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A SINGHEALTH NEWSLETTER FOR MEDICAL PRACTITIONERS MICA (P) 065/10/2011
02
Treating Breast Cancer
06
Family History
and Cancer Risk
10
Prostate Cancer:
To Screen
or Not?
13
Advances in Early
Cervical Cancer
Management
Focus:
cancer
julsep 2012
Issue04
Members of the SingHealth Group
Singapore General Hospital • KK Women’s and Children’s Hospital
• National Cancer Centre Singapore • National Dental Centre of Singapore • National Heart Centre Singapore
• National Neuroscience Institute • Singapore National Eye Centre • SingHealth Polyclinics • Bright Vision Hospital
Medical Update
Focus:
cancer
Appointments: 6436 8288
Email: [email protected]
julsep 2012
Issue04
Breast Cancer:
What are My Treatment Options?
Dr Chay Wen Yee, Associate Consultant, Department of Medical Oncology,
National Cancer Centre Singapore
Overview of breast cancer
Breast cancer is the
most common female
cancer diagnosed in
Singapore. It is also
the most frequent
cause of female cancer
deaths in Singapore.1
Based on cancer trends
in Singapore, the
incidence of breast
cancer has been
rising. Many factors
contribute to this
rise – better statistical
reporting, increased
role of screening
and dietary and
socioeconomic changes
over the years.
In Singapore, the incidence of breast
cancer among Chinese is higher when
compared to Malays and Indians.
This still pales in comparison to
breast cancer rates in various western
countries. Although breast cancer
affects primarily females, men also
account for 1% of all breast cancer
cases diagnosed in Singapore. The
treatment modalities used for the
management of male breast cancer
remain similar to those in females.
Risk factors and screening
Multiple risk factors contribute to
the increased risk of breast cancer.
Understanding the modifiable and
non-modifiable risk factors that increase
or decrease breast cancer risk allows
family physicians to counsel women
appropriately. It also allows women the
opportunity to participate more actively
in their healthcare as patients are able
to make behavioural changes that may
reduce their risk of breast cancer.
Screening plays a key role in the
prevention of breast cancer. Women
above the age of 20 are advised to
perform breast self examination. A
clinical breast examination may also
be performed by the family physician.
Breast imaging is an important
component of breast screening. Breast
mammograms are used both as an
investigative tool for screening any
breast abnormalities and to further
evaluate any suspicious breast lumps
Non-Modifiable Risk Factors
Age
Reproductive factors
a) Menarche
b) Parity
c) Breastfeeding
d) Menopause
Genetic factors
detected on palpation. Ultrasound
of breasts are not routinely used as a
screening tool because their sensitivity
and specificity are inferior to that of
mammograms.
Women should be advised to seek
treatment if they detect an abnormal
swelling or lump in the breast or axilla.
In addition, the overlying skin may be
thickened and indurated presenting
as Peau d’Orange in advanced cases.
Nipple pain, nipple retraction, bleeding
and unusual discharges from the nipple
are also sinister signs which warrant
further investigation.
Investigations to guide diagnosis
and treatment
Biopsies are performed to obtain a
histological diagnosis of breast cancer.
Increased risk of breast cancer with increasing age
a) Risk is reduced with later age of menarche
b) Decreased risk with increased parity
c) Risk is reduced with breastfeeding
d) Risk is increased with a later age of menopause
Established BRCA 1 and 2 mutation carriers have
an increased risk of breast cancer
Family history
10% of breast cancers are hereditary
Previous radiation exposure Increased risks especially in younger women
Modifiable Risk Factors
Alcohol consumption
Increased alcohol intake has been linked to
increased risk of breast cancer
Hormone therapy
Combination hormone replacement therapy has
been shown to increase the risk of breast cancer
as shown in the Women’s Health Initiative study
Obesity
Risks of breast cancer increased with increasing
body mass index
Figure 1 Risk factors for breast cancer.
- 2 -
Medical Update
0
Breast
Colo-rectum
Lung
Corpus uteri
Ovary
Skin (incl. Melanoma)
Stomach
Cervix uteri
Lymphoma
Thyroid
5
10
15
20
25
30
35
29.3
14.1
7.7
5.9
5.5
4.3
4.2
3.7
3.6
3
Figure 2 Ten most frequent cancers in Singapore Females (%), 2006-2010.
This may be performed as an open surgical
biopsy or by the use of core needle biopsy.
In certain circumstances, the use of
ultrasound-guided mammotome biopsy or
the use of a hookwire localisation biopsy
under X-ray or ultrasound guidance
enables the localisation and treatment
of small breast lesions. Upon the
confirmation of a malignancy, further
staging investigations are performed to
determine the extent of cancer spread.
Common sites of metastasis for breast
cancer include the lung, liver, brain and
bone. Common staging investigations
include a CXR, the use of ultrasound
liver and a bone scan. In cases of
more advanced disease, a CT scan is
also performed.
Common histological classifications of
breast cancer include invasive ductal
carcinoma, invasive lobular carcinoma
and carcinoma in situ. Apart from
histology, the biopsy sample is also
examined for various prognostic factors
which guide the treatment of breast
cancer. These include the estrogen
receptor status, orogesterone receptor
status, Her2 status.
Breast cancers positive for estrogen
and progesterone receptors tend to
have better prognosis in terms of better
disease-free survival, overall survival and
longer survival compared to hormone
receptor negative cancers. Overexpression
of Her2 is associated with a poorer
prognosis. Other prognostic factors are
obtained after surgery for the breast
lump. These include the number of
lymph nodes involved with tumour, the
grade of differentiation of the tumour
and the presence or absence of any
lymphovascular invasion. A higher
number of lymph nodes involved leads to
a poorer prognosis. In addition, tumours
of a higher grade tend to be poorly
differentiated and hence do poorly.
Breast cancer treatment options
and prognosis are generally
based on the TNM staging
system. Although family
physicians do not generally
make primary decisions on
the treatment modalities for
breast cancer, understanding
the rationale and underlying
evidence of these evolving
treatment options can help
family physicians care for their
patients during and after cancer
treatment. Management of
breast cancer remains challenging
and requires a coordinated,
multidisciplinary approach. The
four key components of breast
cancer treatment are surgery,
chemotherapy, radiotherapy and
hormonal therapy.
Surgery
Early breast cancer is treated surgically
by either a wide excision or mastectomy.
In patients with clinically negative nodes,
sentinel lymph node biopsy is performed
to determine if breast cancer has spread
to the nodes in the axilla. Should the
- 3 -
“
Many women suffer
a loss of body image
after a mastectomy.
Hence, options of
breast reconstruction
can be discussed with
the patient. This can
be performed using
myocutaneous flaps or
by the use of saline or
silicone implants.
“
excised sentinel nodes be involved with
tumour, a full axillary clearance would
be performed. The use of sentinel lymph
node biopsy has reduced the risk of
lymphedema post-surgery.
If the tumour was treated by a wide
excision, then radiotherapy would be
given to the breast to decrease the
risks of local recurrence.2 The use of
wide excision followed by radiation to
the breasts has shown equivalence in
survival to simple mastectomy.
Many women suffer a loss of body
image after a mastectomy. Hence,
options of breast reconstruction can be
Medical Update
discussed with the patient. This can be
performed using myocutaneous flaps or
by the use of saline or silicone implants.
Chemotherapy
Most women would require adjuvant
systemic therapies after surgery.
These therapies substantially reduce
the risk of disease recurrence and
cancer-specific death. Chemotherapy
and anti-cancer drugs are used to kill
cancer cells. These cytotoxic drugs
work by affecting cell growth and
reproduction. For patients with locally
advanced breast cancer, chemotherapy
can also be given prior to surgery to
downstage the disease.
Chemotherapy can be administered
orally or intravenously. Hormone
receptor negative disease derives
more benefit from chemotherapy
than hormone positive disease. Other
factors affecting the decision on
chemotherapy include the patient’s
performance status and underlying comorbidities. Anthracyclines and taxanes
have generally shown benefits when
used in the treatment of breast cancer.
Side effects of chemotherapy include
nausea, vomiting, alopecia, mouth ulcers
and increased risk of infections and
neutropenic sepsis. Known side effects
of taxanes include peripheral neuropathy
and fluid retention. Often, these side
effects are temporary and steps can be
taken to reduce or prevent them.
Radiotherapy
Radiotherapy is administered to reduce
the risk of local recurrence or achieve
“
local control. High energy rays are used
to kill the cancer cells. Side effects of
radiation include a “sunburnt” effect
on the skin, erthyema, tenderness, and
desquamation of the breast. These side
effects are temporary and manageable.
Hormonal therapy
This is used for patients who are
estrogen receptor and progesterone
receptor positive. The use of five years
of hormonal therapy has been shown
to lead to a 39% reduction in disease
recurrence and a 31% reduction in
mortality in ER+ early-stage breast
cancer.3 Options for hormonal
Side effects of radiation include a “sunburnt”
effect on the skin, erthyema, tenderness, and
desquamation of the breast. These side effects
are temporary and manageable.
