A PUBLICATION FOR PRIMARY CARE PHYSICIANS

JANUARY-MARCH 2015MCI (P) 088/03/2014

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Salmon Cha Soba

healthy recipe

Physiotherapy Management of

Cancer-Related Lymphedema

Beyond Breast cancertreatMent, what's next?

no one stands

alone, alone no one walks

Go GReen with youR pRoState

in eveRy iSSue

03 editor’s note

04 in the news

08 UPdAtes on ChAs/CrisP

26 fitness

31 heAlthy reCiPe

in thiS iSSue

10 No One Stands Alone, No One Walks Alone

16 Beyond Breast Cancer Treatment, What's Next?

20 The General Medicine Clinic

22 Go Green With Your Prostate

cancer patient's outlook was not as favourable decades ago, as it is today. To many newly

diagnosed cancer patients, it may seem like the end of the road.

Today, cancer is no longer a death sentence. In the newly released Cancer Registry Report for the Years 2009 – 2013 by the National Registry of Diseases Office (NRDO), it is found that age-standardised modality rates for the two top cancers in men and women, that is lung and breast cancer, have either decreased or stabilised. Active research in cancers and their treatments are still ongoing and we would expect to hear more improvements in modality rates for the other cancers.

This edition of GP BUZZ is dedicated to cancer-related topics and how our primary care practitioners can play a role in enhancing care to our cancer patients.

In Tan Tock Seng Hospital (TTSH), patients have access to our multidisciplinary cancer teams made up of various healthcare professionals such as the surgeon, radiologist, pathologist, and radiation and medical oncologists. In the cover story, GP

BUZZ shares the advent of these multidisciplinary cancer teams and their roles in cancer care. The journey of cancer patients does not stop at the end of the treatment. Paying tribute to all women on International Women’s Day on 8th March, GP BUZZ throws the spotlight on the psychosocial needs of breast cancer survivors and reviews the role that primary care partners can play. TTSH’s team of certified lymphedema therapists in the Physiotherapy department provides details on the management of cancer-related lymphedema. A nutritious Salmon Cha Soba recipe is also introduced for individuals undergoing cancer treatment.

This issue of GP BUZZ showcases recent developments in Community Right-Siting Programme (CRiSP) and the services of the General Medicine Clinic in TTSH – a secondary level of care for patients with diagnosis deemed too complex to be handled by the primary care practitioners. We also introduce the treatment options for benign prostatic hypertrophy, including the latest transurethral vaporisation of the prostate (TUVP).

Happy reading.

The GP BUZZ Editorial Team

A

editor’s notecontents

JANUARY - MARCH 2015

no one StandS aLone, no one waLkS aLone

the Gp BuZZ editoRiaL team:Jessie Tay

Evelyn TanTeo Puat Wen

adviSoRy paneL:Emeritus Professor Feng Pao Hsii Associate Professor Thomas Lew

Associate Professor Chia Sing JooAssociate Professor Chin Jing Jih

Adjunct Assistant Professor Chong Yew LamDr Tan Kok Leong

Dr Pauline Yong

GP BUZZ is a magazine by Tan Tock Seng Hospital, designed by

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comments and queries to gp@ttsh.com.sg.

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for any liability that results from the use (or misuse) of the information contained in this publication.

All information and materials found in this publication are for purposes of information only and are not meant

to substitute any advice provided by your own physician or other medical professionals. You should not use the

information and materials found in this publication for the purpose of diagnosis or treatment of a health condition or

disease or for the prescription of any medication. If you have or suspect that you have a medical problem, you should

promptly consult your own physician and medical advisers.

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10

22 16

02 03

President tony tan Keng yam (second from left) seen here with the late tycoon ng teng fong’s daughter, Mrs dorothy Chan (third from left), dr Amy Khor, senior Minister of state, Ministry of health and Ministry of Manpower and Prof Philip Choo, Ceo of ttsh (now Group Ceo of the national healthcare Group) (right).

Guest-of-honour President tony tan Keng yam and first lady Mary tan arriving at ttsh’s 170th founder’s day dinner.

in the newsin the news

new miLeStone on ttSh 170th FoundeR’S day CeLeBRation

Over 950 guests gathered at the Raffles Convention Centre on 7 October 2014 to celebrate Tan Tock Seng Hospital (TTSH)’s

170th Founder's Day. President Tony Tan Keng Yam graced the event and announced the inception of the ‘Ng Teng Fong Healthcare Innovation Programme’. With the donation of $52 million from the family of the late property tycoon Ng Teng Fong, TTSH plans to fund initiatives channelled into three broad tracks - Training, Innovation and Enabling the Community. The programme will be used in funding the training of healthcare professionals, members of the community (e.g. volunteers, caregivers and members of patient support groups) as well as in developing healthcare innovations to elevate the quality of healthcare service throughout the hospital.

new CLiniCaL BoaRd and aLLied heaLth SeRviCeS & phaRmaCy aS new CLiniCaL depaRtmentS

Tan Tock Seng Hospital (TTSH) is gearing up for team-based care with the redesignation of its Therapists, Pharmacists, Radiographers and

Laboratory Technologists as Clinicians under a new umbrella group known as the Allied Health Services & Pharmacy (AHS&P) Clinical Family Group. The new clinical departments and services include Care and Counselling, the Foot Care and Limb Design Centre,

Tan Tock Seng Hospital (TTSH)’s National Centre for Infectious Diseases (NCID) and

Centre for Healthcare Innovation were unveiled at a groundbreaking ceremony on 3 November 2014.Nutrition & Dietetics, Occupational Therapy, Pharmacy,

Physiotherapy, Psychology, Speech Therapy, Rehabilitation Allied Health Services, Respiratory Therapy, Podiatry, Prosthetics & Orthotics, Medical Laboratory Technology and Radiography. TTSH is also reconstituting its Medical Board into a new Clinical Board comprising Medical, Nursing and Allied Health Services & Pharmacy members. The Board will provide unified clinical governance and a collective leadership structure to foster the development of multidisciplinary, patient-centric clinical care, and to better align its service development with TTSH’s holistic mission in population health. Ms Susan Ngiam heads the new AHS&P family group while Associate Professor Thomas Lew has been appointed the Clinical Board Chairman.

BReakinG new GRoundS in inFeCtiouS diSeaSe ContRoL and heaLthCaRe tRaininG

Groundbreaking ceremony of ttsh’s national Centre for infectious diseases by Guest-of-honour Minister for health, Mr Gan Kim yong (fifth from left), Minister of state for health, dr lam Pin Min (fourth from left), Chairman of the national healthcare Group, Madam Kay Kuok (third from right) and members of the ttsh senior management team.

