salubris - january / february 2011

AN NCCS BI-MONTHLY PUBLICATION January / February 2011

...HELPING READERS TO ACHIEVE GOOD HEALTHSalubris is a Latin word which means healthy, in good condition (body) and wholesome.

Issue No. 14 • MICA (P) 061/10/2010

SALUBRISJanuary / February 2011

PAGE A2

In Other Words RISING TO THE UNKNOWN

Two years of intense discussions and meetings before JCI Day came on 22 September 2010. It was the day that NCCS was subjected to the closest scrutiny ever in all its work flow and practices. External audits are especially

arduous, including the one conducted by the US-based Joint Commission International. The two female auditors are veterans in their own right, both coming with many years spent in the healthcare hospital environment.

They were here to see if NCCS could pass the scrutiny and join the ranks of other renowned organisations that had been recognised for having healthcare practices that ensure safety, confidentiality and quality healthcare for patients.

The auditors were very precised in what they wanted to see. They requested to be shown four perfect medical case notes, where all the information was properly recorded with no “gaps”. Earlier on they had spotted a few minor gaps in some of the notes and they had no intention of letting that pass.

Quick-thinking Dr Wee was also not letting his two years of hard work go down the drain. He ordered everyone to stay back, except for research staff, and retrieved the perfect case notes for the auditors. He was confident that NCCS case notes were up to par. Indeed he was proven right. The staff produced 18 case notes and eventually four were given to the auditors.

The rest as they say is history. NCCS became the first ambulatory cancer centre in Asia to be credited with an audit score of 98% for JCI accreditation.

Recounting that moment, Dr Wee felt very gratified by the tremendous support from the staff. “I am most grateful to all my NCCS colleagues for trusting me at that crucial moment – patiently “swatting mozzies” while waiting for further instructions. What that did was provide me with the mental space to think and strategise how to get the four perfect records,” he said.

National Cancer Centre Singapore is now the first ambulatory cancer centre to be JCI accredited in Asia. This was all thanks to Dr Joseph Wee who steered the staff and won their collective support that led to the centre’s accreditation. CHUA HWEE LENG finds out more about the man behind NCCS’ JCI success.

For our patients, the accreditation means that they can be further assured of high quality in patient assessment and treatment, improved clinician-patient and caregiver communication, patient privacy and confidentiality, and a safe environment from stringent infection control amongst many others.

Dr Wee acknowledged the hard work put in by each and everyone and especially those in what he calls his Quality Special Sub-committee.

“It is the middle managers who are really the true heroes – they are the ones that helped us clinch the 98%. NCCS is extremely fortunate that we have this group of die-hards; they are the ones that make NCCS hum.”

He thought the pass was secured through the skin of the teeth but it was by no means a reflection of how committed the staff was. “There were changes in the policies guidelines earlier this year and adjustments were needed. Considering this, I was glad we made it,” said Dr Wee.

The preparation had been carried out early. He was gathering his team the first instance he was appointed Chairman of the Steering Committee. His selection criteria were that his team had to be extremely competent and the members also had to complement him.


PAGE A3

In Other Words

Since then, whenever he travelled around the region, he would visit the ethnic minority museum of the region. In 2009, he also attended an archeological conference in Hanoi. That was the first time he met real life archeologists and convinced one of them who has a vast collection of skulls from south China to look for skull-base erosions, which was a classic hallmark of NPC (nasopharyngeal cancer).

All this “tomb-digging” adventure has indeed been an eye-opening experience for Dr Wee. He is now expanding his medical field to include anthropological perspectives. Since the interest sparked off, Dr Wee had published a paper titled “Is Nasopharyngeal Cancer really a Cantonese Cancer?” It combined historical, anthropological, archeological and linguistic knowledge as well as modern genetic signatures to hypothesise how the current enigmatic epidemiological pattern of nasopharyngeal cancer could have risen.

The NPC specialist explained, “There are many branches in archeology, including a fairly recent branch known as bio-archeology, whom someone described as being able to test the contents of your stomach and knowing what you have had for breakfast! There were also genetic studies of pigs from various parts of Islandic Southeast Asia, and from there migration patterns of humans were deduced (since pigs do not swim, they were most likely brought along by humans).

Even as a Deputy Director relatively new to management practices, his enquiring mind and leadership skills have brought new perspectives to many of the issues relevant to JCI.

Explaining why this was necessary, the radiation oncologist said, “I am a rather brash sort of chap, so my team had to have exquisite EQ and PR skills and be equally adept at handling anyone from senior management to their own colleagues to their subordinates.”

And everyone has worked well seamlessly.

Throughout the two years, there were many memorable moments that Dr Wee shared. He was pleased to find the doctors very much up to scratch, On one occasion, he was going through a particular casenote with a fine tooth-comb just to look for trouble and was glad no error could be found. That doctor had crossed every “T” and dotted all her “I”s.

His meticulous and precise ways had stemmed from his enquiring nature about events around him. That was also the root for his interest in social science.

Dr Wee, a senior consultant with the Department of Radiation Oncology, can now spend more time on his clinical specialisation and research and other interests.

Currently, he is into the pre-history, migration patterns and genetic anthropology of Southeast Asia. Southeast Asia has a very rich and diverse pre-history and what he hopes for is that his understanding of this historical perspective will help him to pin point the site of the genes involved in Nasopharyngeal Cancer (NPC).