“
- 4 -
Medical Update
Rank
Site
Number
Percentage
CR (95%CI)
ASR (95% CI)
1
Breast
1,841
18.0
20.0 (19.0-20.9)
14.1 (13.5-14.8)
2
Lung
1,739
17.0
18.9 (18.0-19.7)
12.6 (12.0-13.2)
3
Colo-rectum
1,562
15.2
16.9 (16.1-17.8)
11.1 (10.5-11.6)
4
Stomach
635
6.2
6.9 (6.3-7.4)
4.4 (4.1-4.8)
5
Liver
596
5.8
6.5 (5.9-7.0)
4.3 (3.9-4.2)
6
Pancreas
528
5.2
5.7 (5.2-6.2)
3.8 (3.5-4.2)
7
Ovary
499
4.9
5.4 (4.9-5.9)
3.8 (3.4-4.1)
8
Cervix Uteri
357
3.5
3.9 (3.5-4.3)
2.7 (1.8-2.4)
9
Leukaemia
246
2.4
2.7 (2.3-3.0)
1.9 (1.6-2.1)
10
Lymphoma
246
2.4
2.7 (2.3-3.0)
1.9 (1.6-2.1)
10,243
100.0
111.0 (108.9-113.2)
75.5 (73.9-77.0)
All sites
Figure 3 Ten Most Frequent Cancer Deaths in Singapore Females, 2006-2010.
therapy include Tamoxifen and
aromatase inhibitors (e.g. Letrozole,
Anastrozole or Exesmestane).
Tamoxifen is a selective estrogen
receptor modulator and can be used
in both pre- and post-menopausal
women. Tamoxifen acts by blocking
the action of estrogen in the breast.
However Tamoxifen also has agonist
effects on the endometrium and
bone. Side effects include hot
flushes, mood swings, depression,
vaginal discharges, a slight increased
risk of endometrial cancers and
deep venous thrombosis. In premenopausal women, ovarian
ablation or oophorectomy may also
be considered.
Aromatase inhibitors are used in
post-menopausal women where they
inhibit the aromatase enzyme blocking
peripheral conversion of androgens to
estrogens. Trials consistently show a
reduction in the risk of relapse of early
stage breast cancer directly against or
after the completion of Tamoxifen.
Side effects include hot flushes,
myalgia, arthalgia, and an increased
risk of osteoporosis.
Targeted therapy
Approximately 20% of breast cancers
overexpress ERBB2. Although these
cancers have a poorer prognosis,
these cancers are sensitive to the use
of anti-ERBB2 therapy. Trastuzumab
(Herceptin) is a humanised monoclonal
antibody against ERBB2. When added
to anthracycline and taxane based
chemotherapy, Trastuzumab has
been shown efficacy benefit with
improvement of disease-free survival
and overall survival. Side effects include
infusional reactions (fever, chills during
infusion). Care should be given when
used in combination with anthracyclines
as both anthracyclines and herceptin
carry the risk of cardiac toxicity.
Stage IV breast cancer
Some patients present with metastatic
disease at diagnosis. 5-year survival
for stage IV breast cancer is around
20%. Treatment in this case is mainly
palliative. The use of chemotherapy,
radiotherapy and endocrine therapy
should be discussed with the patient
based on her goals of treatment.
Endocrine is better tolerated than
chemotherapy and is frequently used
for low volume or slow growing
disease. In women with rapidly
progressive disease, chemotherapy
is favoured. Radiotherapy and
bisphosphonates are often used
to palliate pain from bony disease,
achieving improvement in quality of life.
- 5 -
Understanding the various breast
cancer treatment options and their
side effects will allow family physicians
to better care for their patients during
this difficult journey. It is only with the
combined efforts of the oncologist and
the family physician that care for the
patient is optimised.
GP Contact
GPs can call for appointments
through the Specialist Outpatient
Clinic at 6436 8288.
References
1. Singapore Cancer Registry: Trends in Cancer
Incidence in Singapore 2006-2010
2. Early Breast Cancer Trialists'
Collaborative Group (EBCTCG). Effect
of radiotherapy after breast-conserving
surgery on 10-year recurrence and 15year breast cancer death: meta-analysis
of individual patient data for 10,801
women in 17 randomised trials. Lancet
2011 378(9804):1707-16.
3. Early Breast Cancer Trialists´ Collaborative
Group (2005) Effects of chemotherapy and
hormonal therapy for early breast cancer
on recurrence and 15-year survival: an
overview of the randomised trials. Lancet
2005 365(9472): 1687-1717
Medical Update
Focus:
cancer
julsep 2012
Issue04
Appointments: 6436 8288
Email: [email protected]
Back to the Future:
Why Family History Remains Relevant and Provides the
Best Tool for Identifying Who is at Risk for Cancer
Dr Joanne Ngeow, Consultant, Department of Medical Oncology,
National Cancer Centre Singapore
Key Points
1. Family history captures genetic, environmental, and behavioural
risks to health
2. Recognition of patterns of concern
is key to using family history
effectively with adult patients
3. Using family history effectively in
clinical practice can:
a. Inform decisions on timing and frequency of screening to prevent disease/identify
disease early
b. Allow for predictive testing of
family members at risk if genetic cause can be found
c. Improve compliance with
preventive care and medical management recommendations
Introduction
Family history has long been used
to guide medical care. At a time of
extremely limited treatment options,
Hippocrates used family history to
help determine prognosis for his
patients.1 Of all common disorders,
scientific knowledge regarding genetic
predisposition to cancer is amongst the
most advanced. An average of 10%
(range 1-30%) of all cancers can be
attributed to a high penetrance genetic
predisposition.2 Indeed an average
“
of 5-10% of all diseases have a high
penetrance genetic cause. Many more
have a genetic component. It is welldocumented and acknowledged that
the family history-based risk assessment
is one of the most effective tools for
predicting what diseases an individual
may be at risk for developing.3 Careful
family history will yield the clinical "red
flags" suggesting heritable cancer: early
age of onset, multifocal disease, bilateral
disease in paired organs, associated
cancers (e.g. colon and endometrial
cancers), familial clustering. Identifying
an underlying gene mutation leads to
genotype-informed personalisation of
medical management such as organspecific surveillance and/or prophylactic
surgery to effect the earliest cancer
diagnosis and prevention. It also allows
for predictive testing of as yet unaffected
family members. Family history’s clinical
utility stems from its role as a proxy for
genetic, environmental, and behavioural
risks to health.
How then does family history compare
to new genomic tests, like genome
wide association studies? Genome wide
association studies (GWAS) are casecontrol studies that study hundreds
and thousands of individuals to search
for genetic markers, typically single
nucleotide polymorphisms (SNPs) that
are more common amongst individuals
with disease over controls. Unlike
traditional genetic testing, which
It is well-documented and acknowledged
that the family history-based assessment
is one of the most effective tools for
predicting what diseases an individual
may be at risk for developing.
“
- 6 -
looks for uncommon genetic changes
with exceedingly high predictive and/
or diagnostic value, most SNPs have a
very modest effect size. Of the SNPs
described to-date, the median odds
ratio is 1.334; this translates to a relative
risk (RR) of ~1.3 for a condition with
a prevalence of 8%.5 In other words,
given the general population risk of
breast cancer is 8%, if a patient had the
“bad” form of SNP with a RR of 1.3,
her lifetime risk for breast cancer would
increase from 8% to ~10%. In most
cases, having a single affected firstdegree (parent, sibling, child) relative
doubles the risk of disease, i.e. RR ~2.6
Returning to our earlier example of
breast cancer, this translates into an
increase from 8% to ~16% lifetime risk
of breast cancer for a woman with a
sister with breast cancer. While GWAS
has provided useful insights into our
understanding of the pathogenesis of
diseases, when compared directly with
family history-based risk assessment, it
was shown recently to be discordant in
many cases7, missing cases which were
identified via family history-based risk
assessment. For this reason, most experts
recommend continuing to use family
history for personalising risk assessment
over SNP analysis at this time.8, 9
In addition, just the discussion of family
history can improve outcomes with
at-risk patients. Individuals with a family
history of disease are not only more
knowledgeable about risk factors for the
disease10, discussion of family history has
been shown to motivate these patients to
greater compliance with disease screening
and higher rates of adherence to medical
recommendations.10, 11
Despite family history’s clear clinical
utility, there is ample evidence that
family health history is underutilised
across the healthcare community, with
Medical Update
most practitioners asking infrequently
and inconsistently about their patients’
family history.12, 13
How can we improve our use of
this powerful tool to enhance our
daily clinical practice and improve
care for our patients?
Step 1: Ask about diseases with a
hereditary pattern of inheritance,
particularly those that present in
adulthood
When considering family history, disease
can be broadly grouped into three
categories:
Sporadic: With no apparent hereditary
component; most likely due to
environment/chance
Familial: Greater preponderance of
disease in a family than would be
expected by chance, but with no apparent
association with an identifiable hereditary
syndrome or known genetic etiology
Hereditary: Part of a known hereditary
syndrome/disease, with known or
suspected genetic etiology
Don’t forget to ask about hereditary
diseases which present in adulthood.
These are limited in number and
examples include hereditary breast
and ovarian cancer syndrome and
hereditary non-polyposis colorectal
cancer. A minority of patients will
report a positive family history of a
hereditary disease. Most of these
patients will benefit from a
referral to genetic counselling
which provides complete
family history collection,
risk assessment,
and management
recommendations.
to note that for family history to
be optimally utilised, clinicians will
need to take a detailed family history
preferably spanning three generations.
There are three family history patterns
common in both hereditary and
familial disease:
• Multiple family members with the
same condition
• Early onset of disease
• Disease in the less-often affected sex
In this next section, we will review
key family history patterns using
conditions commonly seen in adult
oncology practices.
Early onset of disease
Early onset of disease in a family
is often indicative of hereditary or
familial disease. An example where
we see early age of onset in both
hereditary and familial forms of a
disease, but much less commonly
in the sporadic form of disease, is
breast cancer.