Developed as part of the Health City Novena masterplan, a 17-hectare integrated healthcare hub in Novena, the two medical developments are slated for completion in stages from 2018.

The 14-storey NCID is expected to house 330 beds in 17 wards and could be ‘locked down’ to isolate and manage highly infectious outbreaks safely. Key features of the new centre include separate lifts for visitors, patients and staff to reduce the risk of cross-infection. While the centre can be self-contained to confine treatment of infected patients to a single place, it is also connected to the main TTSH building for more coordinated operations, which require the use of hospital resources.

TTSH’s Centre for Healthcare Innovation was also launched at the event and the future nine-storey building is slated to be a training and medical hub for healthcare professionals to be better prepared against rising complexities in the acute and primary care settings.

04 05

in the news

patient enGaGement at the 2nd SinGapoRe patient ConFeRenCe 2014

About 400 patients, caregivers, volunteers, patient support group members, community partners and healthcare professionals attended

the 2nd Singapore Patient Conference on Friday, 31 October 2014. This is an annual platform for learning with patients on co-creating a healthcare experience valued by patients and in which healthcare professionals can thrive in.

The Conference, which was opened by Guest-of-Honour, Dr Lam Pin Min, Minister of State, Ministry of Health, saw inspirational sharing by six speakers on their healing journeys and their selfless contributions to the community.

Themed ‘Celebrate Life, Celebrate Health’, the 2014 event also saw a line-up of exciting fringe activities - the CareConnect Open House activities and social enterprise bazaars create opportunities for patient learning and engagement as well as generate awareness to various social causes in Singapore.

Keynote speaker, dr tan lai yong, resident fellow, College of Alice and Peter tan, national University of singapore, addressing the audience on the benefits of listening by healthcare professionals.

dr lam Pin Min, Minister of state, Ministry of health (centre) with participants of the CareConnect open house activities and members of Amberbrook, a social enterprise.

Tan Tock Seng Hospital (TTSH)’s CareConnect Volunteer Committee (CVC) was also introduced during the Conference. Made up of volunteers, healthcare professionals and community representatives, CVC serves as a bridge between the hospital and its patients and caregivers in communicating feedback, fostering good outcomes and safe care, and caring for the needs, feelings and relationships between patients and their loved ones.

in the news

ttSh muSCuLoSkeLetaL CentRe expandS with inteGRation oF pain manaGement and SpoRtS mediCine & SuRGeRy

The Pain Management Clinic and Sports Medicine & Surgery Clinic have relocated to new

premises at Clinic B1C on 24 November 2014. Together with Clinic B1A and Clinic B1B, Pain Management Clinic and Sports Medicine & Surgery Clinic now form part of the Musculoskeletal Centre in Tan Tock Seng Hospital (TTSH). Occupying over 650 square metres of floor area, Clinic B1C is housed within the Atrium Block of TTSH. It comprises 11 consultation rooms, a treatment room, an interventional pain procedure suite* and a gym area. Our specialists in Pain Management and Sports Medicine & Surgery now share this facility, together with allied health professionals, giving our patients better access and enhancement to interdisciplinary management of various musculoskeletal conditions.

The Pain Management Clinic provides one-stop service with a range of treatment options for patients with sub-acute and chronic pain - a common occurrence with diseases, surgeries or trauma. This new facility will introduce an interventional day procedure facility to improve the coordination and timing of interventional pain procedures (such as nerve blocks, spinal cord stimulation, epidural injections) as part of a

multidisciplinary management programme.

With the new gym area of 145 square metres, Sports Medicine & Surgery Clinic is able to enhance its current services and offer new services for everyone – from athletes to members of the public. Enhancement to current services includes sports injury diagnosis and treatment, fitness testing, exercise prescription and exercise training for the management of chronic diseases, video gait analysis and pre-participation screening. The new facility now offers new screening services such as musculoskeletal screening and functional movement screening. Strength training and conditioning, and mobility and stability testing

are also available for those who are engaged in sporting activities, such as running and dancing.

A multidisciplinary team of physicians, nurse clinicians, dieticians, exercise physiologist, physiotherapists, occupational therapists, podiatrists and psychologists can now holistically manage different musculoskeletal conditions.

Pain Management and sports Medicine & surgery services in Clinic B1C.

new gym area offering more services.

*interventional Pain Procedure suite will be operational in the second quarter of 2015.

06 07

Updates on chas / crisp Updates on chas / crisp

crisp developMents and oUtreach

Chronic diseases pose a significant cause of death and disability in Singapore. The increasing

prevalence of chronic diseases is largely due to a rapidly ageing population, and also the population's leading sedentary lifestyles.

The risk of getting chronic diseases increases with age. Serving the population in the central region of Singapore, Tan Tock Seng Hospital (TTSH) is experiencing a faster rate of ageing at 15.1%, as compared to other parts of Singapore at around 10%. It is crucial to delay or prevent the onset of health complications for such diseases and high medical costs through early detection and appropriate management.

ChroniC diseAse MAnAGeMent ProGrAMMe (CdMP)

The Chronic Disease Management Programme (CDMP) was launched in October 2006, to cover the first chronic condition, diabetes. More conditions were later added to CDMP over the years and to date, the scheme has expanded to include a total of 15 conditions. CDMP also formed the basis of TTSH’s Community Right-Siting Programme (CRiSP). Through appropriate right-siting, patients can use their Medisave or Community Health Assistance Scheme (CHAS) and/or Pioneer Generation subsidies to help pay part of their total medical bill and reduce out-of-pocket payment.

CoMMUnity riGht- sitinG ProGrAMMe (CrisP)

CRiSP was launched on 1 April 2014, drawing on the right-siting strengths of TTSH’s Asthma Decant Programme in 2009 and Heart Failure Programme in 2010. Besides fostering closer working relationships with National Healthcare Group (NHG) Diagnostics, NHG Pharmacy and General Practitioners (GPs), CRiSP provides continuing care to right-sited patients and encompasses the following eight CDMP chronic conditions:

Asthma Benign prostatic hyperplasia (BPH)

Diabetes Hypothyroidism Osteoarthritis knee Parkinson’s disease Post-percutaneous transluminal coronary angioplasty

(Post-PTCA) Stable stroke

CRiSP aims to promote the benefits of right-siting to patients and encourage them to extend their care journey beyond TTSH specialist outpatient clinics (SOCs)

and with our GP partners. This will, in turn, foster a closer doctor-family relationship, which will see patients returning to the same doctor for medical care.