His interest in this aspect of social science arose after he noticed that the Tinkling (“Bamboo Pole Dance”) – the National Dance of the Philippines, is also practiced by other ethnic groups in Southeast Asia – from Sabah to Indochina to south China and Hainan – all the way to northeast India – Assam region.

The connection struck him, “This similarity of material culture, when there was no YouTube, suggest that there was some form of contact or relations between all these different ethnic groups spread over such a vast area. What was also interesting was that all these groups had a fairly high incidence of Nasopharyngeal Cancer.”

Dr Joseph Wee receiving the report of accreditation from Ms Marlis Daerr, Surveyor, JCI.


PAGE A4

In Focus BIOMARKERS FOR BREAST CANCER TREATMENT

B iomarkers are substances produced by normal tissues in minute quantities and secreted in excess by cancers. They include circulating tumour products in bodily fluids as well as protein and genes expressed by cancer cells.

For the past 40 years, biomarkers had captured scientific and public attention and led to hopes that the above wish list may be fulfilled. Biomarkers can be classified by its utility — diagnostic, prognostic or predictive.

DIAGNOSTIC MARKERS address Wish 1. The best known diagnostic breast cancer markers include CA153 and CA27.29. Both tests detect a transmembrane glycoprotein which becomes overexpressed in breast cancer cells. However, CA153 has a sensitivity of only 9-38% for early disease detection and will thus miss majority of early breast cancers. Hence, they shall not be used as screening or diagnostic tools and the public shall not take a normal test to mean that there is no cancer. They can however be sometimes useful to monitor response to palliative chemotherapy in patients with advanced breast cancer.

PROGNOSTIC MARKERS address Wish 2. The most important treatment for early breast cancer is surgery but some patients still face recurrence after cancer. More recently, a test known as Oncotype Dx is used to express a panel of genes in breast cancer specimens. It helps to predict the risk of recurrence in women diagnosed with breast cancers which have not spread to lymph nodes and which are hormone receptor positive breast cancer. The expression level of several sets of genes in the tumour allows for the assignment of a recurrence score. A low recurrence score is associated with a ten year risk of relapse in organ site below ten per cent. Furthermore, the low score shows that patients will not benefit from combination adjuvant chemotherapy and hormonal therapy compared to hormone therapy alone.

A number of prognostic tests involving gene expression are under investigation, including Mammaprint and the Rotterdam signature.

Tumour expression levels of proteins such as urokinase plasminogen activator (uPA) and plasminogen activation inhibitor 1 (PAI-1) have also been measured to predict the risk of recurrence in early stage lymph node negative breast cancer. Low expression levels of the two proteins in tumour tissue is associated with low risk of recurrence. This assay requires fresh or frozen tumour tissue and may be affected by prior biopsy, and as such has not gained wide acceptance locally.

With the recent passing of the annual Breast Cancer Awareness Month and coming of the new year, it is perhaps timely to review a wish list that is common to breast cancer specialist doctors and patients coping with this condition.

1 We wish to be able to diagnose breast cancer at the earliest stage and detect recurrence before harm occurs.

2 We wish to be able to predict which patients will suffer a relapse after surgical treatment and thus require further adjuvant therapy. Similarly, we want to know

which patients are cured by surgery alone and spare them unnecessary treatment.

3 We wish to predict which treatment will benefit a patient and which will be futile, allowing personalised therapy.

PREDICTIVE BIOMARKERS address Wish 3. Estrogen/Progesterone receptors and HER2 are established markers found on breast cancer cells which strongly predict for response to hormonal therapy and anti-HER targeted therapy (such as trastuzumab and lapatinib) respectively. Intensive research efforts are underway globally to develop other markers which can predict response to commonly used chemotherapy agents with the hope of selecting the correct drug for the individual patient. Many candidate markers were tested in single arm studies from which definite conclusions on the predictive value of these markers cannot be drawn.

A promising area of biomarker research involves pharmacogenomics, which deals with the inheritance and genetics behind drug response and metabolism. A prominent example is the enzyme CYP2D6, which converts tamoxifen to its active metabolites endoxifen. Detection of genetic variants coding for this enzyme could identify patients with impaired activation and hence reduced response to tamoxifen, a commonly used drug used to treat early and advanced hormone receptor positive breast cancer.

As we bid 2010 farewell and step into the new year, we are still a distance away from fulfilling our biomarker wish list. The optimal utilisation of biomarkers may involve consideration of a panel of markers pertaining not just to the tumour, but also patient factors.

By Dr Wong Nan Soon Senior Consultant Department of Medical Oncology NCCS


PAGE B1

Looking Forward

Continued on page B2.

SEEKING A SECOND OPINION: LABORIOUS OR PRUDENT?