Example I: Breast cancer
Although highly treatable when detected
early, female breast cancer is the second
leading cause of cancer deaths (after
lung cancer).14 Like other
Step 2: Pattern
recognition
As family history
information is
gathered, pattern
recognition is the key
to using this valuable
information to its fullest
potential. It is important
- 7 -
cancers, the majority of both male and
female breast cancer is sporadic, due to
chance. Approximately 5-10% of breast
cancer is part of a hereditary cancer
syndrome, many of which have a known
genetic etiology. An additional 15-20%
of breast cancer is categorised as
familial: there is an increased incidence
of breast cancer within a family in the
absence of an identifiable hereditary
cancer syndrome.15-18 One of the key
differentiators between sporadic and
hereditary/familial breast cancer is
age of onset. Breast cancer incidence
follows a bimodal distribution with a
peak at approximately 50 years of age,
coinciding with the peak incidence
for hereditary and most familial breast
cancer, and a second peak at 70 years of
age, coinciding with the peak incidence
of sporadic breast cancer.19
The most prevalent breast cancer
predisposing hereditary cancer
syndrome is Hereditary Breast and
Ovarian Cancer (HBOC) syndrome,
caused by mutations in the breast
cancer 1 (BRCA1) and breast cancer 2
(BRCA2) genes. The role of the BRCA
genes in increasing cancer risk was
identified through family studies in the
mid-1990’s; clinical testing for
BRCA mutations has been
available since 1998.18
Medical Update
“
Our hope is that this article provides tips for
pattern recognition and collection of family
history which will facilitate and re-energise
our efforts to use family history to inform
patient care.
Individuals with a genetic risk of
breast cancer have tremendously
increased risk of breast and related
cancers over their lifetimes. For
example, women with a BRCA
mutation have up to a 65% lifetime
risk of developing breast cancer
and up to a 40% lifetime risk of
developing ovarian cancer.20 Men
with a BRCA mutation are at 10-100
times population risk (1-10% vs.
0.1%) for developing breast cancer,
and are at increased risk for prostate
and other cancers.17 Medical and/or
surgical interventions are available
for patients with hereditary cancer
syndromes predisposing to breast
cancer to reduce their cancer risk.
These options include increased
frequency of screening, use of
advanced screening modalities,
and prophylactic surgery.14, 21
The probability of a woman
with breast cancer having a
hereditary cancer syndrome is
greater the younger her age
at diagnosis. For example,
risk modeling estimates a
woman diagnosed with
“
breast cancer at age 30 has a ~10%
chance of having a BRCA mutation
compared with a ~1% chance for
a woman diagnosed at age 70.22 In
individuals without a personal history
of breast cancer, a family history
of early onset breast cancer is also
predictive of genetic etiology. For
example, based on genetic testing
results of over 185,000 individuals,
the prevalence of BRCA mutations
among individuals with no cancer
diagnosis and no risk factors (i.e. no
family history of early breast cancer
or of ovarian cancer in any relative is
1.5%).23 By contrast, individuals with
no personal history of cancer who
have a family history of breast cancer
before age 50 have a 5.6% a priori
risk of BRCA mutation.23
In the absence of a hereditary cancer
syndrome, women with a firstdegree relative with breast cancer
are at approximately two times the
population risk for developing breast
cancer themselves, with this risk
increasing based on many of the
same risk factors associated with
HBOC, including a history of younger
(≤ 50 years) age at diagnosis.14
Women at familial risk of
breast cancer may be
candidates for earlier
initiation of annual
mammogram, more
frequent screening,
and/or the use of
- 8 -
advanced screening modalities. Due
to the variety and individual nuances
of the risk models available to assess
breast cancer risk, risk assessment
by a cancer geneticist or certified
genetic counsellor can be helpful in
determining the appropriateness of
modifying standard of care breast
cancer screening for patients.24
Family members with different,
but related conditions
Recognising related conditions
can be important in distinguishing
familial disease from hereditary
disease. For example, family history
of colorectal cancer (CRC) is an
important risk factor for developing
familial CRC, but what about a
family with one case of CRC and one
case of some other cancer? Is this
family at greater risk or less risk of
disease than with a family history of
colorectal cancer alone?
Example II: Colorectal cancer
Colorectal cancer is the most
common cancer among Singaporean
men and second most common
cancer in Singaporean women.25
Colorectal cancer is usually an
older person’s disease, with peak
incidence in the mid-60’s.14 The risk
conferred by a family history of CRC
is similar to that of other diseases;
first-degree relatives of an individual
with CRC have a 2- to 3-fold
increased risk of developing CRC
themselves.14, 26 This risk increases to
approximately four times population
risk for individuals with a first-degree
relative diagnosed with CRC before
age 45 years, equivalent to the
increase in risk conferred by having
two affected first-degree relatives.14
When there is a family history of
CRC in the presence of additional
cancers, it is important to consider
a hereditary CRC syndrome. The
most common form of syndromic
CRC is Hereditary Non-Polyposis
Colorectal Cancer (HNPCC)/Lynch
syndrome. HNPCC is responsible for
2-4% of all CRC as well as 2-5%
of all endometrial cancers, with a
Medical Update
general population prevalence of ~1
in 370.27-29 80% of individuals with
HNPCC develop CRC, and 20-60%
of women develop endometrial
cancer.28 In addition to CRC and
endometrial cancers, families with
HNPCC may also have a history of
gastric, ovarian, pancreatic, ureter/
renal pelvis, biliary tract, brain, and/
or small intestine cancer.
Unfortunately HNPCC is vastly underrecognised; Hempel and colleagues
estimate that only 1 in 100
individuals with HNPCC are aware of
their diagnosis.29 This is particularly
tragic considering identification
and surveillance of HNPCC families
reduces CRC development by 60%
and decreases overall mortality
within this group.30
Conclusion
Even with the advent of new genomic
technologies, family history is still
the most clinically useful and valid
information to predict risk for disease.
The literature clearly indicates that
medical providers have room for
improvement in our collection of
family history and in our use of family
history to predict risk for disease. At a
juncture in medicine when caregivers
strive to provide higher quality of care
References
1. Margotta R. The story of medicine. New York: Golden Press; 1968.
2. Lichtenstein P, Holm NV, Verkasalo PK, Iliadou A, Kaprio J, Koskenvuo M, et
al. Environmental and heritable factors in the causation of cancer – analyses
of cohorts of twins from Sweden, Denmark, and Finland. N Engl J Med.
2000;343(2):78-85.
3. Guttmacher AE, Collins FS, Carmona RH. The family history – more important
than ever. N Engl J Med. 2004;351(22):2333-6.
4. Hindorff LA, Sethupathy P, Junkins HA, Ramos EM, Mehta JP, Collins FS, et al.
Potential etiologic and functional implications of genome-wide association loci
for human diseases and traits. Proc Natl Acad Sci U S A. 2009;106(23):9362-7.
PMCID: 2687147.
5. Viera AJ. Odds ratios and risk ratios: what’s the difference and why does it
matter? South Med J. 2008;101(7):730-4.
6. Hemminki K, Sundquist J, Bermejo JL. How common is familial cancer? Ann
Oncol. 2008;19(1):163-7.
7. Heald B, Edelman E, Eng C. Prospective comparison of family medical history with
personal genome screening for risk assessment of common cancers. Eur J Hum
Genet. 2012;20(5):547-51. PMCID: 3330209.
8. Ioannidis JP. Prediction of cardiovascular disease outcomes and established
cardiovascular risk factors by genome-wide association markers. Circ Cardiovasc
Genet. 2009;2(1):7-15.
9. Khoury MJ, McBride CM, Schully SD, Ioannidis JP, Feero WG, Janssens AC, et
al. The Scientific Foundation for personal genomics: recommendations from
a National Institutes of Health-Centers for Disease Control and Prevention
multidisciplinary workshop. Genet Med. 2009;11(8):559-67. PMCID: 2936269.
10.Baptiste-Roberts K, Gary TL, Beckles GL, Gregg EW, Owens M, Porterfield D, et al.
Family history of diabetes, awareness of risk factors, and health behaviors among
African Americans. Am J Public Health. 2007;97(5):907-12. PMCID: 1854868.
11.Qureshi N, Kai J. Informing patients of familial diabetes mellitus risk: How do
they respond? A cross-sectional survey. BMC Health Serv Res. 2008;8:37. PMCID:
2275238.
12.Fuller M, Myers M, Webb T, Tabangin M, Prows C. Primary care providers’
responses to patient-generated family history. J Genet Couns. 2010;19(1):84-96.
13.Acheson LS, Wiesner GL, Zyzanski SJ, Goodwin MA, Stange KC. Family historytaking in community family practice: implications for genetic screening. Genet
Med. 2000;2(3):180-5.
14.National Cancer Institute. The Web site of the National Cancer Institute 2011
[updated 2011; cited February 28, 2011]; Available from: http://www.cancer.gov.
15.Claus EB, Risch N, Thompson WD. Autosomal dominant inheritance of earlyonset breast cancer. Implications for risk prediction. Cancer. 1994;73(3):643-51.
16.Vogel VG. Management of patients at high risk for breast cancer. Malden, Mass.:
Blackwell Science; 2001.
despite ever-reducing time with patients,
our hope is that this article provided tips
for pattern recognition and collection of
family history which will facilitate and reenergise our efforts to use family history
to inform patient care. We believe
that collection of family history and
recognition of patterns of disease will
allow creation of personalised preventive
care plans.
GP Contact
GPs can call for appointments
through the Specialist Outpatient
Clinic at 6436 8288.
17.Korde LA, Zujewski JA, Kamin L, Giordano S, Domchek S, Anderson WF, et
al. Multidisciplinary meeting on male breast cancer: summary and research
recommendations. J Clin Oncol. 2010;28(12):2114-22. PMCID: 2860409.
