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Issue No. 17 • MICA (P) 061/10/2010

AN NCCS BI-MONTHLY PUBLICATION July / August 2011

...HELPING R E A DERS TO ACHIEV E GOOD HE A LTH Salubris is a Latin word which means healthy, in good condition (body) and wholesome.

ART EXHIBITION FOR CHARITY – ELEMENTS FROM THE SOUL


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In Other Words

SALUBRIS

July / August 2011

NCCS DOCTORS OFFER NEW INSIGHTS ON CANCER AT ASCO MEETING

Our oncologists presented eight research abstracts at the meeting in Chicago, USA after stringent review by the committee. CHARISSA ENG reports on the highlights. Dr Richard Quek and Dr Mohd Farid at the ASCO general poster session.

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ne of the missions of National Cancer Centre Singapore (NCCS) is to “conduct cutting-edge clinical and translational research”. It was in this frame of mind that NCCS doctors have always strived to be at the forefront of cancer research so as to improve clinical care towards their patients. These efforts paid off when teams of NCCS Medical Oncologists were selected to present their research at the ASCO Annual Meeting.

The American Society of Clinical

The ASCO meeting is a premier educational and scientific event in the oncology community with more than 30,000 cancer specialists gathered together to discuss the latest innovations in research, quality, practice and technology in cancer. The research findings presented are from eight different projects by NCCS and they span across the continuum of cancer care.

Cancer Research recognised the

In Diagnostics, Dr Ravindran Kanesvaran used a simple bedside test, a handgrip test together with comprehensive geriatric assessment tools to evaluate how the elderly cope with cancer and its treatment. This is a particularly pertinent issue and has nationwide implications given the problem of an ageing population in Singapore. In another study involving more than 500 patient samples collected from six cancer centres worldwide, Dr Iain Tan used advanced genetic techniques to accurately classify different types of stomach cancer, leading to more precise estimates of patient prognosis. This project was selected to receive the ASCO Merit Award. In Patient Outcomes Research, Dr Richard Quek and Dr Mohd Farid detailed the clinical outcomes for patients with sarcoma, a fairly uncommon form of cancer. Dr Yap Yoon Sin evaluated the use of existing targeted therapies in breast cancer patients whose disease had spread to the brain while Dr Tham Chee Kian evaluated the effect of combining chemotherapy with radiation therapy in an uncommon form of cancer that originates from the brain. Last but not least, in Novel Therapeutics and Drug Development, Dr Tan Eng Huat described an early phase clinical trial employing a unique strategy of adding a new therapeutic antibody to an established oral targeted drug to overcome drug resistance in patients with advanced lung cancer. Dr David Tai described an upcoming trial that will be the first worldwide to employ a new “targeted” drug in the treatment of stomach and colon cancer.

Oncology (ASCO) was founded in 1964 when members of the American Association of need to create a special group dedicated to clinical oncology. Since then, their aim has been to focus on conducting cancer research. ASCO holds annual meetings where they attract thousands of abstracts each year representing the latest research in areas of cancer prevention, diagnosis and treatment. The ASCO Special Awards are given to recognise individuals or organisations that have made significant contributions to ASCO, the practice of clinical oncology and cancer patients. These awards are presented during their Annual Meeting.


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In Other Words

SALUBRIS

July / August 2011

These presentations and the conferment of the ASCO Merit Award will indeed encourage NCCS doctors in knowing that their works are well recognised by their peers internationally. It also expanded the Centre’s international presence. A humble Dr Iain Tan, who was conferred his first Merit Award, said, “All these would not have been possible without the collective effort on multiple fronts.” A/Prof Patrick Tan, Principal Investigator of the Laboratory of Molecular Development at NCCS who supervises Dr Tan’s research, was full of praise for his young clinician researcher. Dr Iain Tan He said, "Iain is a superb candidate for the ASCO Merit Award. His work is cutting edge, clinically impactful and balances high quality clinical expertise with the latest genomic technologies. Importantly, beyond his own research, Iain is a very good collaborator and is always willing to help others in the laboratory. He is a wonderful example of a home-grown clinician scientist, doing work that is competitive on the world stage.”

HERE’S A CLOSER LOOK AT SOME OF THE PROJECTS… Prognostic Factors in Leiomyosarcoma: Does Primary Site Influence Outcome? The truth about Sarcomas is that they are rare cancers. This makes Dr Mohd Farid’s study a crucial one because many may still be unclear about the disease. Research more often than not leads to greater knowledge to better fight the disease. Sarcomas are aggressive tumours that comprise one percent of all malignancies. They arise from an embryologically primitive tissue subtype known as mesoderm, and can affect a large variety of tissues and organs in the body. Leiomyosarcomas (LMS) are sarcomas of the smooth (involuntary) muscle and they comprise 25 percent of sarcomas. LMS that arise from the uterus, or uterine LMS (uLMS), comprise more than half of all LMS. LMS that arise from outside the uterus are thus known as extra-uterine LMS (euLMS). What Dr Farid aimed to find out from his study was whether there are indeed differences in clinical outcomes and treatment responses between uLMS and euLMS. Although approximately 60 percent of uLMS are diagnosed in the early stages, most patients develop disease relapse and more than two-thirds of them would have succumbed to the disease within five years of diagnosis. In advanced cases, patients would only survive for less than one year. Dr Farid started his study by reviewing data from the NCCS Sarcoma registry to evaluate the disease‘s natural history, treatment modalities and responses, and clinical outcomes. The results that he presented at the ASCO Annual Meeting showed that there is a clear difference in outcomes favouring patients treated for earlier stages of the disease, highlighting the importance of early detection and access to treatment. While some clinical differences exist between uLMS and euLMS, the evidence for differing responses to treatment remains inconclusive at this stage. The main point that Dr Farid wants to get across is that it is important to get evaluated early on in the course of the disease. Women who develop abnormal patterns of uterine bleeding, pressure or pain in the abdomen or pelvis and abnormal vaginal discharge should have these symptoms promptly evaluated.

