the National Cancer Centre Singapore, to deliver the 14th Humphrey Oei Distinguished Lecture on 19 July 2013, also took part in several other activities organised by the Towards a Tobacco Free Singapore (TTFS), including a 100 km bicycle ride around Singapore on 20 July. This movement was started by Prof Koong Heng Nung, head of Division of Surgical Oncology, NCCS, together with NUS Mathematics Prof John Berrick. Their goal was to disallow children who are born in year 2000 and after from buying cigarettes.

The pre-dawn bicycle ride was a round trip from CHIJ school in Toa Payoh, with Dr Janil Puthucheary, MP for Pasir Ris-Punggol GRC, as the guest-of-honour. Dr William Tan, an NCCS resident physician, who is also a paralympic medalist, led the group of cyclists.

BY SUNNY WEE AND RACHEL TAN

15SALUBRIS OCTOBER – DECEMBER 2013

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NATURAL COMPOUND AA IS FOUND TO BE THE MOST POTENT CARCINOGEN

A joint study conducted by researchers from National Cancer Centre Singapore (NCCS), Duke-NUS and Taiwan’s Chang Gung Memorial Hospital, LinKou, has found that Aristolochic Acid (AA) – a natural compound found in Aristolochia plants – is a carcinogen that causes abundant DNA mutations that can lead to kidney and liver cancers. Traditionally, Aristolochia plants are used in herbal remedies for weight loss, slimming and other purposes. Although AA was officially banned in Europe and North America since 2001 and in Asia since 2003, certain AA-containing products are still permitted under supervision and are easily available worldwide, including over the internet.

U sing advanced DNA sequencing technologies, the team, led by Professors Teh Bin Tean, See-Tong Pang, Patrick Tan and Steve Rozen discovered that AA is the most potent carcinogen identified to date, causing

more DNA mutations than cigarette smoke or ultraviolet light.

“AA’s contributions to kidney failure and cancer have been documented, but AA’s possible role in other cancer types was unknown. In this study, we found that the AA-related DNA fingerprint could be used to screen for the potential involvement of AA in other cancers, such as liver cancer,” said Dr Poon Song Ling, the lead author of the study and a research fellow from NCCS.

From left to right: Prof Teh Bin Tean, Prof Patrick Tan,

Associate Prof Steve Rozen, Dr John McPherson, Dr Poon Song Ling

The findings could lead to a new wave of DNA-based detection systems for monitoring carcinogen exposures in humans and the environment.

The research was supported by grants from the Singapore National Medical Research Council, the Singapore Millennium Foundation, the Lee Foundation, the National Cancer Centre Research Fund, The Verdant Foundation, Duke-NUS, the Cancer Science Institute of Singapore, the Chang Gung Memorial Hospital, LinKou, the Taiwan National Science Council, and the Wellcome Trust.

BY RACHEL TAN

Aristolochia plants. Photo credit: Chang Gung Memorial Hospital

16 SALUBRIS OCTOBER – DECEMBER 2013

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NOVEMBER 2013Date Time Event Information CME Pt Registration Contact

7, 21 5.00pm NCCS-SGH Joint Lymphoma Workgroup Meeting

@ NCCS Level 2, Clinic C, Discussion Room

1 Tan Si Xuan / Rachel Tan

6436 8280 / 6436 8172 [email protected] / [email protected]

28 5.00 pm NCCS Neuro Onco Tumour Board Meeting

@ NCCS Level 2, Clinic C, Discussion Room

1 Low Peak Wah / Ang Hui Lan

6436 8165 / 6436 8174 [email protected] / [email protected]

28 7.30 am Endocrine and Rare Tumour Meeting

@ NCCS Level 2, Clinic C, Discussion Room

1 Tan Si Xuan / Rachel Tan

6436 8280 / 6436 8172 [email protected] / [email protected]

6, 13, 20, 27 6, 13, 20 27

1, 8, 15, 22, 29

11, 18, 25

4.30 pm 5.00 pm

5.00 pm

5.00 pm

NCCS Tumour Board Meetings: Sarcoma Tumour Board Meeting General Surgery Tumour Board Meeting

Breast Tumour Board Meeting

Head & Neck Tumour Board Meeting

@ NCCS Level 2, Clinic C, Discussion Room

1 1

1

1

V. Kalai / Lim Shufen

6436 8924 / 6436 8283 [email protected] / [email protected] Lim Shufen / V Kalai

64368283 / 6436 8294 [email protected] / [email protected] V. Kalai / Lim Shufen

6436 8924 / 6436 8283 [email protected] / [email protected]

7, 14, 21, 28 12.00pm Lung Tumour Board Combine SGH-NCCS Meeting

@ SGH Blk 2 Level 1, Radiology Conference Room

1 Christina Lee Siok Cheng

6326 6095 [email protected]

6, 13, 20, 27 1.00pm Gynae-Oncology Tumour Board Meeting

@ NCCS Level 1, Clinic A, Discussion Room

1 Lim Shufen / V Kalai

64368283 / 6436 8294 [email protected] / [email protected]

6, 13, 20, 27 1.00pm Hepatobiliary Conference

@ NCCS Level 4, Lecture Hall

1 Lim Shufen / V Kalai

64368283 / 6436 8294 [email protected] / [email protected]

SEMINARS / FORUMS / TUMOUR BOARDS / SMC-CME ACTIVITIES

17SALUBRIS OCTOBER – DECEMBER 2013

Page 18: Salubris Oct - Dec 2013

DECEMBER 2013Date Time Event Information CME Pt Registration Contact

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

@ NCCS Level 2, Clinic C, Discussion Room

1 Tan Si Xuan / Rachel Tan

6436 8280 / 6436 8172 [email protected] / [email protected]