18.Rubenstein WS. The Genetics of Breast Cancer. In: Vogel VG, editor.
Management of patients at high risk for breast cancer. Malden, Mass.: Blackwell
Science; 2001. p. xv, 306 p.
19.Anderson WF, Pfeiffer RM, Dores GM, Sherman ME. Comparison of age
distribution patterns for different histopathologic types of breast carcinoma.
Cancer Epidemiol Biomarkers Prev. 2006;15(10):1899-905.
20.Antoniou A, Pharoah PD, Narod S, Risch HA, Eyfjord JE, Hopper JL, et al. Average
risks of breast and ovarian cancer associated with BRCA1 or BRCA2 mutations
detected in case Series unselected for family history: a combined analysis of 22
studies. Am J Hum Genet. 2003;72(5):1117-30. PMCID: 1180265.
21.Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD, et al. American
Cancer Society guidelines for breast screening with MRI as an adjunct to
mammography. CA Cancer J Clin. 2007;57(2):75-89.
22.Antoniou AC, Pharoah PP, Smith P, Easton DF. The BOADICEA model of genetic
susceptibility to breast and ovarian cancer. Br J Cancer. 2004;91(8):1580-90.
PMCID: 2409934.
23.Myriad Genetic Laboratories. Mutation Prevalence Tables. [February 2010; cited
April 28, 2011]; Available from: http://www.myriad.com/lib/brac/brca-prevalencetables.pdf.
24.Ready K, Arun B. Clinical assessment of breast cancer risk based on family history.
J Natl Compr Canc Netw. 2010;8(10):1148-55.
25.Singapore Cancer Registry Interim Annual Registry Report. Trends in Cancer
Incidence in Singapore 2006-2010. [updated 2012; cited 13 July, 2012];
Available from: http://www.nrdo.gov.sg/uploadedFiles/NRDO/Cancer_Trends_
Report_06-10_final2.pdf.
26.Bond JH. Polyp guideline: diagnosis, treatment, and surveillance for patients with
colorectal polyps. Practice Parameters Committee of the American College of
Gastroenterology. Am J Gastroenterol. 2000;95(11):3053-63.
27.Dinh TA, Rosner BI, Atwood JC, Boland CR, Syngal S, Vasen HF, et al. Health
benefits and cost-effectiveness of primary genetic screening for Lynch syndrome
in the general population. Cancer Prev Res (Phila). 2011;4(1):9-22.
28.Kohlmann W, Gruber SB. Hereditary Non-Polyposis Colon Cancer. 2006 [updated
2006 November 29, 2006; cited March 4, 2011]; Available from: http://www.
ncbi.nlm.nih.gov/books/NBK1211/.
29.Hampel H, de la Chapelle A. The search for unaffected individuals with Lynch
syndrome: do the ends justify the means? Cancer Prev Res (Phila). 2011;4(1):1-5.
30.Regula J, Kaminski MF. Targeting risk groups for screening. Best Pract Res Clin
Gastroenterol. 2010;24(4):407-16.
31.Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM.
American College of Gastroenterology guidelines for colorectal cancer screening
2009 [corrected]. Am J Gastroenterol. 2009;104(3):739-50.
- 9 -
Medical Update
Focus:
cancer
Appointments: 6436 8288
Email: [email protected]
julsep 2012
Issue04
The Prostate Cancer Conundrum:
To Screen or Not?
Dr Ravindran Kanesvaran, Associate Consultant, Department of Medical Oncology,
National Cancer Centre Singapore
Prostate cancer is the third most common
cause of cancer amongst men in Singapore
and the sixth leading cause of cancer death
amongst men.1
The disease however has a remarkably heterogeneous natural history. It may
present as a low grade indolent disease with a long natural history (seen in
most patients) or present with locally advanced/metastatic disease which
has a median survival of just about two years. Strategies for managing
prostate cancer as such have been aimed at early detection, using a tailored
management method.
Case study
Mr KC is a 52-year-old Chinese gentleman who presents to his GP for a
routine medical check-up. His best friend had recently been diagnosed
with prostate cancer and had undergone a surgery (radical prostatectomy)
for it. Mr KC is otherwise a fit, healthy individual with no other medical
co-morbidities and has no family history of cancer. He does not smoke or
drink. He is very anxious to know what his risks are in getting prostate
cancer (especially since his friend was recently diagnosed with it) and is
keen to undergo prostate cancer screening.
- 10 -
What is prostate cancer screening?
The prostate cancer screening test
consists of both a PSA test and a
digital rectal examination (DRE).
Studies have shown that when used
in combination it was superior to
the use of either test alone.2 PSA
is a glycoprotein that is made by
the prostate gland. It is used as
a marker for early detection of
prostate cancer (screening), as well
as a marker of treatment response
and disease recurrence in patients
with active disease. Prostate cancer
screening has been fraught with
some controversy over the past few
years due to some evidence showing
that it leads to overdiagnosis and
overtreatment.3
Risks and benefits of prostate cancer
screening
Men with metastatic prostate cancer
have a dismal prognosis. The Surveillance,
Medical Update
Epidemiology and End Results (SEER) programme database
in the US indicates that the 5-year survival for this group of
patients is a mere 32%. Hence a screening programme for
patients who fall into this group may help detect the disease at
an earlier stage, when it can still be cured. Screening with PSA
has been shown to be responsible for a stage migration of those
detected with disease to an earlier stage.4
Intuitively it would seem that early detection and treatment in
this minority group of patients with advanced disease should
translate to an overall survival benefit for the screening of all
men in general. However this was not shown to be the case in a
recent large randomised controlled trial in the US.5 In this large
study of 76,693 men, who were randomised into a screened or
usual care group, they found there was no significant difference
in mortality rates between the groups. However there were some
major criticisms of the trial as more than half of the patients (52%
in the sixth year) in the control group had been screened too.
This compounded with the fact that some 44% of the patients in
both groups had done PSA screening before entering the trial and
would have definitely diluted any potential benefit that may have
been seen in this study. Another larger study involving 162,000
men in Europe however showed that there was a 20% relative
reduction in mortality in the group that was screened. In this study
they found that 1,410 men needed to be screened and 48 men
treated to prevent one cancer death over a period of 10 years. 47
men would have been treated in futility.3
“
It is important to get a detailed
history from patients who plan to
get PSA screening done.
Who should then be screened and how frequently
should it be done?
Based on Grade D evidence (evidence based on expert
opinion), the Ministry of Health (MOH) Singapore Clinical
Practice Guidelines on Cancer Screening 1/2010 suggest
the following groups (after having counselled about the
risks and benefits of prostate cancer screening) could
consider getting screened:
• Men who are between 50 to 75 years of age with
an estimated life expectancy of more than 10 years.
PSA screening comes with some risks as well. Biopsy risks
(though rare at <1%) include pain, bleeding, infection,
haematuria and haematospermia.6 A major side effect of
screening is overdiagnosis – which may lead to unnecessary
treatment like surgery or radiation therapy. Both these
therapies come with inherent risk like operative mortality,
urinary problems and sexual dysfunction. Most of these men
would not have had any problems at all if they had not been
screened. Finally like any other screening test, PSA may yield
a false positive result as well. This may cause patients intense
anxiety which may not resolve even with a negative biopsy
thereafter.7
What if the screening findings are abnormal?
A DRE finding of a palpable mass or nodule will definitely
warrant further investigation with a prostate biopsy. The
acceptable upper limit for PSA is generally accepted at 4ng/ml.
Any reading that exceeds 4ng/ml will require a prostate biopsy
to be done.8 That being said, men with PSA below the cutoff of
4ng/ml may also have prostate cancer, though the risk is lower.
In view of the fact that PSA increases with age, age-specific
reference ranges for PSA have been developed. However using
such reference ranges, or other PSA modifications [like free/
total PSA ratio, complexed PSA and PSA/TZPSAD (transition zone
PSA density)] though not used widely, are recommended by the
American Urological Association (AUA) as adjuncts to PSA and
DRE in deciding whether to do a prostate biopsy or not. This is
because the use of a specific PSA cutpoint combined with DRE
alone can lead to overestimation or sometimes underestimation
of risk in some patients.9
“
Other factors that may contribute to a raised PSA
It is important to get a detailed history from patients who plan to
get PSA screening done. Other prostatic diseases like prostatitis
and benign prostatic hyperplasia (BPH) may cause a rise in PSA
levels. Urethral, prostatic trauma and the use of a cystoscope may
also cause PSA elevations. The use of 5-alpha reductase inhibitors
like finasteride (for either BPH or male pattern baldness) will lower
PSA levels by about 50%.10 Hence patients on these drugs should
have their PSA levels adjusted to estimate their true PSA level.
Prostate biopsy has also been shown to cause a rise in PSA, hence
PSA testing should be postponed for at least three to six weeks
after a biopsy is done. DRE and ejaculation however have not
been shown to cause a significant rise in PSA (hence its testing
after a rectal examination can still be performed).11
• High-risk men – African American men, men with a
strong history of prostate cancer (one or more firstdegree relatives diagnosed before age 65 years) may
be offered screening at an earlier age.
• Routine screening of men younger than 50 years of
age should not be offered. Men with a life expectancy
of less than 10 to 15 years should be informed that
testing and treatment is unlikely to be beneficial.12
The PSA screening frequency as recommended
by the above guidelines recommends it should be
repeated annually. However the screening may be
performed every two years in low risk men with a
baseline PSA of less than 1.0ng/ml (recommended
best practice by the guideline development group).
