salubris oct - dec 2014

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

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  • RESEARCH UNCOVERS NEW TOOLS TO HELP DIAGNOSE BREAST CANCER

    AN NCCS QUARTERLY PUBLICATION October December 2014

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

    ...HELPING R EADERS TO ACHIEVE GOOD HEALTH

    Issue No. 31 MICA (P) 140/03/2014

  • DISCOVERY OF FREQUENT GENE MUTATIONS IN BENIGN BREAST LUMPSBY DR LIM WENG KHONG Research Fellow Laboratory of Cancer Epigenome

    Fibroadenomas are the most common benign breast tumours found in women of reproductive age, affecting thousands of women in Singapore and millions worldwide annually.

    I t is frequently discovered in clinical workups for breast cancer diagnosis and during routine breast cancer screening. The challenge commonly faced by clinicians is distinguishing some fibroadenomas from breast cancer.

    Fibroadenomas are generally benign and harmless, though these common breast tumours may exhibit indeterminate clinical and radiological features which will require further studies to differentiate them from malignant tumours.

    Currently, the best way to confirm whether a patient has a fibroadenoma is to examine a tissue sample from the lesion under a microscope. While this form of examination is the gold standard in making a diagnosis, it is not always a straight forward process.

    To facilitate this diagnostic question, a multi-disciplinary team of scientists from the National Cancer Centre Singapore (NCCS), Duke-NUS Graduate Medical School Singapore, and Singapore General Hospital embarked on a study and the good news is that they may have found a way to do so.

    The team analysed all the protein-coding genes in a panel of fibroadenomas from Singapore patients and they have successfully identified frequent mutations in a gene called MED12 over a remarkable 60% of fibroadenomas.

    By measuring the presence of mutated MED12 in breast lumps, clinicians would be able to more confidently make a diagnosis of fibroadenoma, avoiding additional steps. This way, patients can avoid unnecessary surgery, reducing hospitalisation costs as well as relieving patients anxiety knowing the tumours are benign.

    The team hopes to produce a diagnostic gene test based on the research findings in the near future, and possibly a drug that targets the MED12 gene and resolves benign breast tumours.

    2 SALUBRIS OCTOBER DECEMBER 2014

  • Excised Fibroadenoma

    The findings have also deepened the conceptual understanding of how tumours can develop. Like most breast tumours including breast cancers, fibroadenomas consist of a mixed population of different cell types, called epithelial cells and stromal cells.

    However, unlike breast cancers where the genetic abnormalities arise from the epithelial cells, the scientists, using a technique called laser capture microdissection (LCM), showed that the pivotal MED12 mutations in fibroadenomas are also found in the stromal cells. Targeting such stromal cells may be an important avenue for therapy in the future as fibroadenomas and possibly other tumours may actually arise from genetic lesions in the stromal cells.

    The study also shed light on the cause of uterine fibroids, another common benign tumour in women where similar MED12 mutations have been observed and may attests to a role for abnormal response to female hormones in the birth of these tumours.

    The scientists are already planning on subsequent studies to explore more possibilities by investigating the role of MED12 in other categories of breast tumours and hope to develop a drug that may target the MED12 gene and cause the resolution of benign breast lumps in the near future.

    The study was published in Nature Genetics, August 2014.

    By measuring the presence of mutated MED12 in breast lumps, clinicians would be able to more confidently make a diagnosis of fibroadenoma, avoiding additional steps. This way, patients can avoid unnecessary surgery, reducing hospitalisation costs as well as relieving patients anxiety knowing the tumours are benign.

    Histopathology of Fibroadenoma (higher magnification)

    Histopathology of Fibroadenoma (low-power magnification)

    3SALUBRIS OCTOBER DECEMBER 2014

  • BREAST CANCER SURGERY IS SAFE FOR ELDERLY PATIENTSBY DR ONG KONG WEE, DR VERONIQUE TAN AND DR LEE CHEE MENG Division of Surgical Oncology

    Breast cancer is the top cancer among women in Singapore and an estimate of 1 in 16 Singaporean women will develop breast cancer by the age of 80. The life-time risk of women contracting breast cancer is approximately 6.5%. This incidence rate is expected to rise with increasing life expectancy and an ageing population.