Since October 2014, CRiSP administrators from TTSH Primary Care Partners Office (PCPO) have been visiting GPs who are interested to know more about the core infrastructure of CRiSP. This infrastructure is developed to equip and support GPs in managing right-sited patients holistically and it includes: CRiSP Symposium, where GPs can receive up-to-date information on chronic care management, discuss cases and share the best care practices through peer learning

Subsidised diagnostic support by NHG Diagnostics

Drug support by TTSH and NHG Pharmacy

Right-siting officers who coordinate care between patients, GPs and TTSH SOCs on discharges and referrals to SOCs

National Electronic Health Record (NEHR)

NHG Mobile Community Health Centre (CHC) provides allied health services such as diabetic

Members of ttsh PCPo (first and second from left) in a CrisP engagement session with our GP, dr edward wong.

retinal photography, diabetic foot screening and nurse counselling on chronic disease self-management

Referral to SOC as subsidised patients by GPs, when patient conditions deteriorate within 24 months from their date of discharge

Referral to SOC through CHAS by GPs beyond 24 months

sUpport Us in adding years of healthy lifeCurrently, CRiSP is implemented in the following regions:

Ang Mo Kio

Serangoon

Seng Kang

Hougang

Tampines Jurong East

BedokBishan

Yishun

Woodlands

CRiSP DeveloPmentS anD outReaCh

If your clinic is located in any of these locations and you would like to find out more about CRiSP, please email TTSH Primary Care Partners Office (PCPO) at:

evelyn tan (Ms)Senior Account ManagerEmail: Evelyn_SM_Tan@ttsh.com.sg

Jayne tong (Ms)Account ManagerEmail: Jayne_LM_Tong@ttsh.com.sg

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cover story cover story

With the evolution of cancer care, patients now undergo varied modalities of treatment by various healthcare specialists. The burden on the patient begins with diagnosis, and worsens as they navigate the complex healthcare system, managing various procedures, diagnostic tests and doctor visitations.

At Tan Tock Seng Hospital, multidisciplinary cancer teams and clinics are created to lessen such a burden on patients, and enhance the efficiency and standards of care.

Caring for newly diagnosed cancer patients is becoming an increasingly complex task. The practice of a lone practitioner or surgeon,

utilising a single modality of treatment and managing various aspects of care is a thing of the past.

Current treatment approaches involve the use of a variety of modalities, either sequentially or concurrently. Surgery, radiotherapy, chemotherapy, and interventional radiology are a few in this range of modalities employed. To assist in the delivery of care, input from various allied healthcare professionals are often needed. Separate clinic visits on different days are often required, adding on to the strain in the patient experience.

To a patient, the diagnosis of cancer comes as a burden. Having to navigate complexities and inefficiencies of the healthcare system is an additional burden patients should not shoulder. Having to keep track of the various procedures, diagnostic tests and doctor visits are often difficult enough. Having to understand the purpose of these various tests and their results, takes this challenge to another level.

Managing physicians who are involved in the care process face similar frustrations, having to collate the opinions of other specialists involved. Separate calls to radiologists, pathologists, radiation and medical oncologists for their opinions are needed, in order to formulate a complete care plan. Then comes the arduous task of coordinating different clinic visits for the doctors involved. Opinions between physicians may differ, leading to added confusion for patients.

The advent of a multidisciplinary team has helped ease this burden significantly, improving treatment efficiency and results of care, especially in complex cases. This is a team of healthcare professionals who work together on each cancer patient, working through a forum to go through their radiology and pathology results. Opinions of the various physicians and allied healthcare professionals are sought in a single meeting, with various viewpoints heard and discussed. State-of-the-art treatment approaches and modern techniques from various international meetings are often discussed, to keep the various members updated.

no one stands

alone, alone no one walks

10 11

cover story cover story

Treatment recommendations are thus formulated in accordance to internationally recognised best practices and guidelines.

A care coordinator would then plan a course of action that would allow smooth treatment sequencing and delivery – cutting down on unnecessary hospital visits for patients. For more commonly occurring cancer types, multidisciplinary clinics have been developed for patients to see the different doctors involved on a single day, at a single location. This allows for different treatment options to be presented, discussed, and planned for in one sitting. This approach increasingly practised in major centres globally has shown improvements to patient care, with enhanced efficiency and standards of care.

Several multidisciplinary teams operate at Tan Tock Seng Hospital (TTSH), with different teams

possessing different modes of treatment delivery and systems. Refinements are constantly made as new team members bring in newer techniques that can enhance care delivery. A few of the multidisciplinary cancer teams are illustrated below:

a. lung cancer Multidisciplinary teamThe management of lung cancers can be very diverse. Locally advanced lung cancers can be treated by chemotherapy, concurrent or sequential chemo-radiation, and radiotherapy alone.

Surgery is included in selected cases. Our lung cancer tumour board meeting is conducted fortnightly, to determine how best to manage this diverse group of patients. Respiratory physicians, surgeons, radiation oncologists, medical oncologists, pathologists and radiologists are also involved.

B. head and neck cancer Multidisciplinary teamIncluded in this group of

malignancies are nasopharyngeal cancers, squamous cell cancers of the various locations (including tongue, buccal cavity, larynx, pharynx, hypopharynx), thyroid cancers and salivary gland tumours. Management of this

diverse group of malignancies differs greatly based on the

tumour site and pathology subtype. For operable tumours, surgery is often carried out upfront.

Further adjuvant treatment is added in selected cases. Adjuvant treatment options include radiotherapy, chemo-radiation and radionuclide therapy in thyroid malignancies. For operable cases where the extent of surgery results in loss of speech or swallowing function, patients are often offered organ preservation methods by means of chemo-radiotherapy alone.

Otorhinolaryngology (ENT) surgeons, head and neck surgeons, radiation oncologists, medical oncologists, plastic surgeons, dental surgeons, speech therapists,

dieticians, and pharmacists are often engaged in the decision- making process to formulate care plans for this diverse tumour type.

c. Breast cancer Multidisciplinary teamBreast cancer is the most common malignancy among women. Treatment options include upfront surgery with mastectomy or lumpectomy, with sentinel lymph node sampling or axillary clearance. Breast reconstruction can also be performed, either at the time of surgery or at a later date. Neoadjuvant chemotherapy is used, prior to surgery for selected cases. Following surgery, adjuvant chemotherapy, hormonal therapy and radiotherapy are added on in certain cases.