Best practice statements in other notable guidelines
1. AUA PSA best practice statement updates 2009
Age to obtain a baseline PSA was lowered to 40 years old.
No longer recommends a single PSA threshold value to prompt a
- 11 -
Medical Update
biopsy but to take into account other PSA modification values (like
free/total PSA ratio, complexed PSA and PSA/TZPSAD) as well.
2. American Cancer Society (ACS website, last revised Feb 2012)
a) The discussion for screening should take place at age 50 years
for men who are at average risk of prostate cancer and are
expected to live at least 10 years or more.
b) For men with high risk of developing prostate cancer (AfricanAmericans and those with one first-degree relative who were
diagnosed younger than age 65 years), screening should take
place at age 45.
c) For those with even higher risk (those with more than one
first-degree relative who had prostate cancer younger than
age 65 years), screening should take place at age 40.
3. US Preventive Services Task Force (USPTF) Recommendation
Statement, Nov 2011 (Draft Statement)
a) It recommends against PSA based prostate cancer screening
in all asymptomatic men.
Conclusion
After going through all the above information with his GP,
Mr KC decided against doing prostate cancer screening. He
felt reassured after getting all the necessary information
about the pros and cons of screening.
The decision to use PSA for the early detection of prostate
cancer should be individualised. Physicians should continue
to provide men with all the information about the risks and
benefits of screening for prostate cancer before coming to a
shared decision. Routine screening without proper counselling
should be discouraged.
GP Contact
GPs can call for appointments through the Specialist
Outpatient Clinic at 6436 8288.
Summary of key points in patient education and
counselling for prostate cancer screening
(I) Prostate Cancer
1.Prostate cancer is rare in men under the age of
50 years.
2.The risk is greater in those with a family history.
3.Prostate cancers range from slow growing to
aggressive cancers. Slow growing cancers are common
and may not cause any symptoms or shorten life. Most
men with prostate cancer will
not die from it.
(II) Prostate Specific Antigen (PSA)
1.PSA is a substance made by the prostate gland. The
PSA test is a blood test measuring the level of PSA in
the blood. A raised PSA can be an early indication of
prostate cancer. However there are other conditions
which can cause a rise in PSA, for example, prostate
enlargement, prostatitis, urinary infection.
2.Approximately 2/3 of men with a raised PSA level will
not have prostate cancer.
3.The higher the PSA level, the more likely it is to
be cancer.
4.The PSA test can also miss prostate cancer.
5.There is no conclusive evidence that PSA screening in
asymptomatic men will improve the mortality of men
with prostate cancer.
(III) Further tests when PSA level is raised
1.A prostate biopsy is required to determine if cancer
is present.
2.Prostate biopsy is generally safe. However there is a
small risk of complications such as bleeding and urinary
tract infection.
3.Approximately 2/3 of men who have a biopsy will not
have prostate cancer.
Extract from MOH CPG on Prostate Cancer Screening
Guidelines 1/2010.
References
1. Trends in Cancer Incidence in Singapore 2006-2010. Singapore Cancer
Registry, 2010: p. 1-15.
2. Catalona, W.J., et al., Comparison of digital rectal examination and serum
prostate specific antigen in the early detection of prostate cancer: results of a
multicenter clinical trial of 6,630 men. J Urol, 1994. 151(5): p. 1283-90.
3. Schroder, F.H., et al., Screening and prostate-cancer mortality in a randomized
European study. N Engl J Med, 2009. 360(13): p. 1320-8.
4. Etzioni, R., et al., Impact of PSA screening on the incidence of advanced stage
prostate cancer in the United States: a surveillance modeling approach. Med
Decis Making, 2008. 28(3): p. 323-31.
5. Andriole, G.L., et al., Mortality results from a randomized prostate-cancer
screening trial. N Engl J Med, 2009. 360(13): p. 1310-9.
6. Rietbergen, J.B., et al., Complications of transrectal ultrasound-guided
systematic sextant biopsies of the prostate: evaluation of complication rates
and risk factors within a population-based screening program. Urology, 1997.
49(6): p. 875-80.
7. Fowler, F.J., Jr., et al., The impact of a suspicious prostate biopsy on patients’
psychological, socio-behavioral, and medical care outcomes. J Gen Intern Med,
2006. 21(7): p. 715-21.
8. Catalona, W.J., et al., Measurement of prostate-specific antigen in serum as a
screening test for prostate cancer. N Engl J Med, 1991. 324(17): p. 1156-61.
9. Thompson, I.M., et al., It’s time to abandon an upper limit of normal for
prostate specific antigen: assessing the risk of prostate cancer. J Urol, 2008.
180(4): p. 1219-22.
10.Andriole, G.L., et al., Treatment with finasteride preserves usefulness of
prostate-specific antigen in the detection of prostate cancer: results of a
randomized, double-blind, placebo-controlled clinical trial. PLESS Study Group.
Proscar Long-term Efficacy and Safety Study. Urology, 1998. 52(2):
p. 195-201; discussion 201-2.
11.Effect of digital rectal examination on serum prostate-specific antigen in a
primary care setting. The Internal Medicine Clinic Research Consortium. Arch
Intern Med, 1995. 155(4): p. 389-92.
12.Lim, L.S. and K. Sherin, Screening for prostate cancer in U.S. men ACPM position
statement on preventive practice. Am J Prev Med, 2008. 34(2): p. 164-70.
- 12 -
Medical Update
Focus:
cancer
Appointments: 6394 2160/2158, 6294 4050
Email: [email protected]
julsep 2012
Issue04
Advancement in the Management
of Early Cervical Cancer in Singapore
Dr Timothy Lim, Head, Pre-Invasive Disease & Screening Unit, Department of Gynaecological Oncology,
KK Women’s and Children’s Hospital
Introduction to cervical cancer in Singapore
Cervical cancer is the second most common
cancer in women worldwide with half a million
new cases diagnosed each year. It is a major
cause of gynaecological deaths with a death rate
of approximately 250,000 per year.
However in Singapore, as a result of
pap smear screening and early detection
and treatment of pre-invasive cervical
lesions, the incidence of cervical cancer
has declined. It is now the ninth
most common women’s cancer and
approximately 200 to 250 cases are
diagnosed every year.
Research has shown the high-risk
oncogenic human papillomavirus (HPV)
to be a necessary cause of the majority
of cervical cancers, in particular, HPV
types 16 and 18 which account for up to
70%. Low-risk HPV such as types 6 and
11 cause genital warts.
The most common presenting
symptom is abnormal vaginal
bleeding such as post-coital
bleeding. However in very early
cancer there are usually no
symptoms and when patients do
have symptoms, it is usually quite
advanced. As such, they may also
present with other symptoms such
as foul-smelling vaginal discharge
or even vaginal passage of urine
or faeces.
Pelvic examination would usually
reveal a tumour growth or
ulceration on the cervix and a
biopsy should be performed to
confirm the diagnosis. A patient
with a normal-looking cervix but
an abnormal pap smear requires
a colposcopy examination and
directed biopsy to diagnose a
micro-invasive cervical cancer.
General physical examination
should be performed to exclude
metastatic disease.
A patient who is suspected of
having a cervical cancer should
be promptly referred to a
gynaecologic oncologist (i.e.
gynaecologist with sub-specialty
training in cancer management)
for assessment and treatment to
avoid time delay.
Unlike other gynaecological
cancers, cervical cancers are staged
clinically because most patients
worldwide are treated only with
radiotherapy. Therefore, a careful
clinical examination should be done
by an experienced oncology team
preferably under anaesthesia. Other
investigations include hysteroscopy,
cystoscopy, proctoscopy, intravenous
urogram and X-rays of the lungs
or bones. CT scans, MRI or even
PET scans are of value in planning
treatment.
Cervical cancer management may
involve: surgery, radiotherapy,
chemotherapy and palliative care.
Advanced cervical cancer that involves
neighbouring organs is difficult to treat
and has a high mortality rate.
- 13 -
Surgery is generally reserved for
medically fit patients with cancers
up to stage IIA. However for stage
IA2 to IIA, a Wertheim’s radical
hysterectomy (removal of the uterus,
cervix, supporting ligaments and the
upper vagina, pelvic lymph nodes
and sometimes the para-aortic lymph
nodes) is generally recommended.
Pelvic radiotherapy can be utilised for
all stages. However since 1999, the
addition of chemotherapy as a radiation
sensitiser (chemo-radiation) is used as a
standard form of treatment for locally
advanced cervical cancers.
Fertility sparing surgery for young
women with early cervical cancer
The standard treatment for cervical
cancer usually results in the loss of
fertility. For decades, only young
patients with micro-invasive Stage IA1
disease could be fertility-spared with
a simple cone biopsy of the cervix.
However the technique of radical
trachelectomy has been developed as
a form of fertility sparing surgery for
young patients with Stage IA2 to IB1
cancer. Essentially radical trachelectomy
involves the removal of the cervix, the
surrounding parametrial tissue and the
upper portion of the vagina as well
as the pelvic lymph nodes but sparing
the uterus and the ovaries. The main
approaches to this technique are either
vaginal or abdominal.
Radical Vaginal Trachelectomy (RVT)
was first described in 1987 by Professor
Daniel Dargent from France and since
then, several centres in Europe and USA
have described favourable oncologic
and obstetric outcomes from this
technique in women aged between 21
to 45 years. To date almost a thousand
women worldwide have undergone
RVT to preserve fertility. However the
vaginal route was difficult to master
hence an alternative technique was
Medical Update
While preserving the ovarian vessels,
the cervix is amputated together with
a 2cm vaginal cuff leaving 5mm of the
internal os intact.