I am a 33 year-old male, recently diagnosed with a rare type of thyroid cancer. I first thought something was off when my voice sounded funny — like I was going through puberty again. “Vocal cord palsy”, the doctors called it. Before I knew it, I was getting a needle jabbed into my neck for “diagnosis”, getting a “CT scan”, and making an appointment with a surgeon. I was told that the cancer had spread to the lymph nodes of my neck and chest. The surgeon said I needed an operation called “thyroidectomy” (removal of thyroids). He said a feared complication was nerve injury causing a hoarse voice. The tumour had already done this, so no worries there, I guess. The operation proceeded without any major glitches. During my follow-up visit, the doctor said I still had cancer in lymph nodes of the neck and chest. He recommended that I get radiation treatment. Couldn’t they have removed those during surgery, I sheepishly inquired? “Radiation is good enough,” he said. Unsettled, I went home and although no more than a gut feeling, I couldn’t help but question the response. I enlisted the help of some friends, and started searching for an expert in the field. I found one. Fast-forward a few days. I was at a clinic that specialises in cancer. I felt calm but my hands were cold and my heart was racing. The visit was over soon enough. My “case” was then discussed in “tumour board”. They agreed that I needed another operation. Sometimes good enough is not good enough. I am only 33 years old. I deserve as good as it can get.

In May 2008, the late Senator Edward M. Kennedy of Massachusetts, USA, made headline news not for pioneering political

policies, but the disquieting revelation that he was diagnosed with a malignant brain tumour (glioma). The tumour was discovered when he suffered a seizure. He underwent a comprehensive diagnosis at Massachusetts General Hospital, one of the premier hospitals in North America. The tumour was deemed inoperable, and chemo- and radiation therapy were recommended.

Senator Kennedy was not your average patient. This is pure speculation but “whatever you say, doctor” was likely not in his medical vernacular. To tackle the glioma, consultants at MGH conferred their opinions. Kennedy’s response: to swiftly assemble a team of specialists from across the US. This cream-of-the-crop gathering, in person and via telecommunication, gave rise to differing views. The end result was the proposal of a seemingly aggressive yet viable alternative: surgical resection.

For most of us, it is redundant to highlight the impracticality of gathering a group of elite surgeons to deliberate over our medical problems. Many people, particularly those in developing countries or remote regions, do not have any medical access, let alone the luxury of choosing hospitals or doctors.


PAGE B2

Looking Forward SEEKING A SECOND OPINION: LABORIOUS OR PRUDENT?

Continued from page B1.

With information coming at us from left, right, and centre, what are we to do?

If you feel the need to seek a second opinion, you are not alone. To minimise “doctor shopping” and maximise the chance of best outcomes, however, try to direct your focus at a setting where:

1) a multidisciplinary approach to cancer care is par for the course; and

2) specialists exist with practice expertise in your area of concern.

In today’s medicine, practice may not make perfect, but for the time being, it brings us that much closer to “as good as it can get”.

By Dr Shiva Sarraf Yazdi Associate Consultant Department of Surgical Oncology NCCS

For those faced with complex cancer decisions and a semblance of a choice, it is not unreasonable, and at times even prudent, to seek another opinion. To do so does not equate to “doctor shopping”, remaining in denial of the diagnosis, and delaying an inevitable course that may at times be harrowing. As with any human endeavour, not every second opinion leads one down the right path. The second voice, rather than more experts, may simply be someone more skilled in selling an opinion. Our personal biases in seeking particular places or people, through word-of-mouth or self-directed research, may also limit our choices from the very beginning.

We seek second opinions for any number of reasons, but the ultimate goal is to find an optimally meaningful patient-doctor match. The latter is essential not only for patient satisfaction, but also compliance with subsequent therapy. At the crux of many failed patient-doctor relationship is the timeless line from the movie Cool Hand Luke (1967) starring Paul Newman: “What we’ve got here, is failure to communicate”.

One doctor’s input alone may portray only a partial view of potential options.

For example, a study of 2,647 women with breast cancer showed that their general surgeon discussed reconstructive options with only a third of them. Importantly, this absence of information heavily influenced the patients’ choice of subsequent surgical decisions. More than four times as many patients chose mastectomy (removal of the breast) over lumpectomy (removal of a portion of the breast) when they are aware of reconstructive options. Discussion of reconstructive options may not register on some general surgeons’ radar screen, whether from lack of expertise, experience, or awareness that it will influence patients’ decisions.

Senator Kennedy’s example is not an illustration of one doctor or institution’s superiority over another. It simply highlights that even amongst experts in an evidence conscious era, medicine as a science remains inexact. Making decisions is made all the more complex because as people, we are by nature subject to many whims, wishes, and worries. These can leave the playing field open to multi-pronged approaches to the same medical dilemma.

How then do we mitigate potential oversights in managing complex cancers?

One highly effective strategy is through multidisciplinary teams dedicated to cancer care. This approach extends the second opinion concept into the realm of healthcare providers. A multidisciplinary or “tumour board” setting allows multiple cancer specialists, from medical, surgical to radiation oncologist etc., to discuss patients’ queries and consternations.

Although not typical, the forum assembled to discuss Senator Kennedy’s treatment plan was a tumour board of sorts. Such a venue reassures all stakeholders that before reaching a consensus, complex facts, figures, and personal factors are considered. Especially when complications ensue, it becomes crucial for all to know that decisions were made with due deliberation. This is not a mere academic exercise. A study showed that in one year, more than half of patients whose cancers were discussed in a multidisciplinary environment had their surgical plans changed. This was because some part of their radiographic, pathologic, or clinical findings was re-interpreted at a multidisciplinary conference. It is alarming to imagine decisions that are left uncorrected in the absence of such forums.

One doctor’s input alone may portray only a partial view of potential options.