TTSH runs a weekly tumour board meeting, which is followed closely by a multidisciplinary clinic where patients are seen by various physicians during a single session. The team members include the

breast surgeon, plastic surgeon (involved in breast reconstruction), radiation oncologist, medical oncologist, breast care nurse, radiologist and pathologist to ensure best possible treatment results.

d. Urological tumour Multidisciplinary teamThe urological tumour board convenes monthly. Malignancies reviewed include prostate cancers, invasive bladder cancers and kidney cancers. Options for the treatment

of localised prostate cancer include surgery, radiotherapy, hormonal therapy and observation. Decisions are made on the patient’s clinical, biopsy and radiological findings.

For invasive bladder cancers, treatment options include surgery and chemo-radiotherapy. Neoadjuvant and adjuvant chemotherapy options are discussed in certain instances. Multidisciplinary input is often needed in arriving at treatment recommendations.

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cover story cover story

e. gastrointestinal Multidisciplinary teamEsophageal, gastric and colonic and rectal tumours are included in this large group of malignancies. Our TTSH team holds weekly meetings to look into this common cancer group. Treatment options

for this large group are relatively diverse, ranging from neoadjuvant chemotherapy, neoadjuvant chemo-radiotherapy, primary chemo-radiotherapy, surgery, adjuvant chemotherapy and adjuvant chemo-radiotherapy.

TTSH runs a twice-monthly multidisciplinary clinic, where patients needing combination chemotherapy and radiotherapy before or after surgery, are seen at a single setting.

f. hepatobiliary cancer Multidisciplinary teamLiver, pancreas and biliary tract malignancies are discussed by this team. Common liver malignancies include hepatocellular cancers (HCC) and cholangiocarcinomas. For HCCs, treatment modalities include surgery, local ablative therapies such as transarterial chemo-embilisation (TACE), liver transplantation and selective internal radiotherapy treatment (SIRT).

The role of a skilled interventional radiologist is paramount in the selection of the various modalities available. The management of bile duct malignancies and pancreatic malignancies typically involves upfront surgery for operable cases and chemo-radiotherapy for inoperable cases.

Dr Yeo Wee Lee Dr Yeo Wee Lee is a Consultant of the Medical Oncology Department at Tan Tock Seng Hospital and the Johns Hopkins Singapore International Medical Centre. He graduated from the National

University of Singapore and went on to receive his specialist training in medical oncology at the National University Hospital. He spent a year pursuing lung cancer research at Harvard Medical School. His sub-specialty interests are in head and neck, thoracic and gastrointestinal malignancies.

common team members of a multidisciplinary cancer care team include:

surgeon Medical oncologist radiation oncologist diagnostic radiologist interventional radiologist pathologist nursing specialists dietician speech therapist Medical social worker

As more research is done to improve the treatment of cancer patients, greater teamwork is required between the various members of the multidisciplinary healthcare team. At TTSH, such teams work closely with the ultimate goal of delivering care with greater precision and efficiency.

J.o.i.n.t. Movement to enhance oncology care in ttsh

Joint Oncology INnovation Taskforce (JOINT) was established in 2012 and led by Adjunct Assistant Professor Chong Yew Lam, Divisional Chairman of Surgery with a multidisciplinary team of healthcare professionals at Tan Tock Seng Hospital (TTSH).

Recognising that the care of cancer patients is increasingly complex, JOINT is created to address these complexities, improve work processes and research to enhance cancer care efficiencies, and improve service delivery for a better patient experience.

This oncology integrated care cluster was established with three key thrusts:

Personalised Medicine - JOINT looks at the utility of cancer tests – that specific and targeted treatments go to the right patients at the right time. JOINT hopes to contribute to research capabilities for personalised medicine.

Care and Counselling – Cancer patients experience a lot of anxiety when they transit through the hospital. JOINT hopes to identify ways to address the emotional needs of our patients. JOINT plans to start by enhancing the awareness of patient anxieties among our staff, so that they can be better equipped to manage the simpler problems and escalate the complex cases to the specialist.

Multidisciplinary One-Stop Cancer Clinics – JOINT aims to enhance the patient care experience by creating one-stop clinics, where patients could be arranged to see different disciplines in one visit. One such example is the TTSH Gastrointestinal Cancer Centre (TGICC) operating from Outpatient Clinic 5A.

TGICC is a multidisciplinary collaboration that is run by three main disciplines, namely medical oncology, radiation oncology as well as general surgery. In TGICC, waiting time is cut short as patients who require oncology care could see three disciplines in one visit. This will help to fast forward the treatment plan for our patients. Our clinicians can also benefit from giving patients a unified human voice to improve treatment outcomes and overall experience.

14 15

Beyond Breast cancer treatMent,

what’s next?

Four years after having a mastectomy for ductal carcinoma in situ (DCIS), my

patient, Madam Lim (not her real name) came in for a routine follow-up visit. She requested to withdraw her CPF savings on medical grounds. I told her she would not be eligible, since she was not going to die from DCIS. Unconvinced and terribly fearful for her state of health, she was unwilling to continue working and yearned to focus on other life pursuits.

featUre featUre

what’s next?

constitute failing in our duties as caregivers.

caring for their eMotional needs In the previous article, Dr Yeo Wee Lee spoke about a multidisciplinary approach to cancer management. While we strive to achieve holistic treatment for our cancer patients, we may fail to take their emotional and psychological wishes into treatment plans. Our duty to patients no longer ends with just the administration of medication and a successful surgical procedure.

In the October 2011 issue of the Wall Street journal, Melinda Beck explores the psychosocial aspects of breast cancer survivors after treatment in her article, 'The new front in breast cancer: After treatment ends'. In the article, Carie Capossela, 43 years old, who has been free of breast cancer for the past 10 years shared that "...the next challenge after diagnosis is when the treatment ends. The reality sets in that you have to live with this the rest of your life and the safety net is gone. That's when you really freak out."

Medical school may teach us that a DCIS patient will require surgery, hormonal therapy and perhaps radiotherapy. However, it does not provide insights into a patient's fears and emotional states, post-diagnosis and post-surgery.

Surgeons often shoulder the responsibility of maintaining a professional opinion, free from emotional bias, in order to render effective treatment to our patients. Yet, not addressing their fears may

patient eMpowerMent Model of careThis idea is supported by the study released by the Susan G. Komen® organisation that advocates survivorship care planning (Figure 1) and identification of distress in patients.