The uterus is reanastomosed back to
the vagina via interrupted sutures.
The radical trachelectomy specimen.
The neocervix six months post-surgery.
devised. In 2002, Radical Abdominal
Trachelectomy (RAT) was described in
the world medical literature as being a
successful fertility sparing procedure that
provided oncologic results similar to RVT.
To date there are about 200 women
worldwide who have undergone RAT.
Laparoscopic or robotic approach to
radical trachelectomy has been only
been described in medical literature
recently in the past few years with
encouraging results.
In a large review of 147 RAT and 618
RVT patients by Lukas Rob et al in
2011, it was found that the oncologic
outcome was good for RAT, with only
7 (4.8%) recurrences reported which
is similar to RVT (4.7%). Recurrences
however differed when the size of
tumours is taken into account: 1.9%
for tumours < 2cm vs 20% for tumours
> 2cm. This is a reminder that fertility
sparing surgery should be reserved for
tumours < 2cm. There are no deaths to
date for patients who underwent RAT.
In terms of pregnancy outcome, there
were 32 conceptions in 30 women
(15.5%) but only 20 live births of
which 7 (35%) were premature.
On the other hand, there were 300
conceptions in 237 women (30%) in
RVT patients and 190 live births of
which 38 (20%) were premature.
In Singapore, almost half of all the
cervical cancers are diagnosed in
Stage I and 10% of these are in
young women less than 35 years of
age hence fertility sparing surgery
can potentially benefit a number of
afflicted women. KK Women's and
Children's Hospital (KKH) is the main
hospital in Singapore to offer RAT on a
routine basis since 2010. The eligibility
criteria for RAT include women < 40
years of age, strong desire for fertility,
FIGO Stage IA2 to IB1, squamous
cell carcinoma or adenocarcinoma
histology, tumour size < 2cm and
negative pelvic lymph nodes. Todate, four women diagnosed with
Stage IB1 cancer of the cervix at the
- 14 -
Gynaecological Cancer Centre, KKH have
undergone this procedure successfully.
Minimally invasive surgery for the
treatment of cervical cancer
Minimally invasive surgery for
gynaecological oncology took many years
to be accepted into mainstream practice
due to the fear of compromise to the
patient’s oncologic outcome as well as the
need for additional training in advanced
laparoscopic techniques. However with the
advancement of laparoscopic equipment
as well as the improvement of surgical
techniques over the past decade, it is now
part of mainstream practice to offer this
type of surgery for selected cases. Women
suffering from early-stage cervical cancer
who have completed their families, and do
not desire to retain their fertility, may be
considered for a less invasive procedure,
Total Laparoscopic Wertheim’s Radical
Hysterectomy (TLRH), which involves
the removal of all the female reproductive
organs through keyhole surgery. TLRH has
been shown recently in many established
cancer centres around the world to be a
safe and feasible alternative to traditional
abdominal open surgery for early
cervical cancer.
For a new surgical oncology technique to
be accepted, operative outcome including
complication rates and long-term survival
have to be analysed. Recent evidence from
a few large case series show that TLRH is
a safe procedure with the added benefits
of laparoscopy such as low blood loss, less
wound pain, less wound infection and
better cosmesis without affecting oncologic
outcome when compared to the traditional
abdominal approach.
In most TLRH studies, the intra-operative
complications rates ranged from 0% to
15%, including cystotomy, ureteric injury,
rectal injury and vascular injury. This is
similar to intra-operative complications
rates for traditional abdominal radical
hysterectomy which are reported to
range from 4.4% to 6.6% for urinary
tract and 8.7% for other areas (e.g.
nerves, intestinal and haemorrhage).
On the other hand, the post-operative
Medical Update
complication rate ranged from 4%
to 40% in most TLRH studies, with
urological complications such as urinary
tract infection, voiding dysfunction,
vesicovaginal or utereterovaginal fistulas
being the most frequent. In contrast,
the post-operative complication rates
for abdominal radical hysterectomy lies
between 4.4% to 20%.
The overall 5-year survival for patients
undergoing TLRH ranges from 80% to
90% for patients with Stage IA1 to IB
cervical cancer and this is not inferior
to the traditional route. Cancer relapse
occurs even in early cervical cancer. For
laparotomy cases, it ranges from 12%
to 25%. Relapse rates between 0%
to 13% have been reported in various
TLRH studies in patients with median
follow-ups between 7 to 92 months.
In recent years, Da Vinci Robotassisted laparoscopic radical
hysterectomy has been described
in medical literature and is gaining
popularity especially in the USA.
The advantage of three-dimensional
vision, tremor reduction, greater intraabdominal articulation and motion
scaling makes the surgery easier and
safer but at an increased cost.
KKH is the main hospital in Singapore
which offers total laparoscopic radical
hysterectomy since 2009. Since the
procurement of the Da Vinci robot,
robotic radical hysterectomy has
been offered as well since 2012. The
eligibility criteria include: FIGO (2009)
stage IA to IB1 cervical cancer, clinical
and radiological absence of lymph
node and distant metastases. There
must not be any medical conditions
such as heart or lung problems that
preclude a laparoscopy approach.
Total laparoscopic radical hysterectomy.
Using the harmonic ACE to transect the
parametrium.
A view of the pelvis after the radical
hysterectomy and bilateral pelvic
lymphadenectomy.
hysterectomy. The median operative
time was 268 minutes and the median
blood loss was 300ml. There was no
intra-operative bladder, ureteric or
bowel complications. One patient
(5%) suffered from long-term voiding
disorder requiring intermittent selfcatheterisation and one patient had
a small uretero-vaginal fistula which
healed after insertion of a DJ stent.
For those who do not desire fertility,
the minimally invasive approach
to radical hysterectomy allows the
patient to recover faster with less pain
as well as better cosmesis without
compromising the oncologic outcome.
Conclusion
Early cervical cancer is highly
curable. With the option of radical
trachelectomy, young women afflicted
with this condition can still go on to
have children after cancer treatment.
GP Contact
GPs can call 6394 2160 or
6394 2158 for appointments at
the KKH Gynaecological Cancer
Centre. Appointments can also
be made through the Specialist
Outpatient Clinic Appointment
Centre at 6294 4050.
References
In KKH, about 40 patients with cervical
cancer undergo abdominal radical
hysterectomy every year. However
since the introduction of the minimally
invasive approach, 22 patients have
undergone TLRH and one patient
has undergone robotic radical
• Rob L, Skapa P, Robova H. Fertility sparing surgery in patients with cervical cancer. Lancet Oncol 2011;12:192-200.
• Lee CL et al. Long term survival outcomes of laparoscopically assisted radical hysterectomy in treating early stage
cervical cancer. Am J Obstet Gynecol 2010;203:165e1-7.
• Frumovitz M et al. Comparison of total laparoscopic and abdominal radical hysterectomy for patients with early
stage cervical cancer. Obstet Gynecol 2007;110(1):96-102.
• Total Laparoscopic (Wertheim’s) Radical Hysterectomy in the management of Stage I Cervical Cancer in Singapore:
A pilot study. Under review for publication
- 15 -
Services at SingHealth
Dept of General Surgery
Hepatopancreatobiliary and
Transplant Service at SGH
The Hepatopancreatobiliary (HPB) and Transplant
Service at the Department of General Surgery,
Singapore General Hospital (SGH) has an experienced
team of surgeons who are adept at and perform a
high volume of complex HPB cases annually. Besides
providing cutting-edge surgical services to our local
population, we are also a regional referral centre as
well as a leading centre of clinical research.
Diseases of the liver, pancreas,
gallbladder and biliary system are
relatively common and frequently require
surgical treatment for recovery and
good long-term outcome. HPB diseases
especially malignancies frequently
require complex major operations
which are best performed in a high
volume tertiary centre. Numerous
publications in the medical literature
have repeatedly demonstrated that the
best patient outcomes are obtained
when these procedures are conducted in
a centre performing a high volume of
such complex cases.
Over the past decade, surgeons at SGH
have performed more than a thousand
complex liver and pancreatic operations
(more than any institution in the country)
with surgical outcomes on par with the
very best centres worldwide. Our excellent
surgical results have been published in
numerous world-renowned peer-review
medical journals such as Annals of Surgery
and Archives of Surgery.
Over the past few years, the HPB service
has also adopted minimally invasive
approaches (laparoscopic surgery)
for selected patients requiring liver or
pancreatic resections allowing these
patients to enjoy the benefits of ‘keyhole’ surgery. We have also recently
added robotic surgical techniques into
our surgical repertoire to expand our
indications for laparoscopic surgery.
Utilising surgical techniques from
transplantation, our surgeons are also
experienced in performing complex
vascular resections and reconstructions for
otherwise inoperable malignancies.
The HPB service, working closely with the
Nuclear Medicine, Medical Oncology
and Radiation Oncology units at SGH and the National Cancer Centre Singapore
(NCCS), is not only heavily involved but
is spearheading numerous international
multi-centre clinical trials treating patients
with HPB malignancies. This allows our
patients to gain access to the latest
and costliest cancer treatments which
would not otherwise be available, and
frequently at no additional cost. Members of the HPB/transplant
service are also actively involved
in performing liver and pancreas transplant operations and are
experienced in all technical aspects of
transplantation including deceased
donor and living donor organ
transplantations. Liver transplantation is
indicated in selected patients with severe
chronic liver disease or liver cirrhosis. This
procedure is also the treatment of choice
in selected patients with primary liver
cancers. Pancreas transplantation is
a newly available treatment modality
for Type I diabetics in Singapore. It
has been proven to be an extremely
effective treatment modality for the disease and frequently may be curative.
