salubris july - sept 2013

FUNDING IS THE STEPPING STONE TO FINDING A CURE FOR CANCER

AN NCCS QUARTERLY PUBLICATION July – September 2013

Issue No. 26 • MICA (P) 061/10/2010

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

...HELPING R EADERS TO ACHIEVE GOOD HEALTH

PROF SABAPATHY’S SUCCESS IN RESEARCH OWES IT ALL TO GOOD FUNDING SUPPORTChallenges have never daunted Prof Kanaga Sabapathy. Even in his early days fresh from post-doctoral training, he chose to study p53 tumour suppressor protein against the advice of well-meaning peers and mentors. They felt that alot was already known about the protein and the field was extremely competitive and hence, not quite promising for a new Principal Investigator (PI).

It is a very satisfying experience to be able to find something new, solving scientific mysteries and getting the grants for them. Funding allows for ideas to be tried and developed into something of good quality. Like how electronic engineering science has helped built products, there is a lot of room for science to be developed into something tangible.

PROF SABAPATHY

2 SALUBRIS JULY – SEPTEMBER 2013

B ut Prof Sabapathy believed in himself and went against the odds. Today he has carved out a career by studying the gene, and is one of the few scientists in Singapore who is making impactful discoveries on

p53 and its role in tumourigenesis.

Working within the constraints of a very competitive research funding environment in Singapore, Prof Sabapathy has received over $10 million worth of funding to support his research in the last ten years. However, the past two years had not been a bed of roses. While significant discoveries have been made by his laboratory in the p53 and p73 field in relation to the use of these proteins in cancer formation and response of patients to therapeutic treatment, additional funding was needed to take the research further to translate them into benefits for patients. It was only after two failed grant application attempts that Prof Sabapathy succeeded again.

Recounting the challenge, Prof Sabapathy said it was not all losses without any gain. “It taught me that even if you are already an established investigator, you cannot rest on your laurels. These temporary setbacks help you to learn to improve along the way ahead of time before the current grant expires and make sure that there is a regular supply of funds to keep your research and staff going.”

The experience has made Prof Sabapathy more apt in getting funding for his research. He has also created a stir in the research community by acquiring the largest funding to date - a $26 million grant from the National Medical Research Council (NMRC) to sustain and expand the research infrastructure at NCCS. The funding will help to make it conducive for all the research at NCCS, and to allow them to focus on enhancing the whole value chain of clinical research to patient care for Asian cancers over the next four years. The research will look at all aspects of the cancer, from prevention to early detection through screening, therapeutics to end-of-life and health services research, collaborating with multiple groups to translate all the findings for the benefit of the patient.

As he presented his grant submission, which had morphed from a paper to a 350-page-book submission, he attributed this success to the opportunity given to him by NCCS Director, Prof Soo Khee Chee, who tasked him to write the grant submission before he assumed the headship of the Division of Cellular and Molecular Research in January this year.

Prof Sabapathy said what has kept his interest in science alive is to be able to do the thing he loves. “It is a very satisfying experience to be able to find something new, solving scientific mysteries and getting the grants for them.

Funding allows for ideas to be tried and developed into something of good quality. Like how electronic engineering science has helped built products, there is a lot of room for science to be developed into something tangible.” He is also grateful for the mentorship of Prof Hui Kam Man, who is his predecessor. “Prof Hui has been an inspiration. I’ve learned a lot from him over the years at every stage, from a student to a PI. How he does and handles things is a learning experience for me.”

In his new role as Head of the Division of Cellular and Molecular Research, Prof Sabapathy’s vision is to make NCCS a premier research institution where translational work, through the whole spectrum of cancer research is being carried out.

Beyond that, what is occupying the mind and time of the veteran scientist is his plan to further develop the paths for the younger clinicians by paving the way for them to embark on science and produce integrated research, working with scientists to produce more effective clinical outcomes for patients in the long run. He said it is vital for clinicians and scientists to work together. Acknowledging the benefit of creating an environment where clinicians and researchers are housed under one roof at NCCS as a good starting point, Prof Sabapathy felt that more could be done. “We need to embed a culture of collaborative innovation within us. There is definitely room for growth and we need to transform the research culture from a purely curiosity-based approach to elucidating something that will be applicable for patients.”

While grateful for the extensive help that the government has rendered to the research community with the biomedical push since 10 years ago, Prof Sabapathy felt that what needs to be done is for the industry to enhance the standards of research across all agencies, to ensure a continuum of substantial and quality research. He said funding plays an important role in furthering science and its outcomes, citing the success of agencies like Cancer Research UK, where funding comes wholly from the public.

“We need public support in the form of monetary donations as well as patient material. The former needs more effort as we need to change the mindset of the public and convince them to understand that they are contributing to help scientists make discoveries that will be stepping stones towards finding a cancer cure eventually.”

BY VERONICA LEE

3SALUBRIS JULY – SEPTEMBER 2013

“TO JOIN OR NOT TO JOIN...” FEARS AND MISCONCEPTIONS OF CLINICAL TRIALS DR LEE GUEK ENG, DR MANDY OW, DR REBECCA DENT

Not too long ago, a journalist wrote a commentary in a public newspaper regarding clinical trials in medicine. The picture painted was a daunting one; however it does illustrate the fears and concerns towards participation in clinical trials for many of our patients especially in our Asian cultural context.

G lobally, clinical trial recruitment rates are as low as 4%. Research in US and Canada showed that recruitment was even lower amongst elderly and certain ethnic groups, including Asian patients. In these countries, the

option to enrol in a clinical trial is viewed as an opportunity – a way to access new drugs that are otherwise inaccessible. This mentality is rare in the Asian sociocultural context. Although many reasons are hypothesized for cross-cultural differences in attitudes, actual research into local patient perspectives is lacking.

To understand these perspectives, the National Cancer Centre Singapore (NCCS) recently conducted focus groups among breast cancer patients. This was a research study to understand our local patient perspectives on clinical trials, including their concerns and apprehensions.