The organisation advocates a patient empowerment model that is described as being “founded on evidence that people affected by cancer can become informed, take action and make conscious changes within the context of a supportive community that can lead to improved quality of life and enhanced possibility of recovery.” According to Susan G. Komen®, the patient empowerment model is an evidence-based concept that “combines the patient’s will with the physician’s skill, to improve the cancer survivor experience by

What’s Next?

sUrvivorship care plan:

the crUcial eleMents*

treatment summary, including diagnosis, test and results, tumour characteristics and types, details of treatment (initiation/completion dates) and treatment side-effects.

timing and content of follow-up visits.

tips on maintaining a healthy lifestyle and preventing recurrent or new cancers.

legal rights affecting employment and insurance.

Availability of psychological and support services.

*institute of Medicine, Cancer Patient to Cancer survivor: lost

in transition, 2005.

figure 1.

16 17

reducing the three most significant psychosocial stressors that cancer patients face: unwanted aloneness, loss of control and loss of hope.”

Some of the areas highlighted in the patient empowerment model include quality-of-life scores after surgery or systemic therapies such as hormonal therapy, psychological distress of cancer patients and supportive care, symptom control, and fertility and sexuality issues, which are more prominent in younger patients.

The same study discussed some distress symptoms that clinicians may or may not be trained to recognise as tell-tale signs. As primary care providers, the general practitioners may be well placed to identify and manage these symptoms (Figure 2).

featUre featUre

eMotional physical social• feeling anxious or fearful

• feeling down or depressed

• feeling irritable or angry

• feeling isolated, alone or abandoned

• feeling unsupported by my partner

• Managing my emotions

• Questions and fears about end of life

• worry about the future

• Ability to have children

• eating and nutrition during and after treatment

• exercise and physical activity

• fatigue (feeling tired)

• Pain

• Physical appearance

• sexual function

• sleeping

• swelling (lymphedema)

• weight gain or loss

• finances

• finding reliable information about complementary or alternative practices

• Managing health insurance

• returning to work

• talking with your doctor

• talking with family, children and friends

• Understanding treatment options

figure 2: distress-related problems.

Activities of ttsh Breast Cancer Patient support Group.

the Beginning of sUrvivorship careHealthcare professionals are gradually learning to hear our patients out rather than insist that they only heed our advice. Our treatment regimes are tailored to individual patients and their unique psychosocial situations.

Apart from medical treatment, looking into alleviating relevant side effects can be as crucial. For example, to lessen severe emesis during chemotherapy, patients are prescribed a cocktail of steroids that are given together with chemotherapeutic agents, which can cause weight gain. Present-day research efforts push boundaries to develop agents that deliver the same impact to cancer cells, with lesser side-effects (e.g. weight gain), thereby enhancing the patient's psychosocial well-being.

Dr Chen Jia Chuan, Juliana Dr Juliana Chen is the Clinical Director and Senior Consultant at The Breast Clinic @ Tan Tock Seng Hospital (TTSH). She did her post-graduate fellowship training at New South

Wales Breast Cancer Institute at Westmead Hospital, Australia. Dr Chen’s area of clinical interests include general, breast and endocrine surgery. She is also actively involved in the TTSH Breast Cancer Support Group.

References1. The New Front in Breast Cancer: After Treatment ends.

http://www.wsj.com/articles/SB10001424052970203499704576622873279960148.

2. Health-related Quality of Life in Breast Cancer Patients: A Bibliographic Review of the Literature from 1974 to 2007. Ali Montazeri Journal of Experimental & Clinical Cancer Research 2008, 27:32.

3. The Breast Cancer M.A.P. Project http://www.cancersupportcommunity.org/BreastCancerMAP

New research is emerging with a host of findings regarding the benefits of prolonged hormonal therapy; with new emphasis on the alleviation of post-menopausal symptoms from long-term hormonal therapy.

From diagnosis to post-treatment, we now spend more time individually to access the patient’s emotional recovery. There are also new roles added to the patient’s treatment plan to look into these areas such as the breast nurse, the psychologist and the social worker.

For younger patients, challenges with childbirth and fertility rise with age. The field of fertility in breast cancer treatment is gaining importance as patients value not just a cure from their disease, but also a significant post-treatment lifestyle.

Support groups play a substantial part in the psychosocial aspect of the recovering patient, post-treatment. They not only help to introduce a new patient to a group of understanding professionals, but also serve to form a new support network for them after treatment. Many of our patients form lifelong friendships, post-diagnosis.

At a stage of infancy in the field of survivorship care, awareness and involvement are good points of foundation. Primary care can also play an active role in the post-treatment care of breast cancer patients: we can all listen to and learn from our patients as well.

Breast clinic @ tan tock seng hospital is celeBrating oUr 5th anniversary in JUne 2015! Look out for more information on our Public Forum and the launch of an illustrated patient information booklet for breast cancer patients.

18 19

featUre featUre

THE GENERALMEDICINECLINICat tan toCk SenG hoSpitaL

department of General Medicine in Clinic 5A.

1) undiFFeRentiated ConditionS

Undifferentiated conditions include clinical problems such as involuntary weight loss, dizziness, lower limb edema, anaemia, prolonged fever, polypharmacy as well as abnormal laboratory results that need further workup. Some examples are persistent electrolyte imbalance and proteinuria.

2) diFFeRentiated ConditionSDifferentiated conditions of moderate severity which are difficult to control for various reasons can be referred to our clinic for further evaluation and management. Hypertension, diabetes mellitus, hyperlipidemia and chronic kidney disease (stage 3 and

Dr Teong Hui Hwang Dr Teong Hui Hwang is a Senior Consultant in the Department of General Medicine in Tan Tock Seng Hospital. She obtained her M.D. (with distinction) degree at the University of Alberta, Canada and became accredited as a specialist in internal medicine with the Specialist Accreditation Board, Singapore in 2002. She has a special interest in the field of hypertension.

Dr Chin Mei Lin, Adeline Dr Adeline Chin is a Senior Registrar in the Department of General Medicine in Tan Tock Seng Hospital. She graduated from Universiti Kebangsaan Malaysia in 1993 and obtained her MRCP (UK) in 2003.

below) are some examples. Organ-specific diseases of a more severe stage may be more appropriately managed at the respective sub-specialty clinic. When the above-mentioned disease entities cluster together in a single patient, especially in the presence of progressive target organ damage, management can be complex and may warrant referral to our clinic. Collaboration with other sub-specialties as well as allied health departments are considered in order to manage the patient holistically and expediently.