Comparing the Classification Precision and Prognostic Performance of an Intrinsic Gastric Cancer Signature with Existing Genomic Signatures in Six Independent Datasets Currently, Gastric cancer is the third most common cancer in males in Singapore and the fifth most common cancer among females in Singapore. The rates of incidence of Gastric cancer in Asia are among the highest in the world even though there is a decreasing trend. To classify Gastric cancer and provide prognostic information, several gene expression signatures have been proposed. These signatures are largely developed from supervised approaches based on histology, peritoneal or lymph node metastases. However, there are major disadvantages of these approaches. To overcome them, Dr Iain Tan focused on a diverse panel of Gastric cancer cell lines and hypothesised that any genomic differences detected in cell lines should be by nature tumourcentric and thereby ‘intrinsic’ to the underlying biology of the Gastric cancer cell. Using more than 500 patient samples from six cancer centres worldwide and applying advanced genetic techniques, Dr Tan is able to accurately classify different types of stomach cancer. Dr Tan explained, “This work is still in early development. We seek to classify patients with stomach cancer more precisely so that we can more accurately predict their prognosis, understand the biological basis for developing each type of cancer and tailor treatment strategies to the biological characteristics of the cancer.” Continued on page A8.


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In Focus

SALUBRIS

July / August 2011

WHERE EAST MEETS WEST: CLINICAL TREATMENT AND RESEARCH

“I think it has filtered down to the rest of the institution both in terms of providing holistic patient care and also in conducting cutting-edge research. It is impressive to know that NCCS itself manages up to 70 per cent of the cancer population and it has a good integrated oncology care set up here that rivals the best comprehensive cancer centres in US,” he added.

The bar has been raised for the treatment of Lymphoma cancer with the return of Dr Kevin Tay from USA. VERONICA LEE speaks to the doctor about his aspirations for the sub-specialty.

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s a medical officer while on a six-month rotation at NCCS, Dr Kevin Tay gained a deeper insight into the advances in the field. He became intrigued by the enigmatic complexities of lymphoma, a malignancy of lymphoid cells of the immune system that often astounds with the variety of its clinical presentation.

As a volunteer doctor working with hospice patients, he drew lessons from them. “They not only became my teachers in life but also left an indelible mark. Such is the strength of the human spirit, with a propensity to find joy in times of adversity which never ceases to amaze me,” he said. This experience spurred him on his journey to become an oncologist after completing his basic specialist training in internal medicine in Singapore. After completing his residency training in internal medicine at the University of Hawaii, he was appointed as Chief Resident in internal medicine. Soon he was selected to be a clinical associate at the National Cancer Institute (NCI) in Bethesda, where he completed a fellowship in medical oncology.

During that time, where he received his training in hematology and oncology, he was part of a leading multidisciplinary research group investigating new therapies for lymphoma, with a focus on understanding cell signaling and tumour microenvironment interactions in aggressive lymphomas. Describing his eight-year experience in the US, he said, “The culture of learning and research is very evident in the daily life and in the quality of their work. They work hard and also play hard, finding time for family and loved ones. One of the things that impressed me the most from those I had worked with was that they never stop wanting to learn. That in itself spurs them on.” “As cliché as it may sound, it is truly the journey rather than the destination that inspires the best in us. They do what they do day in and day out purely because they enjoy and love what they do and it is not just a job.” Since returning to Singapore and joining NCCS a year ago, he noted that the Centre has improved by leaps and bounds since its inception. “Much credit goes to Prof Soo Khee Chee and the team who has provided a clear vision of what NCCS should stand for.”

Dr Tay is part of the NCCS Lymphoma Study Group formed to advance understanding of lymphomas in the Asian setting. It comprises senior scientists and physicians from the Departments of Medical Oncology, Radiation Oncology, Pathology, Laboratory Science and Epidemiology on the Outram campus. The Group is currently studying a whole range of issues on multiple fronts. One such project involves the scientific study of T-cell lymphoma, a relatively rare subtype of lymphoma that may have a relative predilection for Asians. Using the latest molecular profiling techniques, the group is studying the genetic profiles of these lymphomas with the hope to find patterns that may lead to the identification of important “biomarkers”, substances used as indicator of biological states to determine processes involving disease or clinical responses so that clinical outcome and effectiveness can be assessed.

Dr Tay is sanguine about the future of lymphoma care and treatment in Singapore. “I am very fortunate to work every day toward a collective goal that cancer will one day not be the feared diagnosis that it is today. With advancements made in our knowledge of the mechanisms driving the development of lymphoma, I believe we are on the threshold of altering the course of this disease for our patients, young and old alike.”