Uncertainty and fear about side effects and the severity of side effects were the most common concerns among patients. Patients reported being apprehensive about the ideas of trying something new and ‘unknown’, and of randomisation, which is the random allocation to one of two possible treatments. In the words of one patient, randomisation felt like “the risk is high and it is like tikam tikam!”(Literally, to stab, but colloquially used to mean “try your luck”).

However, it appears that such apprehension could be related to a lack of understanding of clinical trials. When we correlated patients’ willingness to participate in trials, we found that patients who knew less about trials were less willing to participate. It is often said that that “Fear of the unknown is the greatest fear of all”. Understandably, if a patient knows little about clinical trials, deciding to take part is analogous to hanging their life by a thread. This is especially true in oncology, where side effects of chemotherapy could be severe and sometimes even fatal.

There were also some misunderstanding about trials, including “nothing is known about the drugs and we are asked to try it’, and ‘if we do not get the new medicine then we are not getting any treatment’. Drug development is a long process which includes a pre-clinical phase followed by a clinical phase. Before a new drug enters the market and is tested on humans, there are various safeguards by regulatory bodies to ensure that many aspects of the drug development are fulfilled. These include safety details, toxicity, pharmacokinetics and metabolism of the drug. In addition, the physiochemical properties of the drug including its formulation, preparation, stability as well as solubility will be established prior to human use. It is also a legal requirement by drug licensing authorities that that an assessment of major organ toxicity is performed. These preliminary tests are usually done in animal testing or on cell culture. Hence, it is a mistaken perception that nothing is known about these drugs.

In more detail, the clinical phase of drug development comprises of three parts, and is carried out in humans. Phase I starts with a small number of patients to study dosing and interactions. Phase II is used for studying efficacy of the drug. When the drug is shown to have preliminary efficacy, large pivotal trials i.e. Phase III trials are carried out in a bigger population to conclude its safety and efficacy. All clinical trials must be approved by our local Institutional Review Board, and studies are done in accordance with the ‘Helsinki Declaration’ and ‘Good Clinical Practice Guidelines’. These are ethical bodies that uphold international quality standards and ensure patient safety. Hence, even locally, ethical conducts and protection of human rights are ensured for patients participating in trials. With these guidelines in place, randomisation to either arm of treatment generally means that even if patients do not receive new drugs, they will still be getting a comparator arm of standard and current drug therapy.

As medical oncologists, we want to offer the best treatments for our patients. Clinical trials offer the hope of the next best treatment. Studies have shown potentially better outcomes for patients who were enrolled in clinical trials, and even patients treated at centres involved in clinical trials, when compared to patients treated in centres that are not involved in clinical trials. In addition to the hope of receiving better health outcomes, some patients in our focus groups expressed altruistic beliefs and motivation to enrol in trials, describing the reason for participation as helping to further research and improve treatments for fellow and future cancer patients.

Indeed, the licensing of various chemotherapy drugs today represents the success of numerous clinical trials that these drugs have passed through before they are approved by governing bodies and enter the shelves in our pharmacies. Some patients also view enrolment into clinical trials as a symbol of hope that there is a chance that their condition may improve. Let us hope that with more understanding of drug development and clinical trials, more and more patients are encouraged to participate in such trials, so that they can contribute to the understanding of disease and its treatment, while at the same time possibly benefiting from the trials.


CONTROVERSIES OF PROSTATE CANCER SCREENINGDR JONATHAN TEH Associate Consultant Division of Radiation Oncology

P rostate cancer is the third most common cancer and the sixth most frequent cause of cancer death in Singapore men. The

prostate specific antigen (PSA) blood test is currently the best available screening test used to detect possible prostate cancer, which has to be confirmed with an ultra-sound guided biopsy. While it seems attractive that a simple blood test could lead to early diagnosis and therefore a higher chance of successful treatment, scientific evidence shows the story is not so simple when it comes to prostate cancer screening in men without symptoms.

Population-based observational studies have shown that an increase in PSA-based screening has coincided with an increased incidence of prostate cancer, but a decreased incidence of advanced prostate cancer and prostate cancer related deaths. However, observational studies cannot prove a causal relationship between PSA screening and improved prostate cancer outcomes, since factors like improving treatment modalities could also account for these. Therefore, randomised trials have been conducted in an attempt to prove the efficacy of PSA screening in reducing prostate cancer related deaths. Two such trials, one each side of the Atlantic, have in recent years shaped current guidelines about the role of PSA screening.

The prostate screening component of the USA-conducted Prostate, Lung, Colorectal, Ovarian trial (PLCO) on 76693 men aged 55-74 did not show a reduction in prostate cancer deaths. Reasons cited for the apparent lack of effect of screening included a significant number of patients who were already screened before the trial commenced (pre-screening) and a high number of patients who underwent screening in the control arm. Thus this trial did not provide a direct comparison of screening versus no screening.

Conversely, the European Randomised Study of Screening for Prostate Cancer (ERSPC) on 162,243 men aged 55-69 showed a 20% relative risk reduction in prostate cancer deaths, but the absolute effect was modest, requiring 1,000 men to be screened, and 37 prostate cancers diagnosed, in order to prevent one prostate cancer death.

While there is evidence that PSA screening can reduce the number of prostate cancer deaths, there are potential harms to population based screening. Firstly, a high PSA does not necessarily indicate the presence of cancer. False-positive results may be due to infection, benign prostatic hyperplasia or just normal physiologic variation. Thus, many men who undergo biopsies on the basis of an elevated PSA will have a negative result. Moreover, prostate biopsies do carry some inherent risks too.

We know prostate cancer to be a heterogeneous entity with a spectrum ranging from indolent disease that does not manifest in the patient’s lifetime to locally advanced or metastatic disease with shortened survival. Routine population based screening can therefore lead to ‘overdiagnosis’ of many non-harmful cancers. At present, there is no certain way to tell which cancers need treatment and which do not, and the majority of men diagnosed with prostate cancer will end up undergoing treatment. Active surveillance of cancers with characteristics suggesting indolence is gaining traction, and may well reduce the proportion of men with prostate cancer who end up receiving treatment. However, at present, we do not have enough data to establish the optimal surveillance protocol. Therefore the problem of ‘overtreatment’ is that while all these men will have to live with the potential sequelae of treatment, not all of them will benefit from the treatment itself. These sequelae include urinary incontinence, impotence and problems with bowel control.