Complex cases with multiple disease entities also fall under this category when two or more of the above conditions require collaboration with other specialties as well as allied health departments to manage the patient in a more holistic manner. In addition, there are also clinics of special interest within the Department of General Medicine.

i) Hypertension Clinic Possible secondary, resistant and difficult to control hypertension cases can be evaluated and managed.

ii) Vascular Medicine Clinic Venous thrombosis and peripheral vascular

diseases are diagnosed and treated.

iii) Perioperative Medicine Clinic Uncontrolled medical conditions such as

hypertension and diabetes mellitus are optimised before operation.

iv) Obstetric Medicine Clinic In KK Women's and Children's Hospital, chronic

medical conditions such as diabetes, hypertension and asthma are monitored and managed closely before and during pregnancy as well as post-delivery.

In today’s era of medical sub-specialisation, the General Medicine Clinic continues to play a relevant role in providing a secondary level of care in the

clinical evaluation and management of patient profiles deemed too complex to be handled by the primary care practitioner.

At Tan Tock Seng Hospital, the General Medicine Clinic offers medical consultation for adult patients over a wide variety of conditions.

As the general medicine specialty traditionally adopts a broad perspective, it is well-poised to manage patients with undifferentiated and multiple co-morbidities, requiring further evaluation and management.

Thus, the clinic referrals can be classified into two broad categories.

It is the goal of the General Medicine Clinic to discharge the patient to primary care, once the clinical evaluation is completed and the subsequent management of the patient is stable.

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shown to accelerate the development of BPH.

Other diseases can influence the development of BPH. For instance, poorly controlled diabetes and hypertension increase the risk of lower urinary tract symptoms by up to 70%.

what aRe the tReatment optionS?The choice of treatment is largely governed by the severity of the symptoms. Mild symptoms can be managed through lifestyle changes, while moderate to severe symptoms are managed with medication or surgery.

(a) Managing BPH Without MedicationWhen symptoms are mild, some lifestyle changes may help.

These include: • Reducing fluid intake three hours

before sleeping • Avoiding alcohol and caffeine in

the evenings as these are diuretics that increase urine production

• Elevating your legs before sleep. It improves the circulation of blood in the lower limbs and allows excess water to be cleared by the kidneys before sleep

• Double voiding• Timed voiding• Pelvic floor muscle training

Some medication can make the symptoms of BPH worse, and should

be avoided: • Decongestants, anti-histamines

and some cough medication, as it may make urinating more difficult

• Diuretics will increase urine output

(b) Medication for BPHThe following medication can be started for BPH:

Alpha Blockers• Relaxes the prostate to improve

urine flow• May cause low blood pressure

and giddiness• Can lead to abnormal

ejaculation, though these side effects often resolve with the stopping of the medications

5-Alpha-Reductase Inhibitors• Reduces the size of the prostate

by up to 30%• Reduces libido and may lead to

sexual dysfunction, ejaculation disorders and erectile dysfunction

• Gynaecomastia (enlargement of the breast)

Sildenafil• Drug normally prescribed for

erectile dysfunction. It was found that when taken daily in low doses, it can help relieve some of the symptoms of BPH to a similar degree as alpha blockers.

• Patients with cardiac medication in particular nitrates, should seek their doctors’ opinion before starting this medication.

Go GReen with youR

pRoStatewhat iS BeniGn pRoStatiC hypeRtRophy (Bph)?Mr Chia (not real name) is a typical patient with benign prostatic hypertrophy (BPH). He had been displaying urinary symptoms for the past few years but had ignored it. He finally developed retention of urine and required a catheter insertion.

The prostate is a gland that lies below the bladder, and produces part of the secretions in semen.

Benign prostatic hypertrophy is a condition that will affect 50% of men at 50 years of age and up to 90% of men, by the time they are 80 years old. It is a condition where the prostate enlarges, leading to gradual obstruction of the urinary flow. As the name implies, it is benign and not a cancer.

Patients presenting with lower urinary tract symptoms can be broadly grouped into two main categories; one issue with voiding (urinating) or the other with storage. The symptoms of voiding include

hesitancy, slow flow, dribbling of the urine and incomplete emptying, whereas the symptoms of storage include increased frequency of urination, night-time urination (nocturia) and sometimes incontinence.

If left untreated and allowed to progress, complications can develop. These include repeated urinary tract infections, the formation of bladder stones, the total inability to pass urine (acute retention of urine) and possibly damage to the kidneys.

Can we pRevent Bph?As with many diseases, the development of this condition is a factor of genetics and environment. Genetics cannot be changed, but there is a growing body of evidence to suggest that lifestyle changes can delay and slow down the progression of BPH.

There is a strong correlation between obesity and BPH. In people with a BMI of more than 35, there is a 3.5 times increased risk of BPH. Exercise also seems to delay the progression of BPH. It is recommended that men should exercise at least three times a week for at least 30 minutes.

Diet also plays a role in the development of BPH. High salt, fat and meat diets are associated with BPH, while vegetables, in particular soy products, seem to delay the development of BPH. A high intake of refined sugars has also been

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A scope is passed down the urine tract to the prostate and the enlarged prostate is cored out with a hot metal loop.

There is a small risk of heavy bleeding that may require blood transfusion. The patient stays with a catheter inserted for about two days, and a wash out is required at least one day after surgery to prevent blood clotting in the bladder.

Green Light Laser vaporisation of the prostateTan Tock Seng Hospital has recently adopted a new technique of treating the enlarged prostate called transurethral vaporisation of the prostate (TUVP). This involves inserting a small scope down the urinary tract while the patient is asleep, and a laser is used to vaporise the prostate.

This procedure has the benefit of less bleeding, as compared to the old method of TURP. With the use of green light vaporisation, the patient often stays in hospital for less than a day and with the

The medication above can be taken in combination, but they only yield a 30% improvement in symptoms. They must also be taken for life, to prevent the recurrence of symptoms.

Alpha Blocker 5α Reductase Combination Sildenafil TURP or TUVP

% Improvement in Prostate Symptom Score

30% 37% 37% 30% 80-90%

% Change in Flow Rate 15% 15% 30% No change 83%

Dr Tan Yung Khan Dr Tan Yung Khan is a Consultant in the Department of Urology at Tan Tock Seng Hospital. He is also the Director of Endourology and Co-Director of the Minimally Invasive Urology Fellowship and

a clinical lecturer at National University of Singapore Yong Loo Lin School of Medicine.