A PRIMER ON ECONOMIC EVALUATION OF HEALTHCARE INTERVENTIONS

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Under The Microscope

SALUBRIS

July / August 2011

By Dr Raymond Ng Senior Consultant Department of Medical Oncology NCCS

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e live in a world in which there are infinite healthcare needs and wants but only finite resources and funding. As such, appropriate economic evaluation of healthcare interventions is paramount to ensure that one adopts not only the most clinically appropriate treatment/programme available but also the most cost effective option by comparing their relative efficiencies. Unfortunately, economic evaluation of healthcare is often regarded as a means to rationing and therefore limiting one’s access to choice. However, to disregard the economic element in clinical decisions will ultimately generate wastefulness and unethical practice. Rapid advances in medicine and technology have also significantly outpaced one’s ability to pay for the spiralling healthcare costs throughout the world and this is no different in Singapore. Coupled with a rapidly ageing population, economic evaluation of healthcare needs is now more than ever an essential component of decision making for health policy makers in formulating healthcare strategy. Appropriately implemented economic appraisal helps one to choose the most favourable alternatives for resource use (allocative efficiency), to maximise service outputs with minimum resource inputs (technical efficiency) and to maximise benefit or effectiveness in outcomes with minimum costs (cost effectiveness). Several methods of economic evaluation exist, the most common ones being cost effectiveness analysis (CEA) and cost utility analysis (CUA).

COST EFFECTIVENESS ANALYSIS (CEA) CEA is an economic study design in which consequences of different interventions are measured using a single outcome e.g. life-years gained, cases detected or heart attacks avoided with respect to the costs involved. The result is a cost effectiveness ratio, expressed as cost per outcome (e.g. dollars per life year gained) that can be compared across various types of independent services and placed in a rank order.

Cost effectiveness Ratio = Cost of intervention/Health effects produced (e.g. life-years gained)

For example, in an economic analysis study of adjuvant chemotherapy for early lung cancer, the cost-effectiveness ratio of vinorelbine and cisplatin chemotherapy compared to no treatment was $7,175 Canadian dollars per life year gained. This represents a highly cost effective treatment that compares very favourably with other standard health care interventions. Contrast this with another study comparing with the use of erlotinib (an oral anti-cancer agent) in advanced lung cancer to no treatment, the cost-effectiveness ratio for erlotinib treatment was $94,638 Canadian dollars per life-year gained, a value that may be considered marginally effective.

Hence the lower the cost effectiveness ratio, the more cost effective it is. In general, CEA is appealing to those in public health in deciding on resource allocation with the guiding principle that limited resources available for health should be used so as to maximise the health benefits for the general population. Continued on page C2.


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Under The Microscope

SALUBRIS

July / August 2011

A PRIMER ON ECONOMIC EVALUATION OF HEALTHCARE INTERVENTIONS

Continued from page C1.

In calculation of CEA, measurement of the costs may include not only the direct costs (e.g. costs of the intervention programme such as drugs, wages, rent and subsidies) but also indirect costs such as productivity losses (work absence), time costs (travel, waiting etc) as well as intangible costs such as side effects, pain and suffering.

It is important to note that being cost effective does not necessarily equate to cost saving and similarly, just because an intervention saves money does not also mean that it is cost-effective.

For example, if one compares a very serious but relatively uncommon disease such as meningitis with the much less serious but much more common disease like chickenpox, CEA will tend to favour the latter in comparison of vaccination programmes. As such, cost effectiveness is only one of a number of criteria that should be employed for policy makers in deciding which interventions should be adopted. One also must take into account total cost and whether an intervention is affordable and the capacity of the system to deliver it. It is also imperative that considerations also be given to equity, justice, needs and priorities of the population involved as these qualities cannot be taken in account of in existing economic analysis tools.

COST UTILITY ANALYSIS (CUA)

CONCLUSION

Often, one may have to decide between different interventions for the same condition i.e. one may be interested in what additional gains can be achieved from the new therapeutic intervention but at how much greater cost? This can be calculated by the incremental cost effectiveness ratio (ICER). This compares the difference in costs in terms of difference in health outcomes between the interventions. For example, if one were to consider introducing a new therapeutic drug (T1) that is more effective but also more costly than the current drug (T2), the ICER is calculated as follows:

ICER = Cost of T1-T2/Survival of T1-T2 (Measured in terms of $Cost/life year gained)

In CUA, the outcome measure is expressed as quality adjusted life year gained (QALY), rather than life year gained as in CEA. This allows health to be measured as a combination of the duration of life and the health-related quality of life (HRQoL). HRQoL may be calculated on a preference scale from 0 (as bad as death) to 1 (best imaginable health). Hence, if the life year gained from a particular drug is 1 year but the HRQoL for the duration of life year gained is rated as 0.5, then the actual QALY gained will only be 6 months. Implicit in CUA is the appreciation that any intervention may result in change in HRQoL and CUA allows one to capture the value of improvements in both morbidity and mortality as well as patients’ preferences. The use of CUA also allows policy makers to use QALYs as a common currency to compare the value of interventions across the full range of different healthcare activities.