In May 2012, the U.S. Preventive Task Force (USPTF) issued a final recommendation on screening for prostate cancer and concluded that for any age group, the expected harms of PSA screening are greater than the potential benefit.

The newly released American Urological Association (AUA) guidelines on early detection of prostate cancer recognised the positive results of the ERSPC study and advocated the benefits of screening in men aged 55-69. Because the absolute reduction in prostate cancer specific mortality was relatively small, it advocated taking the life expectancy of each man into account, as men with a limited life expectancy of less than 10-15 years may not benefit from aggressive treatment for localised prostate cancer. To this end, it is emphasized that the decision to screen should be a shared one between doctor and patient, after a discussion about the patient’s individual risk and co-morbidities, how screening might influence his overall life expectancy and the risk of experiencing morbidity from prostate biopsies and prostate cancer treatment. In addition, to reduce the harms of screening, the AUA suggests that a routine screen interval of two years or more may be preferred over annual screening. It is expected that this interval will preserve the majority of benefits of screening while reducing overdiagnosis and false positives.

The Ministry of Health (MOH) Singapore Clinical Practice Guidelines on Cancer Screening 1/2010, which preceded these more recent U.S. based guidelines, are already largely in line with them and provide a good reference point for general practice.

In summary, routine population based screening in asymptomatic men is not recommended. For men who express an interest in screening, the decision to screen for prostate cancer should be a shared one between doctor and patient, after a full discussion of the potential benefits and risks of early detection and treatment. Good two-way communication and sharing of information would go a long way in helping men make an informed choice.


T here are three methods of breast cancer screening programme: breast self-examination, clinical breast examination, and mammography. Only screening mammography has been shown to have a beneficial

effect in mortality. When screening mammography became widespread in the 1990s in the United States, the mortality rate from breast cancer decreased by 31%. While some of this mortality reduction can be attributed to improved treatment of breast cancer, much of the reduction appears to be due to earlier detection of the disease with screening mammography, using calculations based on computer modeling as well as further studies from Sweden and the Netherlands which measured the effects of mammographic screening in large general populations.

Mammography screening is meant to reduce breast cancer mortality through early diagnosis and treatment of disease. However, in some cases a screening mammogram may detect a cancer that would have neither caused death nor presented clinically during the woman’s lifetime, meaning she would never have acquired a cancer diagnosis had she not attended screening. This is termed overdiagnosis. The main questions are how large the benefit is in terms of reduced mortality from breast cancer and how substantial the harm is in terms of overdiagnosis.

Earlier studies on overdiagnosis included estimates and statistical modelling. A Norwegian study showed 50% over-diagnosis, but with insufficient follow-up. More recent studies show varying rates of overdiagnosis ranging from 1% to 54%. Some authors have stated it was possible that the observed incidence could be caused by increased use of hormone replacement therapy or by changes in childbirth alone or in combination with screening.

Randomised controlled trials (RCT) provide the most reliable information about the effects of breast screening. High-quality randomised controlled trials are prone to fewer distorting effects, or biases, than observational studies. The best estimate of the magnitude of overdiagnosis would be to study the cumulative incidence of breast cancer over time in women invited to screening, compared with a group of unscreened controls. These studies should consist of screening for 20 years or more, involving subjects with similar age, exposure to breast cancer risk factors (e.g. hormone replacement therapy and availability of treatment - and followed up until death. An excess of cancers in the screened group would represent the amount of overdiagnosis. Unfortunately, such a study does not exist, and therefore estimations of overdiagnosis require some indirect inference from available studies.

The most reliable estimates of overdiagnosis come from 3 RCT, in which women in the control group were not offered screening at the end of the trial (in the other RCT all the women in the control group were offered screening at the end of the active period of the trial, which might be expected to lead to some overdiagnosis and thus to an overall underestimate of overdiagnosis). These three trials are Malmö I, for women aged 55-69 years, and the two Canadian trials which screened women for five years and reported follow-up data at 11 years.

On the basis of direct observations the authors of the Malmo trial found a 10% rate of overdiagnosis of breast cancer 15 years after the end of the original Malmö I mammographic screening trial. This trial was population based, randomisation was by individual, and the trial time was longer and more screening rounds were completed than in any other trial of screening for breast cancer. The randomised design was maintained for almost five years after the trial had ended.

MAMMOGRAPHY IS STILL TOP FOR BREAST CANCER SCREENINGDR PATRICK TEO Consultant Division of Oncologic Imaging

The aim of any screening programme is to detect life-threatening diseases at an earlier, more curable stage. It is well established that the five-year survival rates for women with early stage breast cancer are far better than those with regional disease or distant metastases. Therefore, the earlier breast cancers are detected, the better the prognosis and treatment options for the patient. Screening mammography allows detection of a clinically occult breast cancer which belongs to the disease stage when there is greater potential to be treated successfully. Screening thus advances the time of diagnosis so that prognosis can be improved by earlier intervention.


Ductal carcinoma-in-situ (DCIS) is a malignant tumour composed of cells that do not infiltrate beyond the limiting basement membrane and remain within the ducts where they arose. The importance of DCIS in breast screening is that before screening mammography was introduced, DCIS made up only 2%-5% of breast cancers. It was diagnosed only when the tumour became palpable. In mammographic screening programs, DCIS now makes up 20%-30% of the cancers detected.

A recent article in the mainstream media suggested there was no merit in treating ductal carcinoma-in-situ (DCIS) and its treatment would be considered as part of overdiagnosis.

The RCTs of treatment of DCIS give us clear evidence that DCIS generally does have progressive potential and that its detection and treatment are valuable. Results of the Gothenburg and Two-County Trials have proved that DCIS is a precursor lesion for invasive breast cancer. Detection and removal of DCIS resulted in fewer subsequent invasive cancers. In one of the largest trials involving DCIS, the recurrence rate for surgically resected DCIS, without radiation therapy, was 26.8% at eight years with half of the recurrences being invasive cancers. Complete therapy with postsurgical radiation therapy reduced the recurrences to 12.1%, with only 3.9% being invasive. This frequency of relapse in ductal carcinoma in situ that has been treated shows that although it may contribute to overdiagnosis, it is wrong to assume that all ductal carcinoma-in-situ represents overdiagnosis and does not require treatment.