PAGE B3A FESTIVE CALORIE Tender Care

Another new year brings about an onslaught of promises, plans, and pleas to change personal practices. The list of resolutions is frequently topped by a pledge to change personal dietary habits. In the spirit of the season, there will be no advice or admonition in this column; only practical bits of information as you reach for that second piece of pie over the next few weeks...

Some of us don’t have enough time in the day to consume this amount of food, let alone to keep it all down.

But if we somehow follow this menu everyday for a few months while remaining inactive, aside from doubling our size, we will eventually be struck by diabetes and heart disease, and increase our chances of certain cancers.

This diet is an absurd example, you say. And you are right. It contains 10,000 calories, enough for five average sized men per day. It is also short on fruits and vegetables. However, this diet is not a mythical one: Michael Phelps, USA swimming championship fame, reportedly followed this menu everyday while training for his plentiful Olympic gold medals.

So how is such an extreme diet humanly possible?

In the case of extreme athletes who train vigorously for hours each day, their muscle content is vast compared to the fat, allowing them to burn off more calories by just sitting than most of us do walking our legs off. The key to a healthy weight is an appropriate balance between our body’s needs and calorie intake. Of the latter, neither too much nor too little is healthy. Our body needs a certain number of calories a day. When we ignore the need and take in lots of calories without physical activity, for example, we tend to become wobbly. That “wobble”, a highly unscientific term, is stored body fat.

Some of us confuse body fat with dietary fat. If we manage to avoid fatty foods, for example, we’d be slim and trim like Tiny Tim right? Not necessarily.

Dietary fat, or fat in food is not synonymous with unhealthy. In fact, our body needs a certain amount of fat to function, just as a car engine needs oil to run properly. Gram for gram, fat in food has more than twice the calories than carbohydrates and protein do. But eat plenty of the latter two, and the calories will add up sooner or later. Even fat-free food does not necessarily mean calorie-free or healthy, as it may be loaded with sugar which eventually turn into body fat as calories add up.

DON’T TRY THIS AT HOME BUT LET’S START WITH AN EXTREME DIET EXAMPLE:

• BREAKFAST Three fried egg sandwiches; cheese;

tomatoes; lettuce; fried onions; mayonnaise; three chocolate-chip pancakes; five-egg omelette; three sugar-coated slices of French toast; bowl of grits; two cups of coffee

• LUNCH Half-kilogram of enriched

pasta; two large ham and cheese sandwiches with mayonnaise on white bread; energy drinks

• DINNER Half-kilogram of pasta, with

carbonara sauce; large pizza; energy drinks

Continued on page B4.


PAGE B4

Tender Care A FESTIVE CALORIE

If you’ve fallen off the health bandwagon, and yearn for your image of the past, there is hope.

Extra calories can go away with exercise. As more studies pile up, monumental health benefits of regular physical activity become even more evident, regardless of an individual’s weight. The caveat here is that the more excess calories on board, the more aggressive an exercise regimen is needed to keep up. It is highly impractical to run four hours a day to make up for giant bags of potato chips washed down with coke. Frankly, anyone who can run that much knows better than to pile up empty calories devoid of nutritional benefit.

How can we keep ourselves from “pigging out” when we feel hungry enough to “eat a horse”, as the unsympathetic expressions go? As with most health-related issues, preventive strategies generally work best.

Some practical examples are: learning how to read nutrition labels, avoiding grocery shopping when hungry, avoiding buying unhealthy food, stocking up on fruits and vegetables, using smaller serving plates, waiting a magical 20 minutes before going for second helpings, and snacking properly.

Extra calories can go away with exercise. As more studies pile up, monumental health benefits of regular physical activity become even more evident, regardless of an individual’s weight. The caveat here is that the more excess calories on board, the more aggressive an exercise regimen is needed to keep up.

Simple. No?

Let’s elaborate on the last point, for example. Unlike popular belief, snacking in itself is not a bad habit.

In fact, to ruin the appetite with healthy snacks keeps us from becoming so hungry that by mealtime we eat for two. Success depends on the snack, however, and how much calories and nutritional benefit it generates. Frequent snacking with fruits, vegetables, and nuts, for example, can fill us up without contributing to a massive calorie count, not to mention the time-honored benefits of such ingredients. In between, water and tea can act as hydrating fillers but don’t fill up half the tea cup with sugar.

Disclaimer: Reading this paragraph selectively, i.e. replacing “healthy snack” with chips, cream, coke, candy, cookies, and cakes will only succeed in creating a larger than life version of ourselves.

To recap, we each have an appropriate daily allowance of calories based on size, age, metabolism, activity level, stress factors, etc. Perhaps the next time you reach for second and third helpings of what may potentially add to the “wobble” factor, ask yourself: how much of my allowance will this cost me? And is it worth it? If the latter answer is yes, by all means, enjoy!

By Dr Shiva Sarraf Yazdi Associate Consultant Department of Surgical Oncology NCCS

Continued from page B3.