SHORTCOMINGS OF ECONOMIC EVALUATION The concept of cost effectiveness is a value judgment. What one considers cost effective may not necessarily be so for the next person. Ethical and political issues aside, most health providers in developed countries generally consider US$20,000 to $100,000/life year gained to be an economically reasonable value for the provision of health intervention. However, for many in developing countries, such a threshold is often sadly not feasible. An additional shortfall of CEA is that it will often give higher priority to preventing the high incidence/low individual burden disease than to preventing the low incidence/ high individual burden disease. While this fits with the goal of seeking to maximise a population’s health, it ignores how benefits and costs of prevention programs are distributed to different individuals or groups.

With a rapidly ageing population and spiraling healthcare costs, health policy makers are increasingly faced with the difficult task of fair and appropriate resource allocation. Economic evaluation is a vital part of decision making in ensuring that limited resources available for health should be used so as to maximise the health benefits for the population.


KNOW BEFORE WHOM YOU STAND – NARRATIVES IN THE DECISION MAKING PROCESS

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Spotlight

SALUBRIS

July / August 2011

By Dr Lalit Kumar Senior Consultant Department of Palliative Medicine NCCS

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s I stood with David marveling at the study, the massive library filled with the great works, tomes of poetry and a jaw dropping number of first editions, it dawned on me how little I knew of Jeremy. The three books on poetry he had written and the assortment of short stories were not what I had envisaged of the man that had been my patient these last few months. Indeed he had remarked on more than one occasion that he was ‘merely a husk’ of the man he once was. I had given credence to this comment but now in hindsight, in front of a picture of him in all his glory standing next to a jazz icon with a trumpet in his hand, maybe I hadn’t done enough. Continued on page C4.


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Spotlight

SALUBRIS

July / August 2011

KNOW BEFORE WHOM YOU STAND – NARRATIVES IN THE DECISION MAKING PROCESS

Continued from page C1.

Neither David nor I had fully grasped the person behind the unassuming smile and gentle grace that was Jeremy. Yet we were his physicians. David was an excellent GP, one I had come to trust and one who took pride in knowing and caring for his patients. Indeed, he prided himself on his encyclopedic knowledge of his patients yet here he was, bemused. David had referred Jeremy to me not long after it was decided that he had ‘stared intently into the contents of one too many bags of chemotherapy’. His cancer wasn’t responding and whilst trials were offered, Marie felt that he had had enough. Quality of life was his desire but pain remained a problem.

Too often as we decide

I met Jeremy some months back and had been reviewing his progress both at the clinic and later on when he was too ill, at home. Yet I had never wandered beyond the sitting room where he regularly held court. Looking at the collection of CDs and a hi-fi system that would make most enthusiasts green with envy, I could envisage him sitting by the bay doors, looking out into his lovely garden and manicured lawn with Miles for company.

the patient. Too often

We saw now the reasons why he had held so strongly to have his treatment stopped, his medications rationalised and his painkillers reduced. His vehemence at wanting to go home, defying the wishes of family and physicians became clear as Marie read aloud his last entry in his journal. As he put it, he had come home to make peace with the man that he was. We hadn’t known the suffering he saw in the ‘troubles’ and the torture that he endured in the hands of his captors. How ironic he felt, that the drips and tubes that served to keep him alive were so reminiscent of the instruments of torment. As stoic as he was, that last course was a step too far, too close to old fears and nightmares alive. Yet we weren’t to know. Marie herself had heard little of those times and it was only now in his journals we heard from the man that was. In an era where medical practice is increasingly guilty of indulging in cold detached calculations of competing prima facie duties in its resolve to elucidate ethical dilemmas, medical decisions making is left a decidedly arid plane. Whilst compounded by the predisposition toward the dictates of evidenced based practice, it may be that Narrative input proves a refreshing change. Indeed, whilst there is a scientific platform for medicine, there is also a part of the practice of medicine that is very much an art form honed through clinical experience, judgment and nous. It is supplemented by a keen appreciation of the context of a clinical scenario, the character of the main protagonists and their inclinations, values and moral judgments as well as a good grasp of the principles and duties of care. Directed by a patient’s own perspective, values, beliefs and insights into the situation that they find themselves, narratives provide a large amount of information that require unbiased reception, understanding and contextualising. From this, physicians learn what to take from an encounter, how to distill those material of relevance and amalgamate these into their reckonings. Veritably ‘Illness Scripts’ do not only educate physicians but family and carers to the importance of various elements within a patient’s care and the primacy of a holistic appreciation of the narrative process.

on treatment options we fail to take into account those things that resonate most with in our haste to ‘sort the problem out’ we lose sight of the man before us. Decisionmaking is a difficult process that is all too often compounded by familial determination and collusion. Indeed too much may be left to the discretion of the family and too little to the patient. It is up to health care professionals to find balance in this milieu of sometimes competing opinions. We could do worse than be reminded of the phrase ‘know before whom you stand’.


DIPLOMATS HOST ART EXHIBITION TO SUPPORT NCCS RESEARCH PROJECTS

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Community

SALUBRIS

July / August 2011

Peru’s artist Alfredo Alcalde donates a painting for research fund

“Cultural Exchange and Art Exhibition of Alfredo Alcalde: Elements From The Soul” – A Charity Art Exhibition in aid of NCC Research Fund, 25 April to 2 May 2011

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t was certainly heart warming for the National Cancer Centre Singapore when two foreign ambassadors decided to work together to host an art exhibition to support our cancer research programme.