    W hile there are several treatment options such as radiation therapy and chemotherapy, surgery remains the best option for early and advanced breast cancer. Treatment options outside of surgery would only control the disease. The cancer cells may develop resistance to these treatments over time and when patients require a salvage surgery, it may result in even more complications with lower success rate.

    With the concern on the effects of surgery on elderly women, a retrospective analysis was performed on 109 women aged 80 years and above who underwent surgery in National Cancer Centre Singapore and Singapore General Hospital from 2001 to 2010.

    Most patients were assessed to be fit for surgery under the American Society of Anesthesiologists (ASA) physical classification status with 75% of patients having an ASA physical status of 1 or 2 1. Although approximately 80% of patients had one to four co-existing medical problems such as hypertension, dyslipidaemia and diabetes mellitus, there were no deaths recorded following the breast surgery.

    Results show that 97% of elderly patients aged above 80 years recover without major complications after surgery.

    Surgery should always be considered

    even among elderly patients and performed

    expeditiously.

    DR ONG KONG WEE

    4 SALUBRIS OCTOBER DECEMBER 2014

  • PATIENT PROFILEMDM TAY SAI ENG 87 YEARS OLD

    From left to right: Mr David Cheng (caregiver and son of Mdm Tay), Mdm Tay Sai Eng, Dr Ong Kong Wee, Dr Veronique Tan, Dr Lee Chee Meng.

    More than 60% of patients recovered without any complications, while only 3% developed major complications but recovered subsequently. The average length of stay in the hospital was three days.

    The results of this study are important as they dispel the misconceptions and fear among the public that surgery for elderly patients is unsafe and has a high complication rate. Surgery is the most important modality in the treatment of breast cancer. It also relieves symptoms in patients who have tumours that do not respond to other therapies. Elderly patients should not be deprived of such treatment options.

    Early detection and effective treatment is very important. For elderly patients such as 87 years old Mdm Tay Sai Eng who was diagnosed with stage II breast cancer, she was given surgery despite having active medical conditions, and she is now cancer-free.

    The team plans to conduct further studies to measure the side effects and effectiveness between surgery and other forms of treatment on elderly patients compared to younger patients.

    1 American Society of Anesthesiologists (ASA) physical classification status is a universally accepted score used to assess a patients fitness for surgery. ASA Physical Status 1 refers to a normal healthy patient while Status 2 refers to a patient with mild systemic disease.

    https://www.asahq.org/clinical/physicalstatus.htm

    A mother of five, Mdm Tay was diagnosed with stage II breast cancer in November 2012. She had noticed a lump in her right breast but only decided to consult a doctor after a six-month lapse. Surgery was suggested as a viable treatment but she declined and requested for other treatment options instead. Her main concern was the safety of breast cancer surgery in view of her having pre-existing active medical conditions of diabetes (diet controlled), hypertension, hyperlipidemia and cervical spondylosis.

    Mdm Tay was then treated with a drug commonly used for early stage breast cancer about six months. Unfortunately her cancer cells did not respond well and she experienced multiple discomforts and side effects throughout the treatment. She was then referred to Dr Ong and her family members were immediately counselled on the possibility of having a breast surgery. With the confidence and advice from Dr Ong, Mdm Tay went ahead with the surgery despite mixed feelings within the family.

    The breast surgery was carried out in May 2013. Since then she has been followed up by the NCCS medical team on her condition. Apart from experiencing minor post operation issues, such as a Seroma (the build-up of clear bodily fluids in a place on your body where tissue has been removed by surgery; common after breast surgery), Mdm Tay has recovered well from the surgery.

    Life after breast cancer surgery has been fulfilling and she has resumed her painting and calligraphy sessions, watches her favourite dramas, and even finds the energy to occasionally cook some favourite dishes for her family. Mdm Tay said, I appreciate what NCCS specialists have done for me. They gave me hope and they gave me a new life. Every day I can look forward to the future, spending time with my family and friends.

    5SALUBRIS OCTOBER DECEMBER 2014

  • DOING GOOD BY WALKING DOWN MEMORY LANEBY SHAWN SOH Community Partnership

    NCCS has been a strong supporter of the Presidents Challenge since its inception in 2004. This year, more than $17,000 was raised during a 3-month fundraising campaign in support of the SingHealth Presidents Challenge 2014. The activities included pledge card donation drive, sale of