PAGE B5

往前看征询第二意见：费劲还是谨慎？

我是一名33岁的男性，最近被诊断

出患有罕见的甲状腺癌。当我发现

声音变得怪怪的，好像回到了发育

期时，就已经感到不妥。医生说这

是“声带麻痹”。不久后，针筒刺进

我的脖子以助进行“诊断”，之后

是“电脑断层扫描”及同外科医生

预约问诊时间。

报告说癌细胞已扩散到我的脖子和胸部

的淋巴结。外科医生告诉我，我得动手

术切除甲状腺，并表示手术可能导致神

经损伤以致声音嘶哑。但既然我的声音

已经受到肿瘤影响，因此没什么好担心

的。手术顺利完成。复诊时，医生说我脖

子和胸部的淋巴结仍有癌细胞，建议我

接受放射治疗。我有点胆怯地问：难道不

能在手术时去除吗？医生说：“放射治疗

就足够了。”

我带着不安的心情回家，直觉上不禁质

疑医生的回应。在几个朋友的帮忙下，我

成功找到这方面的专家。几天后，我到了

这家专治癌症的诊所，心情虽然平静，但

双手是冰冷的，心也跳得很快。问诊很

快就结束了。“肿瘤委员会”讨论了我的

病情。委员会一致认为我须要再次动手

术。有时候，“足够”是“不够”的。我只

有33岁，我应该得到最好的治疗。

2008年5月，美国麻省已故参议员爱德

华· 肯尼迪成了头条新闻的主角，但不

是因为什么开拓性的政策，而是因为他

被确诊患有恶性脑胶质瘤。他是在一次

癫痫发作后发现肿瘤的。肯尼迪在北美

首屈一指的麻省综合医院进行全面诊

断，结论是：肿瘤无法通过手术切除，建

议采取化疗和放射治疗对付癌细胞。

肯尼迪参议员可不是普通的病患。这纯

属猜测，但肯尼迪在治病的过程中，不太

可能对医生的指示照单全收。麻省综合

医院的医生交换了意见后，向肯尼迪传

达了治疗脑胶质瘤的建议。肯尼迪的回

应是：迅速聚集来自美国各地的专科医

生，让精英医疗小组面对面或通过电信

提供不同的意见。最终的决定是采取看

似极具侵入性，但不失为可行的替代方

案：进行切除手术。

对大多数人而言，聚集医疗精英为我们

商讨治疗方案是不切实际的。许多人，

尤其是发展中国家或偏远地区的居民连

医疗设备都没有，更遑论享有选择医院

或医生的奢侈。

对癌症病人而言，在面对复杂的病情

或选择时，征询第二意见是无可厚非且

谨慎的做法。这么做并不等同于“选购

医生”、否定医生的诊断，或拖延痛苦

但又无可避免的过程。当然，不是所有

的第二意见都能带领您走上正确的道

路。这第二把声音不一定更专业，它或

许只是出自一个较具说服力的人的口。

我们也有可能因为他人的意见或自行

搜寻资料的影响而对某人或某个地方

带有偏见，使我们的选择一开始就受

到局限。

我们寻求第二意见的原因很多，但最终

目的是为了寻找最具意义的病人与医生

的组合。这样的组合不仅是为了让病人

满意，也符合后续治疗的要求。由保罗

纽曼主演的《铁窗喋血》(1967)中，有

一句经典台词说明了许多病人与医生关

系失败的主要原因，即“我们面对的是

沟通上的失败”。

一个医生的意见也许只呈现对所有备选

方案的片面看法。

例如，一个以2647名乳癌病人为对象的

研究报告显示，只有三分之一受访者的

普通外科医生曾与她们讨论乳房重塑的

选项。重要的是，这则讯息大大影响了

病人之后所选择的手术。超过四倍的病

人在知道可以进行乳房重塑后，都选择

切除整个乳房，而非进行局部切除手术。

一些普通外科医生可能因为专业知识和

经验不足，或是没有意识到这则讯息可

能会影响病人的决定，因此没有与病人

进行相关的讨论。

肯尼迪参议员的例子，不是说明某个医

生或机构较为优越的例证。这仅仅突显

了即使是身处在高证据意识时代的专

家，医学作为一门科学仍有其不精准。

每一个决定更因人的任性和忧虑变得更

加艰难。因此，情况相同的医疗困境，可

以有采取多管齐下办法的空间。

那么，我们要如何避免在面对复杂癌症时可能出现的疏漏？

一个非常有效的策略就是寻求致力于癌

症治疗的多学科医疗团队的协助，这样一

来也能向医护人员索取第二意见。多学科

或“肿瘤委员会”的设置允许来自肿瘤内

科、外科及放射治疗等领域的多个癌症专

家，一起讨论并解答病人的疑问及恐惧。

虽然不是典型的例子，但肯尼迪参议员

治疗方案的研讨会就类似肿瘤委员会。

这样的场合确保了所有相关者在达成共

识之前，已考虑过复杂的实际情况、数据

及个人因素。特别是发生并发症时，至关

重要的是所有人都清楚所做出的决定是

经过深思熟虑的。这不是一个单纯的学

术活动。有研究显示，在一年里，超过半

数在多学科环境中讨论病情的病人改变

了手术方案。这是因为在这些多学科会

议中，病人的部分X光片、病理或临床研

究获得重新诠释。试想想那些因没有经

过多学科会议讨论而无法获得纠正的决

定，是多么令人震惊。

面对排山倒海而来的讯息，我们该怎

么办？

不少人都会想要征询第二意见。

不过，为了减少“选购医生”及增

加取得最佳效果的几率，应尽量

集中在以下几个方面：

1）通过多学科方法提供癌症

护理；

2）在相关领域拥有实践经验的

专家。

在今日的医学界，多加练习未必能提供完

美的结果，但到目前为止，还是能让我们

更接近尽可能是最好的情况。

希瓦沙拉弗亚兹迪医生