The exhibition of works by renowned Peruvian artist Alfredo Alcalde, held from 25 April-2 May 2011, was certainly a good start. The opening night drew some 200 guests including members of several diplomatic corps from Peru, Mexico, Bolivia, Venezuela, South Africa and Rwanda. Held at the Singapore Chinese Chamber of Commerce and Industry, the exhibition “Cultural Exchange and Art Exhibition of Alfredo Alcalde: Elements From The Soul” was organised by the International Culture Centre. Peru’s Ambassador to Singapore, Mr Armando Raul Patiño, and Mexico’s Ambassador to Singapore, Mr Antonio Villegas, made the welcome speeches and shared with the audience the objectives of the event. NCCS Director Prof Soo Khee Chee also spoke briefly, emphasising the need for continuing support from the local and international community to advance the cause of cancer research as part of the global efforts to improve current treatment protocols and eventually to get a cure for this disease. When artist Alfredo Alcalde offered to donate one of his paintings to the NCC Research Fund, it received thunderous applause from the audience and set the tone for the evening’s event.

The guests networked and mingled with NCCS staff to learn more about NCCS work and share their interest to support its cause. Two paintings were sold that evening and the sale proceeds went to the NCC Research Fund.

NCCS is grateful to the organisers, the Embassy of the United Mexican States and the Embassy of the Republic of Peru for their support, and also to Mr Alfredo Alcalde for generously donating one of his prized paintings. Companies or individuals who would like to support NCCS research initiatives through fund-raising projects can write to communitypartnership@nccs.com.sg. We will be pleased to work with you.

By Evangeline Goh

Executive, Community Partnership Division of Community Outreach & Philanthropy NCCS


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People

SALUBRIS

July / August 2011

SERVICE TO PATIENTS: MY UNDYING PASSION

It’s more than a decade of good work that Dr Chua Eu Jin has put in at the National Cancer Centre Singapore. Not surprisingly, when he reached his compulsory retirement age in April this year, the Centre decided to confer on him the title of Emeritus Consultant. CHARISSA ENG speaks to Dr Chua on his life and his passion in medicine.

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r Chua’s contributions to NCCS date back to 1999 when he was appointed the Head of Radiation Oncology. Swiftly, he moved up the ranks and held appointments as chairman of the Medical Board as well as the Head of Medical Affairs and Deputy Director of NCCS. During this time, he was the catalyst who introduced many changes that vastly improved the workflow in NCCS, most important of which was to bring in the technology to facilitate in the treatment of cancer patients. Between 1996 and 1998, he was tasked with planning the establishment of NCCS.

It was a responsibility that enabled him to draw on his experience as the former head of the department of Therapeutic Radiology (TRD) in Singapore General Hospital (SGH) to give NCCS a good head start. When NCCS was operational in 1999, Dr Chua helped to obtain new equipment and a new CT stimulator, the first ever in Singapore. He had the foresight to make NCCS the best equipped centre for the treatment of cancer. He then quickly embarked on the move from 2-D to 3-D planning and also on planning for IMRT. The rest is history as NCCS moved on to even newer treatment modalities. Despite his illustrious career, Dr Chua humbly maintains that the milestones achieved under his leadership would not have been possible without his team’s effort. Credit for NCCS’s recognition as a leading cancer centre goes to its capable managers, department heads and staffs.


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People

SALUBRIS

July / August 2011

The Emeritus Consultant title is awarded to a retiring doctor in recognition of his distinguished services to National Cancer Centre Singapore (NCCS). To be eligible, he has to serve a minimum of 10 years of service as Senior Consultant or Head of Clinical Department, and have made significant contributions to the specialty, department and Centre including taking on headship appointment(s). He demonstrates the desired values of the profession, serving as an exemplary role model for the younger doctors, as well as exhibiting leadership qualities in rallying his fellow doctors together for the benefit of patients and the hospital, among other eligibility criteria.

As Head of Medical Affairs, Dr Chua saw to the establishment of clinical quality and service quality under Clinical Affairs in 2001. He set up the infection control unit in 2002, which stood the test well during the SARS epidemic in 2003.

In times like these, you really know who the committed and loyal staffs are”, said the soft-spoken and bespectacled doctor, who is recognisable as one of the few in the profession who sports a bow-tie as he goes about his duties unassumingly.

The 2003 SARS epidemic was one of the most unforgettable crises. Dr Chua was at the frontline where he witnessed the best and worst in human behaviour. However, what gave him hope were the many unsung heroes who fought hard to maintain the efficient deployment of medical services. These heroes were self-sacrificial and provided excellent care to the patients, such that none of NCCS’s patients was afflicted with the virus.

Another problem the team had to contend with was to make the best use of outmoded equipment while they constantly source for new replacements. Through the creative sourcing and use of limited funding, Dr Chua and the team developed in-house techniques for treatments. Most importantly, as he recalled, was that the staff at NCCS never gave up. Dr Chua explained, “There was no lack of trying. Ultimately, I believe everyone must take ownership of the processes and efforts to make NCCS a truly safe and courteous place to work.”

For NCCS to get to where it is today, it was not all plain sailing. Challenges that confronted Dr Chua and his team include for example, the acute manpower shortage which required the staffs to perform multiple roles. In the words of Dr Chua, those were the days of the “long march experience”. Instead of succumbing to the pressures, the team persevered. “Many of my staff worked tirelessly to see us through.