Dr Tan completed his urology training in Singapore and received the National Medical Research Council (NMRC) scholarship to do advanced research in robotic surgery and minimally invasive surgery at the University of Texas Southwestern Medical Center, Dallas, Texas, USA. He also matched in the Endourology Society training programme in the United States and spent a year at Columbia Medical Center, New York City, focusing on endourology and the management of stone disease.

Green light vaporisation of the prostate.

catheter removed before going home. As it causes less bleeding, it can also be performed on patients with aspirin and warfarin.

So what happened with Mr Chia? Unfortunately, even with medication, he continued to experience urinary retention. Subsequently, he decided to go for the green light vaporisation of the prostate. His procedure went well and he was discharged after an overnight stay without the catheter. He experienced no pain and had excellent flow of urine on his follow-up visit.

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transurethral vaporisation of the prostate (tUVP).

The main aim of the surgical procedure is to create a wide and durable channel for the urine to pass out from. As with any surgical procedure, it is important to choose an experienced doctor skilled in this surgery, so as to get the best possible outcome.

transurethral Resection of the prostate (tuRp)The mainstay of surgical management is the transurethral resection of the prostate (TURP).

(c) SurgerySurgery for the prostate is often performed for patients who have moderate to severe symptoms, and have developed complications of BPH or do not/cannot take medication for the condition.

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phySiotheRapy manaGement oF

[1] Paskett ED, Naughton MJ, McCoy TP, et al.: The epidemiology of arm and hand swelling in premenopausal breast cancer survivors. Cancer Epidemiol Biomarkers Prev 16 (4): 775-82, 2007.

[2] Beesley, V., Janda, M., Eakin, E., Obermair, A. and Battistutta, D. (2007), Lymphedema after gynecological cancer treatment. Cancer, 109: 2607–2614. doi: 10.1002/cncr.22684.

CanCeR-ReLated

Lymphedema is one of the complications that can arise from cancer or cancer-related treatments. Lymphedema can develop at any part of the body, depending on the site of the tumour and its treatment.

Upper limb lymphedema is most commonly found in breast cancer patients. About 8 to 56% of breast cancer patients develop lymphedema, two years post-surgery [1]. Lower limb lymphedema may arise from cancer of the cervical, uterine and prostate regions. Approximately 5 to 36% of patients with gynecological cancers were diagnosed with lower limb lymphedema [2].

Lymphedema may cause physical and psychological stress to patients. Therefore, it is important to identify and treat lymphedema as early as possible.

Lymphedemawhat iS Lymphedema?Lymphedema is an abnormal accumulation of protein-rich lymph fluids in the body tissue spaces, due to the disruption of the lymphatic system either from tumours, surgeries from cancer or radiotherapy.

Lymphedema can be classified into either primary or secondary lymphedemas. Cancer-related lymphedema is classified as a secondary lymphedema.

LymphatiC SyStemThe lymphatic system consists of lymphatic vessels and lymph nodes. The lymphatic system works closely with the blood vessel system. Its functions are to collect and transport fluid from body tissue spaces back to the vein in the blood system, to fight infections and to maintain fluid balance in the body.

Lymph FoRmationNormally, water and nutrients carried in the blood vessels exit the vessels and enter the body tissue spaces to nourish the body cells. The lymphatic vessels will then pick up these water and nutrients, along with some waste products in the tissue spaces,

forming lymph. Lymph is a clear, watery fluid consisting of water, fats, protein and white blood cells. Ultimately, the lymph will be returned to the blood system.

how doeS Lymphedema oCCuR?The amount of lymph transported through the lymphatic vessels at any time is known as the lymph load. The lymph load can be variable. For example, when there

BLood veSSeL

tiSSue SpaCe

LymphLymphatiC veSSeLS

Direction of Blood Flow

Direction of Lymph Flow

FoRmation oF Lymph is an infection or injury to the body, lymph load can increase.

A person’s transport capacity depends on the ability of the lymphatic vessels to hold and transport the lymph. Normally, we have a very high lymphatic transport capacity and as such, we are able to manage with any given amount of lymph load.

The transport capacity can be lowered, due to an obstruction in the lymphatic vessels. The obstruction can be caused by the tumour pressing on the lymphatic vessels or any surgery and/or radiotherapy involving the lymph nodes. Lymphedema will develop once the lymph load exceeds the lymphatic transport capacity.

CompLiCationS oF LymphedemaLymphedema can be quite distressing and can affect one’s

dos Avoid scratches, cuts, burns or injuries to the affected limb.

Apply antiseptic cream to injured area/wound on the affected limbs.

Apply insect repellent to avoid insect bites.

Apply sun block cream to avoid sunburn if you expect to be under prolonged sun exposure.

Always keep affected limb clean. Apply moisturiser regularly to protect against dry and cracked skin.

Wear gloves when doing housework, washing with detergent or gardening.

quality of life, if left untreated. There will be worsening of swelling, feeling of heaviness, aching, pain and discomfort of the affected limb. As a result, one may find difficulties in performing activities of daily living. Besides, it can cause psychological stress as patients may perceive disfigurement of the affected body part and hence withdraw from social events.

As the lymphedema develops, it will lead to tissue hardening (i.e. fibrosis) and may increase the risk of soft tissue infection (i.e. cellulitis). This may cause further progression of lymphedema and disability.

Therefore, early identification of this condition is important to prevent it from developing and early treatment can be started once it is diagnosed.

Wear proper footwear in outdoors. Elevate the affected limb on a pillow when sleeping.

Move affected limb as much as possible after surgery or radiotherapy.

Do the exercises taught by your physiotherapist regularly.

Seek medical advice and attention if there is any swelling, redness or pain on the affected limb.

Keep yourself well-hydrated to maintain supple skin.

Wear a compression garment if you are travelling on a plane.

Avoid aggressive massage and exercises on the affected limb.

don’ts Don’t cut cuticles during manicure or pedicure.

Don’t allow blood pressure taking, injections and having blood drawn on the affected limb.

Don’t use razors to remove body hair; Use electric shavers or depilatory creams instead.

Don’t carry heavy items (e.g. shopping bags, groceries) with the affected arm.

Don’t lie on the affected arm to sleep. Don’t expose affected limb to direct sunlight or heat for prolonged periods (e.g. hot baths, sun tan and sauna).