Conditions treated at the
SGH Hepatopancreatobiliary
and Transplant Service:
- 16 -
Appointments: 6321 4402
Email: [email protected]
1. Surgical Diseases of the Liver
Primary liver cancer such as
hepatocellular carcinoma and peripheral
cholangiocarcinoma are common in
Southeast Asia and our service has
developed significant experience in
the surgery of such conditions with
excellent outcomes.
Secondary liver cancer such as colorectal
liver metastasis frequently requires
surgical resection for optimal outcomes.
Patients are comprehensively assessed in
multidisciplinary meetings with our medical
oncology colleagues regarding suitability
and optimal timing for resection. When
surgery is neither indicated nor useful,
patients are discussed at multidisciplinary
meetings where we work closely with
colleagues in Interventional Radiology,
Nuclear Medicine, Medical Oncology
and Hepatology to offer patients other
treatment modalities.
Cutting-edge therapies available in
addition to surgical resection and
transplantation include selective
internal radiation therapy (SIRT) and
radio-frequency ablation (RFA). The
department is actively involved in clinical
trials offering novel and emerging
therapies, thus making such therapies
available early to our patients.
2. Surgical Diseases of the Gallbladder
Biliary System
Common conditions include gallbladder
and bile duct stones, recurrent
pyogenic cholangitis (RPC) and cancers
involving the gallbladder and bile ducts.
Endoscopic and laparoscopic (Minimally
invasive surgery or MIS) procedures
are the main modalities of treatment
in stone disease while special surgical
techniques, including the creation of
subcutaneous enteric access are used in
the management of the more challenging
cases of recurrent pyogenic cholangitis.
An area that the HPB service has also
developed significant expertise is in
radical surgery, which is frequently
required for cancers of the bile duct
and gallbladder.
3. Surgical Diseases of the Pancreas
These conditions include solid cancers
of the pancreas, cystic lesions of the
Services at SingHealth
pancreas (both malignant and benign) as
well as inflammation and stone diseases
of the pancreas.
and reconstructions for locally-advanced
cancers which would otherwise be
deemed inoperable.
Surgery of the pancreas is a specialised
area and the best outcomes are
obtained in dedicated high-volume
specialty centres. We perform all types
of pancreatic surgeries including Whipples
procedure, total pancreatectomy,
enucleation, distal pancreatectomy and
pancreatico-enteric bypass. We also
adopt minimally invasive approaches
for selected procedures in appropriate
patients. Our service is also adept in
performing complex vascular resections
The HPB Service has also developed
an international reputation in the
management of the less common
cystic lesions of the pancreas with
numerous publications in peer review
international medical journals.
4. Gallstone Disease
Laparoscopic cholecystectomy is
currently the gold-standard surgical
method for treating gallstone disease.
In some patients, the procedure
may not be possible because of
acute or chronic inflammation of the
gallbladder or because of previous
abdominal surgery. Such patients
will then require conventional or
open cholecystectomy. Laparoscopic
cholecystectomy is otherwise safe and
successful in most patients.
We also offer single-incision
laparoscopic surgery (SILS) whereby
the entire operation is performed via
2.5cm incision through the
belly-button for selected patients
resulting in a near ‘scarless’ abdomen
after surgery.
GP Contact
GPs can call 6321 4402 for appointments. Appointments can also be made through the Specialist Outpatient Appointment
Centre at 6321 4377.
For referrals, a friendly chat or discussion, our GP partners can call 6321 4051 (Dept of General Surgery).
News at SingHealth
BREAKTHROUGH
in Study on Bile Duct Cancer with Discovery of
New Gene Mutations
A combined team of scientists
from Singapore and Thailand
made a significant breakthrough
in understanding the cause of
bile duct cancer, a deadly type
of liver cancer. Using the latest
genomic technologies, the
researchers identified several
new genes frequently mutated in
bile duct cancers, paving the way
for better understanding of how
bile duct cancers develop.
The Singapore-Thailand team was led by Professors
Teh Bin Tean, Patrick Tan, and Steve Rozen from the
National Cancer Centre Singapore (NCCS) and
Duke-NUS Graduate Medical School of Singapore,
and Vajarabhongsa Bhudhisawasdi from Thailand’s
Khon Kaen University.
The breakthrough came after two years of intensive
research, which saw scientists from Singapore visiting the
villagers in northern Thailand, and Thai researchers coming
to Singapore to work in NCCS laboratories. The discovery
was published online on 6 May 2012 in Nature Genetics.
Bile Duct Cancer, or Cholangiocarcinoma, is a fatal
cancer with poor prognosis. Accounting for 10 to 25%
of all primary liver cancers worldwide, bile duct cancer
is a prevalent disease in Southeast Asia, particularly in
the Northeast of Thailand which sees about 20,000
- 17 -
News at SingHealth
new cases each year. The high incidence in Thailand is
attributed to long-term consumption of raw fish that is
infected with liver flukes, which are food-borne parasites
found in fish. Liver fluke infections are widespread in
Northeast Thailand, where they are thought to occur in
over 6 million people. Once eaten, the flukes accumulate
in the bile ducts of the human host, causing constant
infection and the onset of cancer.
Prof Teh, who was a recipient of the Singapore Translational
Research (STaR) Investigator Award in 2009 and the head
of the Van Andel Research Institute at the National Cancer
Centre of Singapore, said the study will pave the way for a
better understanding of the roles that newly identified genes
play in the development of bile duct cancer. “This discovery
adds depth to what we currently know about bile duct cancer.
More important is that we are now aware of new genes and
their effects on bile duct cancer and we now need to further
examine their biological aspects to determine how they bring
about the onset of Cholangiocarcinoma."
“
This discovery adds depth to
what we currently know about
bile duct cancer. More important
is that we are now aware of
new genes and their effects on
bile duct cancer and we now
need to further examine their
biological aspects to determine
how they bring about the onset
of Cholangiocarcinoma.
“
Using state-of-the-art DNA sequencing platforms, the
researchers analysed eight bile duct cancers and normal
tissues from Thai patients, and discovered mutations in
187 genes. The team then selected 15 genes that were
frequently mutated for further analysis in an additional
46 cases. Many of these genes, such as MLL3, ROBO2
and GNAS, have not been previously implicated in bile
duct cancers.
“With this finding we now know much more about
the molecular mechanisms of the disease and we can
draw up additional measures that can be taken while
we identify the most appropriate treatment protocols.
We are talking about the potential to save many lives in
Thailand,” said Professor Vajarabhongsa Bhudhisawasdi,
Director of the Liver Fluke and Cholangiocarcinoma
Research Center, Khon Kaen University of Thailand.
“Also, this study shows that we can work closely with our
counterparts in other countries and share our expertise
and experience to improve the lot for the people.”
The researchers also compared the bile duct cancers to other
related cancers of the liver and pancreas. Surprisingly, they
found that the bile duct cancers shared certain similarities with
pancreatic cancer. “This research provides a strong direction
for future studies,” said Associate Professor Patrick Tan, faculty
member of the Cancer and Stem Cell Biology Programme at
the Duke-NUS. “Cholangiocarcinoma and Pancreatic Duct
Adenocarcinoma appear to share more molecular similarities
than earlier studies had indicated, and suggest that there are
common biological pathways between the two cancers. By
studying these pathways, we can then shed more light on how
these tumours develop.”
Dr Chutima Subimerb, a Thai scientist involved in the project,
said she was pleased with the collaboration and to be able
to participate in this health diplomacy project. “We are very
privileged to be able to work alongside Prof Teh and the
other scientists from Singapore. By pooling our resources we
were able to make this discovery which will have very wide
impact on the people, especially the poor people who have
been eating the fish that they catch from the ponds and
rivers in the region. I believe this is only a first step and we
will see even more collaborations in time to come between
our two countries in the field of scientific research.”
The research was funded by the Ministry of Health’s National
Medical Research Council, Millennium Foundation, Lee
Foundation, National Cancer Centre Research Fund, Duke-NUS
Graduate Medical School, Cancer Science Institute Singapore,
Research Team Strengthening Grant, National Genetic
Engineering and Biotechnology Center and the National
Science and Technology Development Agency (Thailand).
- 18 -
News at SingHealth
NHCS New Building
Wins Top Award for
Eco-Friendly Features
The National Heart Centre Singapore (NHCS) new building has
been awarded the Building and Construction Authority (BCA)
Green Mark Platinum Award 2012 – the highest accolade for
green building certification in Singapore – for integrating various
energy-efficient and environment-friendly features and practices
in the new building, including:
Energy savings through sustainable architecture
and engineering
To cut down on the amount of air-conditioning needed, the
new building has been carefully positioned to have no direct
west-facing façade. This reduces significant solar heat from
getting into the building, thus reducing the air-conditioning
consumption. The same benefit is also achieved through the
use of extensive natural ventilation in the concourse area with
a North-South orientation and the installation of an energyefficient air-conditioning plant which runs at less than 0.65
kilowatt per refrigeration ton (kW/RT).
Other green features include regenerative lifts which
generate energy when moving, saving 27% of lift energy;
energy-efficient lights fitted with sensors to switch them
off when not in use; and automatic demand-controlled
ventilation for the carparks, activated only when it detects a
preset carbon dioxide level.
All these features contribute to the new building’s annual
estimated energy savings of 6,500,000 kWh, a 30% reduction
compared to a normal building, with a cost savings of $1.3
million a year.