26 5.00pm NCCS Neuro Onco Tumour Board Meeting

@ NCCS Level 2, Clinic C, Discussion Room

1 Low Peak Wah / Ang Hui Lan

6436 8165 / 6436 8174 [email protected] / [email protected]

26 7.30am Endocrine and Rare Tumour Meeting

@ NCCS Level 2, Clinic C, Discussion Room

1 Tan Si Xuan / Rachel Tan

6436 8280 / 6436 8172 [email protected] / [email protected]

4, 11, 18

4, 11, 18

6, 13, 20, 27

2, 9, 16, 23, 30

4.30 pm

5.00 pm

5.00 pm

5.00 pm

NCCS Tumour Board Meetings:

Sarcoma Tumour Board Meeting

General Surgery Tumour Board Meeting

Breast Tumour Board Meeting

Head & Neck Tumour Board Meeting

@ NCCS Level 2, Clinic C, Discussion Room

1

1

1

1

V. Kalai / Lim Shufen

64368294 / 6436 8283 [email protected] / [email protected]

Lim Shufen / V Kalai

64368283 / 8294

[email protected] / nsokal @nccs.com.sg

V. Kalai / Lim Shufen

64368294 / 6436 8283 [email protected] / [email protected]

5, 12, 19, 26 12.00pm 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 1.00pm Gynae-Oncology Tumour Board Meeting

@ NCCS Level 1, Clinic A, Discussion Room

1 Lim Shufen / V Kalai

64368283 / 8294

[email protected] / nsokal @nccs.com.sg

4, 11, 18 1.00pm Hepatobiliary Conference

@ NCCS Level 4, Lecture Hall

1 Lim Shufen / V Kalai

64368283 / 6436 8294 [email protected] / [email protected]

SEMINARS / FORUMS / TUMOUR BOARDS / SMC-CME ACTIVITIES

18 SALUBRIS OCTOBER – DECEMBER 2013

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CELEBRATE 21 YEARS OF SUPPORTING CANCER RESEARCH. RUN FOR HOPE!BY ADELINE TEO AND HAZLIN HEPBUN

The two organising hotels are celebrating 21 years of supporting cancer research through the annual charity RUN FOR HOPE (RFH). It is the 6th year that the Four Seasons Hotel Singapore and Regent Singapore partner the National Cancer Centre Singapore (NCCS) are hosting the run.

T his year’s run seeks to raise $600,000 and set a new record for the Run for Cancer Research by achieving a target of 15,000

runners supporting the charitable cause.

“Since 2008, Four Seasons Hotel Singapore and Regent Singapore have partnered NCCS to raise awareness and funds for the NCC Research Fund and we’re proud to continue doing so,” said Mr Rizwan Shaikh, manager of Four Seasons Hotel Singapore.

He added, “Run For Hope is a meaningful event for the community to play a significant role in helping cancer patients, and at the same time enjoy a leisurely run through the picturesque Marina Bay area. We would like to encourage as many as possible to participate in this year’s run, whether individually, with families, friends, colleagues, associations, or clubs.”

Fundraising and registration efforts have already started. To date, over $3,800 has been raised by staff at both the hotels, and many more fundraising activities are planned leading up to the run. In August, three RFH ambassadors including two cancer survivors enthusiastically took up the challenge of getting 21 sign-ups for the run within one hour at Raffles Place.

They garnered almost 40 sign-ups within the time limit, doubling what we aimed for. A kind donor also gave $20,000 to NCC Research Fund as a reward for their effort. Together, we can achieve more!

Watch the fun and excitement of the Ambassadors’ Challenge on www.youtube.com/runforhopeSG.

“The Run for Hope has grown into a significant platform raising awareness and funds that go a long way to enabling NCCS researchers and clinician-scientists to carry out their remarkable work in cutting edge research highly relevant to our community,” said Dr Tan Hiang Khoon, Director for Division of Community Outreach and Philanthropy at NCCS.

Dr Tan emphasised, “In the last five years, about $20 million dollars have gone to fund more than 60 worthwhile cancer research projects aimed at cancers relevant to our community and benefiting patients through better treatment outcomes.

A number of them have grown into large-scale projects involving established research and medical institutions and winning internationally acclaimed accolades. Many patients are already benefiting from better outcomes made possible through research.”

Continued on page 20.

19SALUBRIS OCTOBER – DECEMBER 2013

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

Continued from page 19.

More than 10,000 are diagnosed with cancer every year in Singapore. Every day, 28 people here are diagnosed with cancer and 14 people die from it daily. This startling statistic underlines the magnitude of the cancer problem we need to battle. You can help by supporting the run. Spread the word or make a donation. Cancer research saves lives and gives hope to cancer patients. We can make a difference in the lives of those affected by cancer. Let’s make a brighter future, without cancer.

RUN FOR HOPE (10km / 3.5km) on 17 November 2013, Sunday, 7am at

The Promontory @ Marina Bay

Find out more at www.runforhope.sg/.

Like us on Facebook.com/RunForHopeSg or follow us on Twitter.com/RunForHopeSG for latest updates.

If you are missing this event, you can also make an online donation via www.sggives.org/NCCRF to support!

20 SALUBRIS OCTOBER – DECEMBER 2013

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 6283 www.nccs.com.sg

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 Editor

Ms Rachel Tan

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