Don’t wear tight and constrictive clothing, undergarments, jewellery or accessories on the affected limb.

pReventinG Lymphedema and the woRSeninG oF Lymphedema

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tReatment oF LymphedemaThe standard treatment for lymphedema is known as complete decongestive therapy (CDT). CDT is not a cure for lymphedema but it can help to control its symptoms.

Lymphedema must be treated by certified lymphedema therapists.

CDT consists of the following components:1. Good Skin and Nail Care This is to maintain a good

protective layer of skin to reduce the risk of infections.

2. Manual Lymph Drainage (MLD) This is a special form of massage to re-channel lymph fluid from affected areas to non-affected areas. For example, lymph fluid from the swollen left arm can be massaged or drained to the right armpit and neck, which possess many well-functioning lymph nodes. This massage is done in two phases: the intensive phase and maintenance phase.

INTENSIVE: Most reduction is achieved in this phase, which lasts from two to five weeks. It should be done daily for 40 to 90 minutes for five times per week.

MAINTENANCE: A phase of transition to self-care by patients.

Manual lymph drainage (Mld)

ShoUldeR eleVATIoN exeRCISe• Lift the affected arm gently as high as

possible, while taking a deep breath. • Lower the arm slowly and breathe out. • Repeat 10 times, across three sessions daily.

4. Therapeutic Exercises These exercises are done to

facilitate general lymph flow.

NeCk exeRCISe• Turn your neck from side to side gently. • Repeat 10 times, three

sessions per day.

Upper limb compression bandaging

3. Compression Therapy Elastic bandages or compression

garments are used to control swelling. During the intensive phase, compression bandaging will stay on patients for the entire day except during showers.

During the maintenance phase, a compression sleeve or stocking will replace the bandaging. These compression garments can be purchased ready-made or custom-made.

1. 2.

theRapeutiC exeRCiSeS

1. 2.

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Salmon Cha Soba

Nutrition Information Panel Per ServingCalories (kcal) 555Carbohydrates (g) 58Protein (g) 27Total fat (g) 23.8Saturated fat (g) 4.2Cholesterol (mg) 29Dietary fibre (g) 5.7Sodium (mg) 512

fitness

hANd exeRCISe • Keep the affected arm up, open and

close palms. • Repeat 10 times, across three

sessions daily.

Tan Tock Seng hospital (TTSh) has a team of certified lymphedema therapists in the Physiotherapy department that sees patients with cancer and non-cancer related lymphedema in inpatient and outpatient physiotherapy setting and in The Breast Clinic @ TTSh.

(from left) roselyn Choo, senior Physiotherapist; wong li ting, Principal Physiotherapist; Khoo ting yin, senior Physiotherapist; Vernetta wong, senior Physiotherapist; and teo wei Juan, senior Physiotherapist (not in photo).

elBow exeRCISe • Keep affected

arm up, bend gently and straighten the elbow.

• Repeat 10 times, across three sessions daily.

healthy recipe

Salmon Cha Soba (Serves 4)

Ingredients

240g cha (green tea) soba noodles400g salmon fillet (cut into 4 portions)2 small carrots (200g)150g snow peas2 small tomatoes (quartered)100g corn 2 garlic cloves (chopped)1 tbsp canola oil1 tsp light soy sauce

For salmon marinade:1 tbsp dark soy sauce½ tbsp light soy sauce1 tsp sesame oil1 tbsp canola oil4 garlic cloves (chopped)

Method:

1. Mix chopped garlic, dark soy sauce, light soy sauce, sesame oil and canola oil in a large bowl. Add salmon fillet and marinate for at least one hour in the fridge.

2. Boil water and cook cha soba noodles till they are al dente. Dish out the noodles onto four plates and set aside.

3. Heat 1 tablespoon of canola oil in a frying pan. Add in chopped garlic and stir fry till slightly brown. Add in chopped tomatoes, chopped carrots, corn, snow peas and stir fry for two to three minutes.

4. Add in cha soba and soy sauce. Stir the noodles and vegetables until they are well mixed.

5. Plate out the noodles and vegetable mix.6. In a separate pan, add in 1 tablespoon of canola oil and pan

fry the salmon (starting with the skin first if there is skin on the salmon) for 3 minutes until it is light brown. Turn the fillet over and cook the other side for another 3 minutes or until the salmon is cooked thoroughly.

7. Place the cooked salmon fillet with the noodles and vegetable mixture. Serve.

Cha soba noodles (soba noodles flavored with green tea) are a good source of fibre as they are made from buckwheat. Salmon is a good source of protein, which is an important macronutrient for muscle mass maintenance and optimal immune system. In addition, salmon also contains omega-3 fatty acids which has been shown to exhibit anti-inflammatory properties and is also beneficial for the heart. Colourful vegetables in this dish provides a variety of vitamins, minerals and antioxidants.

overall, this dish is packed with nutrients and provides vitamins, minerals, energy and protein for the individual undergoing cancer treatment.

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2.

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2.

Recipe was designed by the Nutrition & Dietetics Department and Hospitality & General Services of Tan Tock Seng Hospital.Photo courtesy of Mr Henry Lim, Photographer, Tan Tock Seng Hospital.

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MULTI-DISCIPLINARY SPECIALIST CARE

TTSH PEARL’s suite of clinics and services is guided by the four pillars of care through

Evidence Care, Destination Care, Team Care and Personalised Care. We remain committed to

delivering a higher level of patient care as We Value Our Patients Most.

PEARL CLINICS AND SERVICES(NON-SUBSIDISED)GP Appointment Hotline: (65) 6359 6500

CLINIC B1B•OrthopaedicSurgery Tel: (65) 1800-73275-00 Email:ClinicB1B@ttsh.com.sg

•Rheumatology,AllergyandImmunology Tel: (65) 6889 4027 Email: Contact@ttsh.com.sg

CLINIC 2B•GastroenterologyandHepatology•GeneralSurgery•Urology Tel: (65) 1800-73275-00 Email:Clinic2B@ttsh.com.sg

CLINIC 4B•DiabetesandEndocrinology•GeneralMedicine•Haematology•MedicalOncology•PsychologicalMedicine•PsychologicalServices•RenalMedicine•RespiratoryandCriticalCareMedicine Tel: (65) 1800-73275-00 Email:Clinic4B@ttsh.com.sg

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•Dental Tel: (65) 6889 4627 Email:Clinic6B@ttsh.com.sg

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