The relevant question is perhaps not whether DCIS progresses to invasive cancer (which it can) but whether it might progress to an invasive cancer that causes symptoms within the lifetime of the woman concerned.

It is important to point out that there are no pathologic features that can help differentiate a progressive cancer from a non-progressive cancer which means there is no reliable method to determine which patient with DCIS, if left alone, would not progress to become frank invasive cancer.

It is widely agreed that screening using mammography can reduce mortality in breast cancer. On the negative side, there is perhaps a 1% chance of having a cancer diagnosed and treated that would never have caused problems if a woman had not been screened. The consequence of overdiagnosis is that although a woman with a screen detected cancer has surgery followed in many cases by radiotherapy and chemotherapy, neither the woman nor her doctors would know whether this particular cancer would be one that would affect her mortality or one that would have remained undetected for the rest of the woman’s life.

RCTs have shown significant decrease in breast cancer deaths among women invited to screening from age 40 years onward in the order of 20%-25%. In two well known RCTs – the Two-County and Gothenburg Trials – the estimated overdiagnosis rate was only 1%. Similar results were also observed in trials from Denmark and Italy.

We must also inform women that early detection, although not perfect, has been repeatedly demonstrated to reduce deaths from breast cancer and that the risk of overdiagnosis is insignificant as compared with its benefits.


FAMILY MATTERSDR TAN MIN HAN Visiting Consultant Division of Medical Oncology

The tearful middle-aged mother dabbed her eyes while her daughter sat to one side looking both anxious and awkward. We just had a long discussion in my clinic about a potential diagnosis of hereditary breast cancer. Like many patients in my genetics clinic, with her strong family history of breast cancer, she needed genetic testing and possibly more surgery and surveillance for cancer prevention.

The majority of our patients in the genetics clinic present with breast, colorectal or genitourinary cancers. It may come as a surprise for some, but for practitioners of genetic medicine, the key tool is not a fancy and expensive gene test, but instead a careful and painstaking family history through several generations. Such an overview, both comprehensive and probing, enables us to consider the potential underlying genetic diagnoses. Such diagnoses are interlaced with the clinical background – for example, all patients with ovarian cancer should be evaluated for hereditary breast cancer-ovarian syndrome; womb cancers, colorectal and other abdominal cancers may be associated in a family with Lynch syndrome.

It is often said that the concept of family is the centre of an Asian community. We have recently found that this sociological observation has also some medical truth. In the largest prospective trial of breast cancer screening in Asia involving some 166,000 Singapore women, we found that this sociological observation has some correlation in medicine. Our cancer genetics service reported to some national interest that family history of breast cancer is a stronger predictor of developing breast cancer in Asian women, than it is in the West. Indeed, family is the foundation of human existence, the window to our past and the bridge to our future.

R ecently, in early May 2013, Angelina Jolie announced to the world that she had a genetic syndrome putting her at high risk for breast and ovarian cancer. Together with her husband Brad Pitt,

she stated “I choose not to keep my story private because there are many women who do not know that they might be living under the shadow of cancer. It is my hope that they, too, will be able to get gene tested, and that if they have a high risk they, too, will know that they have strong options.”

Every day, we see many patients diagnosed with cancer in the clinics and in the wards. It is naturally understandable and desirable for care and attention to be focused on the patient battling cancer. However, in my experience, it is not unusual for the patient’s family members, who faithfully accompany the patient to each doctor’s visit, to quietly wonder about their own personal cancer risk.

Beyond the therapeutic armamentarium wielded by oncologists, cancer genetics permits a holistic evaluation of cancer risk and prevention for individuals and families afflicted with cancer. Appropriate diagnosis and cancer surveillance for high-risk individuals is crucial – after all, prevention is better than cure. As Ms Jolie wrote in the New York Times about her diagnosis of hereditary cancer syndrome, “Life comes with many challenges. The ones that should not scare us are the ones we can take on and take control of.”


It is often said that the concept of family is the centre of an Asian community. We have recently found that this sociological observation has also some medical truth. In the largest prospective trial of breast cancer screening in Asia involving some 166,000 Singapore women, we found that this sociological observation has some correlation in medicine.

Our field thus extends into the most intimate aspects of humanity and families. Scenarios such as pregnant women asking about genetic testing for their unborn foetus or parents struggling about how and when to disclose genetic diagnoses to their children are common, and even adolescents discovering a past history of adoption or unexpected blood ties. A genetic diagnosis in one individual can easily transform the life of not just the person, but that of an extended family, as each member comes to grips with personal risks and fears, and hard decisions are made. Practically, difficult situations can also arise when an affected individual is unwilling to disclose his diagnosis to the rest of the family, who are at real risk of developing cancer.

Indeed, while genetic medicine is a fast evolving field operating at the cutting edge of science and medicine, local regulatory issues of law and ethics are paramount in its development. In Singapore, a key challenge is the absence of a clear legal and regulatory framework for use of genetic information. Unlike the USA where discrimination by insurance companies and employers on the grounds of genetic background is prohibited, the status of this remains unclear in Singapore. As such, some patients are understandably reluctant to undergo further genetic testing even if it means that appropriate screening to detect cancer early can be instituted.

The ongoing achievements in genetic research announced almost daily in the media demand practical translation to actual clinical care for patients. The costs of sequencing a human genome have fallen dramatically from billions of dollars in the 1990s, to ten thousand dollars today; this is likely to fall further. The utilisation of such technology in determining patient risk is likely to transform clinical care. At the same time, there are very real concerns which should not be ignored. Widespread presence of genetic variations between ordinary humans can lead to great ambiguity in interpreting the results of many genetic tests. Both expert clinical interpretation and long-term follow-up are needed, as the same genetic result that is inconclusive and difficult to interpret for now may well be meaningful years later with more information.