Dr Chua believes in using his influence to help patients, not just medically, but in other aspects as well. For example, he called for the alteration of public policies regarding Medisave claims for radiotherapy patients to keep treatment affordable. He has always been attracted by NCCS’s passion to serve and its dedicated, committed and loyal staff.

Certainly, he was motivated and impressed by “the camaraderie, collegiality, common purpose, team spirit, a desire to make a difference to the work, the department and the institution”. His advice for his younger colleagues is: “Always pursue your passion and believe in a cause bigger than yourself. Always be committed, be loyal and never forget your patients who are the reason for your calling.”

On his wish for the future of NCCS, he said, “I hope that NCCS will achieve its vision to be the best and continue to develop its staff and provide opportunities for them to grow and contribute. I also hope that we all can build an institution that everyone is proud of and that at the end of the day we can say ‘Yes I was there, I did the best I could for the good of all who passed through its gates’.”


NCCS DOCTORS OFFER NEW INSIGHTS ON CANCER AT ASCO MEETING

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In Other Words

SALUBRIS

July / August 2011

Continued from page A3.

Mucocutaneous Angiosarcoma (MC-AS) Versus Non-MC-AS: Clinicopathologic Features and Treatment Outcomes in 44 Patients Mucocutaneous Angiosarcoma (MC-AS) is sarcoma that arise from the superficial regions of the body, primarily the skin. The majority of MC-AS occurs in the scalp or head and neck region, and usually affects elderly males. Non MC-AS can occur in the breasts, solid organs or deep soft tissues in different parts of the body. In NCCS, the majority of patients who have this type of cancer develop MC-AS. The prognosis of Angiosarcoma is usually poor and patients diagnosed with Angiosarcoma have a reported five-year survival of about 35 percent. In advanced stages of the disease, average survival is less than one year. To improve prognosis, Dr Richard Quek aimed to compare the clinical presentation and treatment outcomes of patients with MC-AS versus non MC-AS seen in NCCS. What Dr Quek found out has far-reaching implications for the medical community. His results also highlighted the limitations of standard clinical staging tools in stratifying patients for survival within the MC-AS subgroup of patients.

An Analysis of the Prognostic Value of Handgrip Strength and its Incorporation into the Comprehensive Geriatric Assessment (CGA) in Elderly Asian Patients with Cancer From studies done earlier, it has been noted that tell-tale signs of one’s mortality has something to do with one’s handgrip strength. The studies in Britain pointed out that poorer grip strength has been associated with increased mortality from all causes including cancer. This is significant for Singapore with our ageing population. Dr Ravi Kanesvaran’s study aimed to assess how handgrip strength can determine clinical outcomes for older cancer patients in an Asian context. He used the Cox proportional hazard method to identify prognostic factors within comprehensive geriatric assessment to analyse the relationship between handgrip strength and overall survival for patients. About 249 newly diagnosed patients aged 70 years and above, taking into account their age, ECOG performance status, gender, body mass index and the DETERMINE nutritional assessment index, took part in the study.

Dr Ravi Kanesvaran

Editorial Advisors

Contributing Editor

Medical Editor

Dr Kon Oi Lian Prof Soo Khee Chee

Dr Wong Nan Soon

Dr Richard Yeo

Members, Editorial Board

Members, Medical Editorial Board

Mr Mark Ko Ms Sharon Leow Dr Shiva Sarraf-Yazdi Ms Flora Yong

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

Ms Charissa Eng Ms Veronica Lee Mr Sunny Wee

Based on the positive findings of phase three trials in glioblastoma multiforme, concurrent temozolomide (TMZ) and radiation is often used as an initial treatment for anaplastic glioma, an uncommon form of cancer that originates from the brain.

However, there is no prospective randomised data currently to prove the efficacy of combining both TMZ and radiation in the treatment for anaplastic glioma. To investigate this, Dr Tham Chee Kian launched a study to find out if the addition of TMZ to radiation is better than radiation alone for the initial treatment of anaplastic glioma. Dr Tham reviewed patients with anaplastic astrocytoma or oligoastrocytomas treated at NCCS between the years 2000 to 2010. Only patients who received upfront radiation or concurrent TMZ and radiation were included in this study.

The study revealed that handgrip strength is an important prognostic factor in elderly patients and was useful in the comprehensive geriatric assessment of such patients. They include the DETERMINE nutritional index, ECOG performance status and advanced stage as prognostic factors with the CGA.

Executive Editors

Concurrent Temozolomide and Radiation as the Initial Treatment for Anaplastic Glioma

His study revealed that there is not any significant benefit of TMZ with radiation compared to just radiation alone as the initial treatment of anaplastic glioma. Prospective randomised trials will be needed to evaluate the optimal treatment for this disease.

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 salubris@nccs.com.sg.

NATIONAL CANCER CENTRE SINGAPORE Reg No 199801562Z

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


DIPLOMATS HOST ART EXHIBITION TO SUPPORT NCCS RESEARCH PROJECTS

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Community

SALUBRIS

July / August 2011

Peru’s artist Alfredo Alcalde donates a painting for research fund

“Cultural Exchange and Art Exhibition of Alfredo Alcalde: Elements From The Soul” – A Charity Art Exhibition in aid of NCC Research Fund, 25 April to 2 May 2011

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t was certainly heart warming for the National Cancer Centre Singapore when two foreign ambassadors decided to work together to host an art exhibition to support our cancer research programme.