副顾问医生肿瘤外科部门国立癌症中心


PAGE B6

温柔呵护佳节卡路里

新的一年的来临，人们难免再次立下一系列

想要完成的计划及改变个人行为的承诺，而名

列清单榜首的往往是改变个人的饮食习惯。此

时正值佳节氛围浓郁期间，本文不会提出任何

严苛的意见或训诫，而是提供一些实用的讯息，

供您在接下来几个星期“大开食戒”时参考…

首先，让我们举一个极端的饮食例子但读者千万别在家里尝试：

• 早餐三个煎蛋三文治；奶酪；番

茄；生菜；炒洋葱；蛋黄酱；三个巧克力烤薄饼；五个煎蛋；三片铺上糖衣的法式烤面包；一碗玉米糊；两杯咖啡

• 午餐半公斤的丰富意大利面食；两

大份在白面包上涂上蛋黄酱的火腿奶酪三文治；能量饮料

• 晚餐半公斤淋上干酪沙司的意大

利面；大比萨；能量饮料

有些人在一天内根本没有时间吃下这

么多食物，更别说将它加以消化了。不

过，如果我们真的连续几个月天天遵循

这个菜单，而且又没运动，那除了体重

倍增外，最终也会患上糖尿病和心脏病，

并增加患上某种癌症的风险。

您会认为这是个荒谬的饮食例子。没错，

这个菜单的热量多达1万卡路里，是五

个“中等”身材男子每日的摄取量。菜

单上也没有足够的水果和蔬菜。不过，

这样的菜单可不是天方夜谭。据说，在

奥运会上摘下多面金牌的美国泳坛巨

星迈克尔·费尔普斯进行培训时，就天

天按照上述菜单进食。

那么，人体是如何承受这么极端的饮食呢？

每天进行数小时严格训练的极端

运动员，肌肉含量远超于脂肪含量，

因此单单是坐着，所燃烧的热量就

比一般人走得累坏了还要多。保持

健康体重的关键在于适当地摄取身

体所需的热量。人体每天都需要一

定的热量，摄取太多或太少都是不

健康的。如果我们无视人体的需要，

在缺乏运动的情况下摄取大量的热

量，就会导致人体内储存的脂肪变

成赘肉。

有些人将人体脂肪和食物中的脂肪混

淆了。如果我们避免高脂肪食物，就能

拥有苗条的身材吗？未必。

食物中的脂肪并不同等于“不健康”。

实际上，人体需要一定的脂肪量才能

运作，就如汽车引擎需要汽油才能正

常行驶。食物脂肪的热量的确比碳水

化合物及蛋白质来得高。不过，如果大

量吸取后两者，热量迟早会囤积。即使

是不含脂肪的食物，也未必是零卡路里

或健康食品，因为它可能含有大量糖

分，随着热量的增加，最终在人体内转

变为脂肪。


PAGE B7

温柔呵护

当我们饿得可以“吞下一匹马”时，要如何阻止自

己“暴饮暴食”？就如大多数健康相关的课题，预防

往往胜于治疗。一些实际的例子包括：学习如何阅

读营养标签、避免在肚子饿的时候买菜、避免购买

不健康食品、多储存水果和蔬菜、使用较小的盘子、

在拿第二份食物之前先等待个神奇的20分钟，以及

适当地吃零食。

不简单？

让我们说明最后一点。不同于一般人的观念，吃零食本身并不是一个坏习惯。

实际上，在两餐之间吃健康的零食，能避免我们过于饥饿，在正餐时间吃得太

多。不过，成功与否还要取决于零食的热量和营养。例如：经常以水果、蔬菜和

坚果当零食，不单富有营养，还能在让我们有饱足感的同时，避免摄取过多的

热量。此外，在两餐之间也能以茶水补充水分，但千万别在茶中加入太多糖。

免责声明：选择性阅读此部分，即以薯片、奶油、可乐、糖果、饼干和蛋糕取代

“健康零食”，只会增加体重。

如果您之前舍弃了健康生活，如今渴望恢复过去的形象，

那不是没有希望的。只要经常运动，就可以燃烧多余的热

量。越来越多研究显示，无论体重，经常运动对人体健康

能够带来无数益处。值得注意的是，人体摄取的多余热量

越多，就需要越大的运动量来加以消耗。希望靠每天跑步

四小时燃烧好几大包薯片和可乐所含的热量是不切实际的。

不过话又说回来，能有如此运动量的人，也一般不会摄取

那么多没有营养的热量。

扼要重述，根据身形大小、

年龄、新陈代谢能力、活动

量、压力等因素，每个人每日

都必须摄取一定的热量。也

许当你再次想要多吃一、两

份食物，极可能制造赘肉之

前，可以问问自己：这要占据

我一天应该摄取的热量的多

少？值得吗？如果答案是肯

定的，那就尽情享用吧！

希瓦沙拉弗亚兹迪医生

副顾问医生肿瘤外科部门国立癌症中心


PAGE B8

Outreach UPCOMING PUBLIC EDUCATION ACTIVITIES / PROGRAMMES

Event Name Date, Time, Venue Registration Details

CancerWise Workshop –Understanding Liver, Stomach & Pancreatic CancersTOPICS:a. Common problems of the liver,

stomach & pancreasb. Risk factors, signs & symptomsc. Early detection & preventiond. Screening & diagnostic procedurese. Treatment optionsf. Questions & Answers

26 March 2011, Saturday

Talk will be in English.