While technology may continue to evolve, the fundamental principles of genetic medicine are firmly focused on the individual and family. In cancer genetics, as in general practice, caring for a family that has placed their trust in you is an honour and a privilege. After all, isn’t family the most important thing?


家人最重要陈民汉咨询顾问肿瘤内科部门

一位中年妈妈擦拭着眼泪，她的女儿焦虑不安地坐在一旁。我们在诊所里针对可能诊断罹患遗传性乳癌的课题谈了很久。如同其他来我基因诊所的病人一样，她有着明显的乳癌家族史，她须要接受基因检测，甚至可能需要更多的手术和更密切的观察，以预防癌卓症。

基因诊所大多数的病人是乳癌、结肠直肠癌或泌尿生殖

道癌的患者。有些人可能会对自己患癌感到惊讶，但对

遗传医学专家而言，主要的方法不是昂贵的基因检测，

而是对好几代人的家族病史进行缜密的研究。这种全面

的调查可以让我们考虑潜在的基因诊断。这样的诊断和

临床经验有着密不可分的关系，举个例子，所有卵巢癌

症患者都应该检查会否罹患遗传性乳癌—卵巢综合征；

子宫癌、结肠直肠癌及其他腹部癌症可能跟家族的林奇

综合征有关。

我们常说，家庭是亚洲社会最重要的观念。我们最近发现，这个社会观察也有一些医学根据。我们在一项针对16万6000名新加坡妇女展开的亚洲最大规模的乳癌检验中发现，这项社会观察与医学有一些关联。我们的癌症基因服务发表了一些东西方国家都会感兴趣的发现—与西方妇女相比，乳癌家族史能更有效的预示亚洲妇女罹患乳癌的几率。家庭确实是人类存在的基础，既是我们了解过去的管道，也是我们通往未来的桥梁。

2013年5月初，安吉丽娜·朱莉 (Angelina Jolie)宣布她有基因缺陷，罹患乳癌和卵巢癌的风险很高。她在丈夫布莱德·彼特 (Brad Pitt) 的陪同下宣布：“我选择公告天下，因为很多妇女不知道自己可能有患癌的风险。我希望她们也可以进行基因检测，如果她们是高风险群，我也希望她们知道她们是有选择的。”

身为肿瘤学家，我们每天都在诊所和病房里看到很多癌症患者。全心全意照顾抗癌病人，是再自然不过的事。不过，经验告诉我，那些每次陪病人来看诊的家人，心里其实也很想知道他们自己的患癌风险有多高。

至今的癌症防治除了可以依赖肿瘤学家的各种治疗手段外，还可以进行癌症基因检测，以全面评估个人或家人的患癌风险及展开防癌准备。癌症高风险群接受适当的诊断和观察是至关重要的，预防毕竟胜于治疗。正如安吉丽娜在《纽约时报》针对她的遗传性癌症综合症的诊断发表的一篇文章中写道：“生命中需要面对很多挑战。那些我们可以承受和控制的挑战，我们不应感到畏惧和退缩。”


因此，我们的领域扩展至人性和家庭最不为人所知的一面，例如孕妇要求对未出生的胎儿进行基因检测、父母挣扎什么时候及如何告诉孩子基因诊断结果，甚至是孩子成年后发现自己被领养或有意想不到的血缘，都是常见的情况。个人的基因诊断不仅可轻易改变他自己的人生，也会影响整个家族，因为每个家庭成员都会面对个人风险和隐忧，并须要做出困难抉择。此外，如果一个人不愿意把诊断结果告诉其他患癌风险高的家人，情况可能也会变得很棘手。

遗传医学建基于最前沿的科学和医学发现，是快速发展的领域。此外，遗传医学的法律和伦理发展也是至关重要的。新加坡面对的其中一个挑战，是在基因信息应用方面缺乏明确的法律与管制框架。在美国，有基因缺陷的人受到保险业者和雇主的不公平对待是不被容许的；在新加坡，这种状况仍不明朗。因此，即使可以建立机制让病人进行适当检测以及早发现癌症，有些病人仍会拒绝作进一步的基因检测。

几乎每天都可以在媒体上看到的基因研究进展，不断转化成可真正应用在病人身上的临床实践。人类基因组测序工作的费用从1990年代的数十亿元，快速下降至今天的一万元左右；这个成本还会继续下跌。利用这种科技来确定病人的风险，很可能会改变临床医学。不过，我们也不应忽视真正的问题。人与人之间的基因有非常大的差异性，不少基因检测的解读可能会得出非常含糊的结果。专业临床解释和长期跟进是必需的，因为今时今日尚无定论和难以解读的基因检测结果，可能在多年后因为有更多的研究发现而变得有用和有意义。

尽管科技日新月异，但遗传医学的根本原则着重于个人和家族。癌症遗传学和普通看诊一样，能让病人及其家人完全信赖医生，对医生而言是一种特殊的荣耀。说到底，家人难道不是最重要的事吗？

我们常说，家庭是亚洲社会最重要的

观念。我们最近发现，这个社会观察

也有一些医学根据。我们在一项针对

16万6000名新加坡妇女展开的亚洲

最大规模的乳癌检验中发现，这项社

会观察与医学有一些关联。


JULY

Event Date, Time, Venue Registration

Public Forum – Common Cancers Affecting Men

TOPICS:• Commoncancersaffectingmen

• Whataretherisks,signs&symptoms?

• Whatscreeningtestsshouldyoudotodetectcancerearly?

• Whatarethetreatmentoptionsavailable?

20 July 2013, Saturday

ENGLISH SESSION

Session will be conducted in English.

Registration : 11am to 11.15am Workshop : 11.15am to 12.30pm

Auditorium, Level 4 National Cancer Centre Singapore 11 Hospital Drive Singapore 169610

Free Admission

Strictly No Admission for Children below 12 years old. Registration is a MUST as seats are limited.

REGISTRATION IS BY PHONE ONLY

Please call: 6225 5655 / 6236 9447/ 6236 9432

Monday to Friday: 8.30am to 5.30pm

CancerWise Workshop –Basics Of Cancer Part 2

TOPICS:• Diagnosingcancer

• Whatiscancerstagingandgrouping?