The exhibition of works by renowned Peruvian artist Alfredo Alcalde, held from 25 April-2 May 2011, was certainly a good start. The opening night drew some 200 guests including members of several diplomatic corps from Peru, Mexico, Bolivia, Venezuela, South Africa and Rwanda. Held at the Singapore Chinese Chamber of Commerce and Industry, the exhibition “Cultural Exchange and Art Exhibition of Alfredo Alcalde: Elements From The Soul” was organised by the International Culture Centre. Peru’s Ambassador to Singapore, Mr Armando Raul Patiño, and Mexico’s Ambassador to Singapore, Mr Antonio Villegas, made the welcome speeches and shared with the audience the objectives of the event. NCCS Director Prof Soo Khee Chee also spoke briefly, emphasising the need for continuing support from the local and international community to advance the cause of cancer research as part of the global efforts to improve current treatment protocols and eventually to get a cure for this disease. When artist Alfredo Alcalde offered to donate one of his paintings to the NCC Research Fund, it received thunderous applause from the audience and set the tone for the evening’s event.

The guests networked and mingled with NCCS staff to learn more about NCCS work and share their interest to support its cause. Two paintings were sold that evening and the sale proceeds went to the NCC Research Fund.

NCCS is grateful to the organisers, the Embassy of the United Mexican States and the Embassy of the Republic of Peru for their support, and also to Mr Alfredo Alcalde for generously donating one of his prized paintings. Companies or individuals who would like to support NCCS research initiatives through fund-raising projects can write to communitypartnership@nccs.com.sg. We will be pleased to work with you.

By Evangeline Goh

Executive, Community Partnership Division of Community Outreach & Philanthropy NCCS


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People

SALUBRIS

July / August 2011

SERVICE TO PATIENTS: MY UNDYING PASSION

It’s more than a decade of good work that Dr Chua Eu Jin has put in at the National Cancer Centre Singapore. Not surprisingly, when he reached his compulsory retirement age in April this year, the Centre decided to confer on him the title of Emeritus Consultant. CHARISSA ENG speaks to Dr Chua on his life and his passion in medicine.

D

r Chua’s contributions to NCCS date back to 1999 when he was appointed the Head of Radiation Oncology. Swiftly, he moved up the ranks and held appointments as chairman of the Medical Board as well as the Head of Medical Affairs and Deputy Director of NCCS. During this time, he was the catalyst who introduced many changes that vastly improved the workflow in NCCS, most important of which was to bring in the technology to facilitate in the treatment of cancer patients. Between 1996 and 1998, he was tasked with planning the establishment of NCCS.

It was a responsibility that enabled him to draw on his experience as the former head of the department of Therapeutic Radiology (TRD) in Singapore General Hospital (SGH) to give NCCS a good head start. When NCCS was operational in 1999, Dr Chua helped to obtain new equipment and a new CT stimulator, the first ever in Singapore. He had the foresight to make NCCS the best equipped centre for the treatment of cancer. He then quickly embarked on the move from 2-D to 3-D planning and also on planning for IMRT. The rest is history as NCCS moved on to even newer treatment modalities. Despite his illustrious career, Dr Chua humbly maintains that the milestones achieved under his leadership would not have been possible without his team’s effort. Credit for NCCS’s recognition as a leading cancer centre goes to its capable managers, department heads and staffs.


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People

SALUBRIS

July / August 2011

The Emeritus Consultant title is awarded to a retiring doctor in recognition of his distinguished services to National Cancer Centre Singapore (NCCS). To be eligible, he has to serve a minimum of 10 years of service as Senior Consultant or Head of Clinical Department, and have made significant contributions to the specialty, department and Centre including taking on headship appointment(s). He demonstrates the desired values of the profession, serving as an exemplary role model for the younger doctors, as well as exhibiting leadership qualities in rallying his fellow doctors together for the benefit of patients and the hospital, among other eligibility criteria.

As Head of Medical Affairs, Dr Chua saw to the establishment of clinical quality and service quality under Clinical Affairs in 2001. He set up the infection control unit in 2002, which stood the test well during the SARS epidemic in 2003.

In times like these, you really know who the committed and loyal staffs are”, said the soft-spoken and bespectacled doctor, who is recognisable as one of the few in the profession who sports a bow-tie as he goes about his duties unassumingly.

The 2003 SARS epidemic was one of the most unforgettable crises. Dr Chua was at the frontline where he witnessed the best and worst in human behaviour. However, what gave him hope were the many unsung heroes who fought hard to maintain the efficient deployment of medical services. These heroes were self-sacrificial and provided excellent care to the patients, such that none of NCCS’s patients was afflicted with the virus.

Another problem the team had to contend with was to make the best use of outmoded equipment while they constantly source for new replacements. Through the creative sourcing and use of limited funding, Dr Chua and the team developed in-house techniques for treatments. Most importantly, as he recalled, was that the staff at NCCS never gave up. Dr Chua explained, “There was no lack of trying. Ultimately, I believe everyone must take ownership of the processes and efforts to make NCCS a truly safe and courteous place to work.”