1pm – Registration 1.30pm to 4pm – Workshop

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

Admission fee: $5

To register, please call: 6225 5655 or online: www.nccs.com.sg (click events).

CancerWise Workshop –Basics of Cancer Part 1TOPICS:a. What is cancer?b. How does cancer spread?c. What causes cancer?d. Risk, signs & symptomse. Prevention & screeningf. What are Cancer Tumour Markers?g. Common Types of Tumour Markersh. How are Tumour Markers used?i. Questions & Answers

2 April 2011, Saturday




Admission fee: $5


CancerWise Workshop –Basics of Cancer Part 2TOPICS:a. Diagnosing cancerb. What is cancer staging & grouping?c. The common elements of staging systemsd. Cancer treatments options e. New development in cancer treatments f. Questions & Answers





Admission fee: $5


CancerWise Workshop –Nasopharyngeal CancerTOPICS:a. Common nasal problemsb. What is NPC?c. Causes of NPCd. How does NPC develop?e. Risk Factors, Signs & Symptomsf. Early Detection & Screeningg. Diagnosis & Treatmenth. Questions & Answers





Admission fee: $5


Information is correct at date of printing.


PAGE A5

PeopleSELF-TALK, TALK TO YOUR CELLSCancer survivor Ezzy Wang shares how he stays positive

Despite being well-prepared for the winter games, the biting cold weather was not something Singaporeans were attuned, especially when the thermometer read a low of 2-5 degree Celsius. Even Guangzhou was not accustomed to

such bitter cold and it was the city’s coldest day in 30 years. As Ezzy found out, even wearing three pairs of gloves could not prevent his fingers from turning numb.

Ezzy was one of the two hand-cyclists representing Singapore at the Asian Para Games’ Road Cycling Competition.

Despite the odds, he did relatively well in the trials with keen competition coming from a fellow Singaporean and six other hand-cyclists from Japan, Korea, China and Lebanon. It pushed him to clock a personal best timing of 32.44 minutes doing 13.6km.

On the actual race day, the weather was much kinder, at a cool 14 degree Celsius with a clear blue sky. Ezzy was positioned 6th.

Though he returned without a trophy or medal, 44-year-old Ezzy took it in his stride. He saw it as an invaluable experience being in the Games Village. Looking at other athletes including some who lost their sight or other limbs, he realised that he was better off in many ways. He still has one leg and is able to do many more things that others cannot. After the trip his wife told him, “Dear, if you do have a disadvantage, you’re certainly not showing it.”

In fact, with his positive demeanour, it is easy to overlook the fact that Ezzy has only one leg. He was first diagnosed with “synovial chondromatasis”, a mass disorder of the pelvis due to leakage of bone calcium. Unfortunately, the condition mutated to a rare bone cancer called “chondrosarcoma of the pelvis”. Ezzy had to remove his right pelvis which seemed fine for three years before he suffered a relapse. This time he had his entire right leg amputated.

For many, amputation may be one of the hardest decisions they will ever have to make. But for Ezzy, there was only going to be one outcome. He said, “I know it has to be done as no treatment is 100 per cent foolproof. I have the utmost confidence in my surgeons’ decisions.”

Eleven years hence, Ezzy not only drives to work but he gives his wife a ride to her office. He also finds the time to exercise daily.

He believes that nothing is impossible. Although he can no longer participate in track and field sports or play basketball (because he does not want to be in a wheelchair), he had successfully attained a scuba diving certificate.

“I just have to think of sports that will suit me,” he said matter-of-factly.

Now, he cycles every day, with his hands. Ezzy would like to participate in the next Asia Para Games again, in celebration of the “can do” spirit.

He has this advice to fellow cancer survivors, “Think positive, be positive. There is a relationship between your mind and your cells. Your cells in your body will react based on your thinking.”

By Chua Hwee Leng

Guangzhou, 16-17 Dec – The sudden cold snap was an additional challenge that Ezzy Wang had to contend with during the inaugural Asian Para Games.


PAGE A6

Community

The singers and musicians certainly brought smiles to the audience, some of whom also clapped and

sang with the performers.

First to spread the Christmas joy was Ms Corrine Gibbons and her choir of amateur but talented singers on 8th Dec. Together with John Hamilton, Rob White, Sumitra Pasupathy, Kevin Hardy, Nina Pillai, Bojan Tercon, Louise Parr and Zoe Johnson, several of whom took time off from work, they were here to do their bit for the patients. Formed just weeks prior to the show, their vocal chords captivated the appreciative audience.

“The performance was very good and lightened up the whole atmosphere,” commented Madam Kum, an NCCS patient.

The following day, the NCCS public area was engulfed by the angelic voices of students from St Hilda’s Secondary School. Under the baton of music director Ms Joanna Paul, they charmed the waiting patients and staff alike.

SINGING AWAY THE BLUES…

What better way to celebrate the season to be jolly than a rousing entertainment for the patients and staff at the National Cancer Centre Singapore in the last two weeks to Christmas.