• Thecommonelementsofstagingsystem

• CancerTreatmentOptions

• Newdevelopmentincancertreatments



Registration : 1pm Workshop : 1.30pm to 4.00pm


Free Admission



Please call: 6225 5655 / 6236 9447/ 6236 9432

Monday to Friday: 9am to 5pm

Hypersensitivity Reactions To Chemotherapy

TOPICS:• WhatareHypersensitivityreactions?

• WhenareacuteHypersensitivityreactionslikelytooccur?

• Signs&SymptomsofAcuteHypersensitivityreactions?

• ManagementofAcuteHypersensitivityreactions

• CanAcuteHypersensitivityreactionsbeprevented?




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

Free Admission (For Nurses Only)



Please call: 6225 5655 / 6236 9447/ 6236 9432


OUTREACH – PUBLIC FORUMS & CANCERWISE WORKSHOP

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


AUGUST


CancerWise Workshop – Managing Peripheral Neuropathy

TOPICS:

• WhatisPeripheralNeuropathy?

• Riskfactorscontributingtoperipheralneuropathy

• SymptomsofPeripheralNeuropathy

• TreatmentforPeripheralNeuropathy

• CopingwithPeripheralNeuropathy

17 August 2013, Saturday




Free Admission



Please call: 6225 5655 / 6236 9447/ 6236 9432


SEPTEMBER


Public Forum – Liver Cancer

TOPICS:

• CommonProblemsOfLiver

• WhatIsLiverCancer?

• RiskFactors&CausesForLiverCancer

• Signs&Symptoms

• EarlyDetection&Prevention

• TreatmentOptions

14 September 2013, Saturday

MANDARIN SESSION

Registration : 9am to 9.15am Workshop : 9.15am to 10.30am

ENGLISH SESSION

Registration : 11am to 11.15am Workshop : 11.15am to 12.30pm

Health Promotion Board Auditorium, Level 7 3 Second Hospital Avenue Singapore 168937

Free Admission



Please call: 6225 5655 / 6236 9447/ 6236 9432


OUTREACH – PUBLIC FORUMS & CANCERWISE WORKSHOP

OUTREACH – PUBLIC FORUM



OUTREACH – CANCERWISE WORKSHOPS

SEPTEMBER


CancerWise Workshop –Oncologic Emergencies

TOPICS:

• Definition,Pathophysiology& management of:

• NeutropenicSepsis

• Tumorlysissyndrome

• Hypercalcemia

• SpinalCordCompression

• IncreasedIntracranialpressure

• SuperiorVenaCavaObstruction

• Anaphylaxis

7 Sept 2013, Saturday







Please call: 6225 5655 / 6236 9447/ 6236 9432


CancerWise Workshop – Hepatitis B and its Link to Liver Cancer

TOPICS:

• WhatisHepatitis?

• TypesofHepatitis

• CausesofHepatitisB

• Signs&SymptomsofHepatitisB

• ThelinkbetweenHepatitisBand Liver Cancer

• Treatment&PreventionofHepatitisB

• LivingwithHepatitisB

7 Sept 2013, Saturday







Please call: 6225 5655 / 6236 9447/ 6236 9432




GP SYMPOSIUM

As part of the NCCS’ efforts to reach out to the medical community at-large, a symposium for general practitioners was held on the 20th of April at Peter and Mary Fu Auditorium. Our theme was “Caring for Cancer in the Community”.

P rior to the main session, a tour was organised to give participants a rare insight into the facilities and the standard practices at the centre. Guests were treated to sneak peeks of

otherwise restricted areas such as the laboratories as well as state-of-the-art equipment in the radiotherapy suites.

In his opening address, Professor Soo Khee Chee, Director of NCCS, expressed his excitement for future collaborations between the centre and the primary care fraternity. He outlined the need for a strong and mutually beneficial relationship between both bodies in light of cancer’s increasing prominence in today’s society.

Specialists from NCCS’ Division of Medical Oncology and Division of Palliative Medicine engaged the 140-strong crowd with presentations that covered topics such as cancer treatment, cancer prevention, cancer screening and the ecosystem of public cancer care in Singapore. The presenters captured the interest of the audience with their lively case discussions.

The audience was pleased with what the centre had to offer. The participants responded positively to the event and expressed interest in attending future events organised by NCCS. The tour was well received and the case presentations were singled out for their relevance to participants’ clinical practices.

NCCS hopes that this event will be the catalyst for a seamless partnership between NCCS and the community of Primary Care Physicians and strengthen not just cancer treatment programmes, but also advance cancer prevention programmes in the community.


RESEARCH OFFERS BRIGHT HOPE FOR CANCER PATIENTS, SAYS PRINCETON UNIVERSITY PROFESSORProfessor Yibin Kang wears a boyish look that belies his depth of knowledge and expertise in medical science. While understandably one is inclined to judge another’s experience by the lines on the forehead, this 39-year-old high-flyer has achieved scientific endeavours way ahead of his time.

T o date, he has published 80 original articles, and was appointed Endowed Chair Full Professor at Princeton University in 2012, just two years after being promoted to Associate Professor.

A graduated from Fudan University in Shanghai, China, he now lives in the United States. He obtained outstanding academic records that earned him a place at the prestigious Duke University, where he specialised in the study of viruses as a graduate student. After graduating, he came under the stewardship of Dr Joan Massague as an Irvington Institute postdoctoral fellow at the renowned Memorial Sloan-Kettering Cancer Center. It was here that he pioneered a functional genomic approach to elucidate mechanism of breast cancer metastasis.

As a scientist, it is a privilege to be supported by the society to do what we do and be funded to explore new ideas. Funding for science is important as it educates people, gives them knowledge, and allows them to understand the cause and consequences of diseases. It is what drives the society to move forward.

PROF YIBIN KANG


“Asians often find cancer a taboo subject and many are not willing to discuss their disease openly. Patients are not well-informed and ultimately, they have to understand why certain treatments are needed and how they will benefit from them.”