For NCCS to get to where it is today, it was not all plain sailing. Challenges that confronted Dr Chua and his team include for example, the acute manpower shortage which required the staffs to perform multiple roles. In the words of Dr Chua, those were the days of the “long march experience”. Instead of succumbing to the pressures, the team persevered. “Many of my staff worked tirelessly to see us through.

Dr Chua believes in using his influence to help patients, not just medically, but in other aspects as well. For example, he called for the alteration of public policies regarding Medisave claims for radiotherapy patients to keep treatment affordable. He has always been attracted by NCCS’s passion to serve and its dedicated, committed and loyal staff.

Certainly, he was motivated and impressed by “the camaraderie, collegiality, common purpose, team spirit, a desire to make a difference to the work, the department and the institution”. His advice for his younger colleagues is: “Always pursue your passion and believe in a cause bigger than yourself. Always be committed, be loyal and never forget your patients who are the reason for your calling.”

On his wish for the future of NCCS, he said, “I hope that NCCS will achieve its vision to be the best and continue to develop its staff and provide opportunities for them to grow and contribute. I also hope that we all can build an institution that everyone is proud of and that at the end of the day we can say ‘Yes I was there, I did the best I could for the good of all who passed through its gates’.”


NCCS DOCTORS OFFER NEW INSIGHTS ON CANCER AT ASCO MEETING

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In Other Words

SALUBRIS

July / August 2011

Continued from page A3.

Mucocutaneous Angiosarcoma (MC-AS) Versus Non-MC-AS: Clinicopathologic Features and Treatment Outcomes in 44 Patients Mucocutaneous Angiosarcoma (MC-AS) is sarcoma that arise from the superficial regions of the body, primarily the skin. The majority of MC-AS occurs in the scalp or head and neck region, and usually affects elderly males. Non MC-AS can occur in the breasts, solid organs or deep soft tissues in different parts of the body. In NCCS, the majority of patients who have this type of cancer develop MC-AS. The prognosis of Angiosarcoma is usually poor and patients diagnosed with Angiosarcoma have a reported five-year survival of about 35 percent. In advanced stages of the disease, average survival is less than one year. To improve prognosis, Dr Richard Quek aimed to compare the clinical presentation and treatment outcomes of patients with MC-AS versus non MC-AS seen in NCCS. What Dr Quek found out has far-reaching implications for the medical community. His results also highlighted the limitations of standard clinical staging tools in stratifying patients for survival within the MC-AS subgroup of patients.

An Analysis of the Prognostic Value of Handgrip Strength and its Incorporation into the Comprehensive Geriatric Assessment (CGA) in Elderly Asian Patients with Cancer From studies done earlier, it has been noted that tell-tale signs of one’s mortality has something to do with one’s handgrip strength. The studies in Britain pointed out that poorer grip strength has been associated with increased mortality from all causes including cancer. This is significant for Singapore with our ageing population. Dr Ravi Kanesvaran’s study aimed to assess how handgrip strength can determine clinical outcomes for older cancer patients in an Asian context. He used the Cox proportional hazard method to identify prognostic factors within comprehensive geriatric assessment to analyse the relationship between handgrip strength and overall survival for patients. About 249 newly diagnosed patients aged 70 years and above, taking into account their age, ECOG performance status, gender, body mass index and the DETERMINE nutritional assessment index, took part in the study.

Dr Ravi Kanesvaran

Editorial Advisors

Contributing Editor

Medical Editor

Dr Kon Oi Lian Prof Soo Khee Chee

Dr Wong Nan Soon

Dr Richard Yeo

Members, Editorial Board

Members, Medical Editorial Board

Mr Mark Ko Ms Sharon Leow Dr Shiva Sarraf-Yazdi Ms Flora Yong

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

Ms Charissa Eng Ms Veronica Lee Mr Sunny Wee

Based on the positive findings of phase three trials in glioblastoma multiforme, concurrent temozolomide (TMZ) and radiation is often used as an initial treatment for anaplastic glioma, an uncommon form of cancer that originates from the brain.

However, there is no prospective randomised data currently to prove the efficacy of combining both TMZ and radiation in the treatment for anaplastic glioma. To investigate this, Dr Tham Chee Kian launched a study to find out if the addition of TMZ to radiation is better than radiation alone for the initial treatment of anaplastic glioma. Dr Tham reviewed patients with anaplastic astrocytoma or oligoastrocytomas treated at NCCS between the years 2000 to 2010. Only patients who received upfront radiation or concurrent TMZ and radiation were included in this study.

The study revealed that handgrip strength is an important prognostic factor in elderly patients and was useful in the comprehensive geriatric assessment of such patients. They include the DETERMINE nutritional index, ECOG performance status and advanced stage as prognostic factors with the CGA.

Executive Editors

Concurrent Temozolomide and Radiation as the Initial Treatment for Anaplastic Glioma

His study revealed that there is not any significant benefit of TMZ with radiation compared to just radiation alone as the initial treatment of anaplastic glioma. Prospective randomised trials will be needed to evaluate the optimal treatment for this disease.

SALUBRIS

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NCCS Salubris Issue No. 17 (Medical Edition)  

A razorSHARK design. Salubris is a National Cancer Centre Singapore (NCCS) bi-monthly publication.