Ms Paul, who has spent 32 years teaching and performing music as well as conducting, played the electric organ, while her students sang traditional Christmas songs.

The third performance on 16th Dec was by students from the Singapore American School who arrived in green and red – colours of Christmas. The 14 students formed a mini-orchestra that consisted of choral singers, violinists, clarinetists and flutists. The group also performed at the Morning Glory Suite to cheer the patients who were receiving chemotherapy. This performance was arranged by student Preeti Varathan. The 17-year-old had months earlier held a solo Carnatic violin concert in New York to raise funds for NCCS research projects.

Said a patient who caught one of the performances, “Christmas is the season of sharing, giving, caroling and caring. It is nice that I get to enjoy the Christmas mood despite being in a hospital.” He left with a smile.

By Mark Ko


PAGE A7

CommunityLIVING LIFE TO THE FULLEST

Instead of the usual formal setting, there was mirth and laughter at the NCCS patient waiting area when it turned into

a party venue on 18th December 2010. On hand were 172 cancer survivors, caregivers and staff from NCCS patient support groups. It was time to celebrate 2010 and to welcome the New Year.

The gathering which included food, performances and lucky draws, was an important event for many friends to catch up with one another. It was here that they shared their many experiences and showed just how far they had come since they were first diagnosed with cancer.

It was a sight to behold to see so many survivors whose presence was testimony of the good work done by NCCS doctors.

HERE’S A SAMPLE OF WHAT THE SURVIVORS HAD TO SAY:

“The Exhibition Corner was a new item in the year end party this year. We wanted to showcase the creative talent of our members in addition to the usual party fare of food and lucky draw. Members who visited the Corner were impressed with the painting, handicraft, poems and deco arrangement, and many expressed their wish to join the classes to learn the art of making them. Yes, this is our ultimate aim – that members are motivated to discover the joy of immersing in art and craft, living life to the fullest, despite cancer.”

– WAI CHENG

“It was a party organised by the survivors for the survivors in an atmosphere filled with the spirit of fun and teamwork. It all goes to show that despite cancer we are all able to continue to lead a full and happy life.”

– T.C.

“We celebrated another year of our survival by having fun and showcasing our artistic and musical talents through dance and song. I think it was the bonding with fellow survivors and the networking across the support groups that I appreciated most amidst the revelry.”

– LAI ORE

“I was particularly touched by a patient I had invited. He and his wife, in spite of being held back by unforeseen as well as difficult circumstances, turned up at the end of the party to thank me. He was comforted to learn from the massive turnout that there were many others like him.”

– MERLE

By Chua Hwee Leng


PAGE A8

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

Editorial Advisors Dr Kon Oi Lian Prof Soo Khee Chee

Executive Editors Ms Chua Hwee Leng Ms Veronica Lee Mr Sunny Wee

Contributing Editor Dr Wong Nan Soon

Members, Editorial Board Mr Mark Ko Ms Sharon Leow Mr Joshua Tan Dr Shiva Sarraf-YazdiMs Flora Yong

Medical Editor Dr Richard Yeo

Members, Medical Editorial Board Ms Lita Chew Dr Mohd Farid Dr Melissa Teo Dr Teo Tze Hern Dr Deborah Watkinson

Cover Illustration: Roy Foo

NCC Foundation MANY HELPING HANDS

Christmas is always a busy time for many people, but some were looking for more meaning in their holiday. That was what some 89 people did last Christmas when they answered NCCS Foundation’s call for volunteers to help

with gift wrapping to raise funds for cancer research at both Borders Bookstores from 10am to 10pm daily.

From 26 Nov to 24 Dec, NCCS and Borders Bookstore worked together to raise the much needed funds for cancer research in their first collaboration. Patients and survivors also chipped in by allowing their artwork to be printed on gift cards which sold for a minimum of $1 donation to NCC Research Fund. NCCS staff from the Research departments, Human Resource, Department of Radiation Oncology, Healthcare Performance Office, Service Quality Management Unit and Corporate Communications also volunteered their time over weekends and after work hours to wrap gifts for customers at Borders.

After countless paper cuts on their fingers, sore and tired feet from many hours of standing and acceding to the demands of customers, the volunteers raised $10,053 for cancer research. Between the two Borders stores, the volunteers wrapped more than 15,000 books and other gifts. A BIG THANK YOU, to all the volunteers and Borders staff who have helped in this meaningful project.

“Successful people are always looking for opportunities to help others. Unsuccessful people are always asking “What's in it for me?” BRIAN TRACY

We all lead such busy lives whether we are working a full time position, married or dating, taking care of the kids or going to school. Our lives feel complicated and rushed, sometimes not even being able to keep our heads on straight to look forward to what lies ahead of us.

It is not difficult for many people to give back to the community; they open their checkbook, write a dollar amount and sign it over to the charity of their choice. They give annually because they know their money can help. However, charities do not live by money alone; they need the help of volunteers.

Barbara Bush once said, “Giving frees us from the familiar territory of our own needs by opening our mind to the unexplained worlds occupied by the needs of others.”

Giving should be a way of life. Giving makes you part of a community. You see the world for what it really is, and you become aware of problems plaguing our society you may not have been aware of.

By Flora Yong Manager Community Partnerships and Fund Raising, NCCS

salubris - january / february 2011

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