When asked about Traditional Chinese Medicine (TCM) in the fight against cancer, he said, “In general, TCM is met with mixed feelings even among practitioners. There are effective remedies, and modern medicine supports that some chemical ingredients of TCM has anti-tumor effectors, but applications of TCMs without rigorous clinical trials may compromise the effectiveness of current therapy. Importantly, evidence for the anti-cancer effect of TCM should be examined with standard clinical trials as in western medicine.”

Asked for his views on Singapore’s in-roads in medical research, he sees Singapore as a top notch medical and research hub in Asia, next to Japan. Having experienced working with Singaporeans, he considers them to be among the best in research and education. He sees strong integration to encourage more clinicians to do translational research and is equally impressed by the excellent research infrastructure available in Singapore.

In his visit, he met representatives from NCCS and Genome Institute of Singapore and envisions opportunities to work together. In his opinion, basic research is as important as translational research, which he says appears to become the focus in Singapore, as well as in other parts of the world, including the US, and wishes for a balance between the two. Another challenge, Prof Kang explained, is getting society to support research that will enable the full potential of scientists to be met. He is grateful for the support he has received thus far.

“As a scientist, it is a privilege to be supported by the society to do what we do and be funded to explore new ideas. Funding for science is important as it educates people, gives them knowledge, and allows them to understand the cause and consequences of disease. It is what drives the society to move forward.”

BY VERONICA LEE

Grateful for the opportunity, he uprooted himself from China to the “land of possibilities” in the US, as he called it. Recounting his decision back then, he said he was spurred by the abundance of opportunities for young people in the US. “Career mobility was based on merit and interesting ideas were allowed to flourish, quite evident from the innovations of Steve Jobs and Bill Gates. The American society was also culturally interesting for me,” said Prof Kang, who is married to Ling and they have two children, Michelle and Evans.

Recently in Singapore to deliver the Humphrey Oei Distinguished Lecture, Prof Kang has been researching molecular mechanisms of breast cancer metastasis. During the lecture, he shared with a packed auditorium from the medical and research fraternities, why breast cancer metastasis in the bone is a common occurrence among 70% of late stage breast cancer patients.

While studying the subject, Prof Kang, who had spent more than eight years at Princeton University, found novel metastasis genes to be essential in bone, lung and other viral organs. The team discovered novel communication mechanisms among tumour cells, osteoblasts and obsteocasts that promote the formation of osteolytic lesions and the growth of tumours in bone. Innovative technologies are being developed to unlock the mysteries of cancer metastasis to improve treatments for breast cancer patients.

When asked about the outlook on cancer, he responded enthusiastically, “Treatment options are improving incrementally and sometimes dramatically. Adjuvant chemotherapy or molecular targeted therapy after surgery improved survival and quality of life for patients, and all these are evidence-based. Science is also evolving into treatment more quickly now than ten or twenty years ago, when it can take close to 30 years from the original basic discovery to the approval of new drugs.

“Now it can take as short as five years. There is a lot of hope for patients and they should not feel hopeless about cancer as the disease is now much better understood, and likely to be more manageable. Every day brings excitement of new discoveries.”

Responding to queries about the recent interest in double mastectomy among women with BRCA genes that predisposes them to breast cancer, he noted that it is a small population that is affected by this cancer gene, and relevant information for decision-making may not be readily available to those patients, particularly in Asia.


PADDLING THEIR WAY TO RECOVERYBY FLORA YONG Community Partnership

It happened on a warm fabulous Saturday morning on 8 June 2013. More than 250 cancer survivors, their families, doctors, nurses and supporters showed up at Lower Seletar Reservoir for a day of fun and festivities to commemorate cancer survivorship.

F or some, this was no sunset cruise. They came prepared for the highlight of the day; the friendly 250-metre dragon boating competition between healthcare workers and cancer survivors. Ten teams made up from a motley crew

of cancer survivors, doctors, nurses, medical social workers,

students and support staff took part in the friendly challenge.

Dragon boating originated in China around 2,500 years ago. The ancient water sport re-emerged into a modern international sport at the Hong Kong races in 1976. Now, 50 million people worldwide are competitive dragon boat paddlers. The sport is making a unique comeback for cancer survivors as a way to stay active and connect with others. Today, many other cancer survivors participate in the sport. It is estimated that there are about 150 cancer teams around the world. The ancient sport of Dragon Boating has proven effective in helping to restore upper body strength, range of motion, and in reducing the effects of lymphedema after breast cancer surgery or radiation.

A dragon boat is a 40 foot-long, colourful wooden or fiberglass boat resembling a giant canoe adorned with a dragon head at the front and tail at the back with room for about 20 paddlers, a drummer and a steerperson.

“You don’t have to be an athlete to paddle with the team, “said Dr Chay Wen Yee, Senior Consultant, Division of Medical Oncology and Organising Chairperson of CanSurvive 2013. She added that it is an excellent way to build team support and encourage bonding.

The sport’s combination of individual effort and team synchronisation has resonated with many paddlers present; among them is Rachel Woon from the Children’s Cancer Foundation. She admires the courage of cancer survivors and took part in the dragon boating challenge as a testimony of her support and encouragement towards cancer survivors.

Ms Angelina Ong from SAVA opined, “Dragon boating is the best thing for cancer survivors on the road to recovery. It promotes a healthy lifestyle through physical activity. It also goes to show that cancer survivors can live a full and healthy life.”


The Pink Paddlers and their spouses.

With the help of the Pink Paddlers, NCCS cancer survivors were introduced to the paddling sport of dragon boating. Pink Paddlers is a bubbly and energetic group of women who had survived breast cancer. The diagnosis of breast cancer has brought them together. They have created a treasured sisterhood to provide support and encouragement to others. It was clear that these women were on a mission to inspire other cancer survivors to share in the empowering, therapeutic, and symbolic sport of dragon boating. Although the Pink Paddlers were trained to race dragon boats, their race was really against cancer.

The NCCS Spartans was also launched that day through a symbolic ceremony of dotting the dragon’s eye with red paint by the Guest-of-Honour, Dr Vijay Sethi (Senior Advisor, NCCS) and Dr Chay Wen Yee (Organising Chairperson, CanSurvive 2013). Like the Pink Paddlers, NCCS Spartans is also a dragon boating team specially created for NCCS cancer survivors to enjoy the sport.

It is hoped that NCCS Spartans can offer an active, health-giving, life affirming opportunity for those affected by cancer.

For some of the cancer patients who were present that day, they felt that there should be more activities like this. One participant said, “I have not gone out to have fun in a long time since I was diagnosed with cancer. It was worth coming today because I forgot about my illness even if it was just for a few hours. It was worth it.”

The event reached its crescendo with the finals of the dragon boat race. By the end of the three rounds of heats, the Pink Paddlers and the DRO Dragons (NCCS Radiation Oncology Team) went on to the finals. After rounds of furious rowing and paddles slicing through the murky waters of the Seletar Reservior, the Pink Paddlers completed the race with a hairline finish of 0.2 seconds before the DRO Dragons to emerge victorious at the finish line. There was no stopping the Pink Paddlers who were in top form, giving the DRO healthcare team a run for their money.

CanSurvive 2013’s motto “I Can, Together, We Can” was well played out at the event. The participants competed with heart and strength, worked together with synergy, purpose, and laughter. Collectively, reaching out to others to provide unconditional love and support that reaches far beyond the cancer experience. It was evident the focus was on living, rather than on the disease. Each of the cancer survivors that took part in the dragon boat race is a powerful example that cancer survivors can lead a full and vigorous life after cancer.

If you wish to be one of our benefactors in helping those affected by cancer on their road to recovery, please make a sustainable gift through GIRO using the enclosed form in this newsletter. Your gift will enable us to continue funding more rehabilitative and meaningful programmes for our patients and cancer survivors.

For enquiries, please call NCCS Community Partnership (Tel: 6236 9440 / email: [email protected])

Dragon boat race participants from NCCS learning how to paddle for the first time.


WARMING HEARTS, TURNING LIVESBY GILLIAN TAN NCCS Marketing Communications

Family commitments and heavy workload are often our reasons that hold us back from voluntary work. In our busy and hectic lifestyle, we do not realise how little we stop to give our time to others.

M s Tan Tiew Yah is however one of those undeterred from giving her time to the cancer cause. For over a decade, the senior staff nurse at the National Cancer Centre Singapore (NCCS) has been actively volunteering with the Gynae-Oncology (O&G)

Self Help Group.

Driven by A/Prof Tay Sun Kuie – Visiting O&G Senior Consultant at NCCS- and herself, the support group was officially launched during the Women’s Cancer Week in May 1998. Tiew Yah’s inspiration to forming the group came from her work as a coordinator at the Singapore General Hospital’s Gynae-Oncology unit. She realised the importance of socio-emotional support among patients affected by women cancers through experiences from counseling patients. The support group was initiated with seven O&G cancer patients whom she had invited over to her home for a Christmas gathering. Barely knowing one another, the ladies bonded immediately, giving support and sharing their cancer fighting experiences.

This year, the Gynae-Oncology (O&G) Self Help Group celebrates their 15th Anniversary. Now with 30 active members, the closely-knitted group reaches out to newly-diagnosed patients through counseling, sharing and social events.

On my first meeting with Tiew Yah, she presented her albums of captioned photos with pride, taking me through their anniversary celebrations, social outings and cancer awareness events. They had even organised a visit to NCCS’ research laboratories, which she said was an eye-opener and meaningful experience for the cancer patients.

Over the years, journeying with the group has its ups and downs. Despite carrying a positive mindset, there are some “down-times” when members may be emotionally affected when dealing with the death of a fellow patient – this is when group support made a positive difference. Personally, Tiew Yah also learnt to focus on helping patients instead of staying depressed. “I learnt that death is part and parcel of life. I am glad that I am able to assist them during their life journey”, she explained.

Other than attending counseling courses for oncology cancer patients, Tiew Yah depended largely on her good observation skills and on-the-job training in her voluntary work.

She sees volunteering with the support group as a family gathering and part of her personal life. “This is what I want to do and it is my commitment. Whatever time I spend with the patients doesn’t count as work”. As both her sons, aged 28 and 21 have grown up, she is now able to devote more time to volunteering. She readily attends to any events organised by the support group together with her husband, who participates as a photographer.

To her, it is most rewarding to know that the patients are happy, mentally prepared and living their lives to the fullest. There were also times when she managed to bring families closer together through sharing cancer knowledge. She recalled a few incidents where family members stayed away from the patient because of the misconception that cancer is contagious. She helped them by clarifying the facts.

Volunteering had reshaped her perspectives on life such that she has learnt to count her blessings and appreciate little things around her. When asked about her goals, she said, “I will continue to do what I am doing as long as I can, even after I have retired”.

When asked to share a tip with those who are keen to volunteer but apprehensive about coming forward, her passionate reply was: “Just do it! To give is to gain. Even the smallest act of caring has the potential to turn a life around.”

Besides being an active volunteer, Tiew Yah is also a donor to the NCC Research Fund. I am inspired by Tiew Yah’s spirit and drive, which is commendable. She also showed me the true meaning of volunteerism. Volunteerism is not just about putting in hours to reach a quota, or to receive credit from the organisation. It is, however, to truly help those in need the best we can, to make a difference in the community.

If you wish to give to the cancer cause by making a donation and/or signing up as a volunteer, kindly contact NCCS Community Partnership at 6236 9440 or email to [email protected].


SALUBRIS is produced with you in mind. If there are other topics related

to cancer that you would like to read about or if you would like to provide some feedback on the articles covered, please email to [email protected].

NATIONAL CANCER CENTRE SINGAPOREReg No 199801562Z

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

Editorial Advisors

Prof Kon Oi Lian Prof Soo Khee Chee Dr Tan Hiang Khoon

Editorial Consultant

Mr Sunny Wee

Medical Editor

Dr Richard Yeo

Executive Editors

Ms Rachel Lim Ms Veronica Lee

Members, Editorial Board

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

salubris july - sept 2013

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