Reducing carbon footprint
Patients will be able to heal in a therapeutic environment with
the introduction of open spaces, verdant terraces and even a
green façade at the drop-off point in the new building. Aside
from lowering building interior temperature and improving air
quality, the wide presence of greenery of almost 2,200 square
metres also helps to bring down the emission of carbon dioxide.
The new building also provides a carpark guidance system
which gives a clear indication of the available parking lots, thus
reducing unwanted engine exhaust emissions.
NHCS will be going a step further in the drive for environmental
sustainability through the provision of charging stations
for electric vehicles. Together, these features will slash the
hospital’s carbon emission by an estimated 3,000 tonnes a year,
equivalent to that of 525 cars’ annual carbon dioxide emission.
“The BCA Green Mark Platinum Award demonstrates our
strong commitment in incorporating internationally recognised
best practices in environmental design and performance in
our new building design. As a socially responsible healthcare
organisation, NHCS is proud to play our part in promoting a
greener and healthier environment for the community,” said
Associate Professor Koh Tian Hai, Medical Director, NHCS.
The new NHCS building will have three additional storeys to
cater for future expansion, making it a 12-storey building with
three basements of 48,000 square metres. The new building is
located opposite Block 4 of the Singapore General Hospital, and
will be operational end-2013.
Artist's impression of the institutional front of the NHCS
new building which is carefully positioned to have no westfacing façade to reduce solar heat gain into the building, thus
lowering cooling energy demand.
Water savings through low water
fittings and rain harvesting
Each year, the NHCS new building will be
able to save about 12,000 cubic metres
of water – almost enough to fill five
Olympic-sized swimming pools. This will
be achieved through the installation
of low water fittings which helps to
reduce water consumption by about
55%, about $26,000 in annual savings.
Another contributing feature includes
rain-harvesting fixtures where collected
rainwater and condensation from the air
handling units will be used to water the
plants and foliage placed strategically
around the building.
ECO
friendly
- 19 -
News at SingHealth
NHCS Performs Asia’s First
Successful Transapical
Transcatheter Mitral
Valve-in-Valve Implantation
During the procedure, the SAPIEN valve crimped onto a catheter
balloon is delivered through a 6-8cm puncture in the apex of the
heart. The valve is guided into position using ultrasound imaging
(transesophageal echocardiography) and the robotic X-ray
imaging system in a hybrid operating room. The balloon is then
expanded to deploy the valve when the heart is kept relatively still
with electrically-induced rapid heartbeat (ventricular pacing).
The procedure lasts one to two hours and the length of hospital
stay is about a week.
Mr Cher’s bill after subsidy (C-class) came up to about $15,000,
fully paid from Medisave and Medishield.
Advantages of the procedure include:
1. Viable alternative to the otherwise high-risk conventional
reoperation, which can be significantly hazardous to the
elderly and can protract the recovery process
2. Small incision, without the need to stop the heart for
the procedure
3. Relieve symptoms such as breathlessness, lethargy, reduced
effort tolerance
4. Improve heart function
5. Expedite recovery
6. Improve quality of life
7. Prolong life
Mr Anthony Cher, first patient in Asia to have successfully
undergone the transapical transcatheter mitral valve-in-valve
procedure in February 2012 at NHCS.
The transapical transcatheter mitral valve-in-valve (TA MViV)
procedure is a new minimally invasive approach that allows
cardiac surgeons to put a new heart valve (Edwards SAPIEN)
within a worn-out valve prosthesis.
Mr Anthony Cher, a 72-year-old retiree, was the first person
in Asia to benefit from this new procedure. The TA MViV was
first performed in Canada in 2007. Mr Cher suffered from a
problematic mitral valve and had worn out his replacement
animal valve implanted in 2005. However, after having
undergone two heart operations, it was risky for him to go for
a third one.
“TA MViV offers patients with worn-out tissue heart valves in the
aortic and mitral positions the opportunity of treatment, speeding
their recovery and potentially improving survival. Alternative
techniques are also available for patients with worn-out valves
in the tricuspid and pulmonary positions,” said Dr Soon Jia Lin,
Associate Consultant, Department of Cardiothoracic Surgery,
National Heart Centre Singapore (NHCS) who performed the
procedure for Mr Cher. This new procedure is currently offered by
NHCS only to selected patients with prohibitively high risk from
conventional repeat open-heart surgeries.
Heart valve replacement surgery is only performed when
repair is not possible. Animal tissue valves are usually
implanted in patients aged 60 and above to avoid the need
for long-term anticoagulation medication. However, these
animal tissue valves wear out over time, becoming narrowed,
blocked or – in the case of Mr Cher – leaky, causing blood to
leak between the heart chambers.
The long-term durability of these new valves are however still
unknown. Although procedural risks continue to improve, the
risks associated with the patients’ coexisting diseases remain.
In 2010, NHCS treated 120 people with mitral
valve problems. One third had to have their valves
replaced. More people are expected to benefit from
this procedure as Singapore’s population ages. By
2030, one in five Singaporeans will be aged 65 and
above, a three-fold increase to 960,000 elderly from
about 350,000 today. Some elderly patients with
worn-out animal valves will become too high-risk for
conventional reoperations.
In the context of an ageing population and with greater
awareness of this service, this procedure will be an area of
growth evidenced by the exponential trend seen in Europe and
North America.
Contact NHCS
GP Fast-Track Appointment
Tel: 6436 7848
Outpatient Appointment Unit
Tel: 6436 7840 Fax: 6222 9258
Email: [email protected]
General Enquiries
Tel: 6436 7800 Fax: 6227 3562
Email: [email protected]
- 20 -
Research at SingHealth
Preventing glaucoma blindness
Researchers identify siblings of glaucoma patients as high-risk
General practitioners caring for Chinese patients suffering from primary
angle closure (PAC) or primary angle-closure glaucoma (PACG) should
encourage them to bring their siblings for regular screening, according to
research from Singapore National Eye Centre (SNEC) and Singapore Eye
Research Institute (SERI).
The team, led by Professor Aung Tin, Senior
Consultant and Head, Glaucoma Service (Research and
Education), SNEC, studied the heritability and sibling
risk of narrow angles. They found a high heritability
(nearly 60%) for narrow angles among first degree
relatives of patients with PAC and PACG. The siblings
of the affected individuals also demonstrated a 50%
probability of developing narrow angles. Narrow
angles are a known precursor to the development of
PAC and PACG.
“
Working together with GPs,
we can prevent unnecessary
loss of sight.
“
“Glaucoma, if left untreated, leads to irreversible
blindness, which is why these results are so
significant,” said Prof Aung. “These results emphasise
the need for targeted screening among family
members of patients with PAC or PACG, so we can
identify and closely monitor those at risk. This is
particularly important for siblings of patients.”
The study, believed to be the first of its kind, was
recently published in the leading ocular research
journal, Ophthalmology.
Referred to as the silent thief of sight, glaucoma affects
more than 3% of people over the age of 50 in Singapore
The prevalence increases with age and is almost 10% for
those over 70. Among those affected, 10 to 15% were
blind in both eyes. Yet, 9 in 10 glaucoma patients are
unaware of their condition at the time of diagnosis.
“
Our primary healthcare providers are ideally
positioned to encourage those patients
suffering from PACG and PAC with siblings
to come for screening.
-Prof Aung
“
- 21 -
CONTACT SNEC
GP Fast-Track Appointment
Tel: 6322 9399
Email: [email protected]
General Enquiries
Tel: 6227 7255
Appointments
Singapore General Hospital
GP Hotline: 6321 4402, Email: [email protected]
Promotions, Senior Consultants
Dr Goh Pheck Suan
Senior Consultant
Dr Goh Su-Yen
Senior Consultant
Dept
Dept
Sub-specialty
Sub-specialty
Anaesthesiology
Neuro-Anaesthesia
Endocrinology
Diabetes, General
Endocrinology
Dr Shanker
Pasupathy
Senior Consultant
Dept
General Surgery
Sub-specialty
Vascular & General
Surgery, Metabolic &
Bariatric Surgery
Dr Cheow
Peng Chung
Senior Consultant
Dr Ong
Wai Choung
Senior Consultant
Dr Loh Su
Ming Yvonne
Senior Consultant
Dept
Dept
Dept
General Surgery
Sub-specialty
Hepatobiliary,
Pancreatic, General
Surgery & Liver
Transplant
Gastroenterology &
Hepatology
Haematology
Sub-specialty
Sub-specialty
Stem Cell /
Bone Marrow
Transplantation
Dr Chin Yuan
Hui Andrew
Senior Consultant
Dr Tay Shian Chao
Senior Consultant
Dr Maciej
Piotr Chlebicki
Senior Consultant
Dept
Hand Surgery
Hand Surgery
Gastroenterology,
Therapeutic
Endoscopy, ERCP
Dept
Sub-specialty
Dept
Infectious Diseases
Sub-specialty
Wrist & Distal
Radioulnar Joint
Disorder, Minimally
Invasive Surgery,
Micro-Reconstructive
Surgery
Dr Cheah
Kee Leong
Senior Consultant
Dr Chia Shi Lu
Senior Consultant
Dr Loh Hwai Liang
Senior Consultant
Dept
Orthopaedic Surgery
Dept
Dept
Sub-specialty
Sub-specialty
Dr Koh
Siyue Mariko
Senior Consultant
Dr Sim Hong Gee
Senior Consultant
Dept
Urology
Micro-Reconstructive
Surgery, Wrist Disorder
Internal Medicine
Dr Rafay Azhar
Senior Consultant
Dept
Pathology
Sub-specialty
Histopathology,
Cytology
Adult Reconstruction
Service
Respiratory & Critical
Care Medicine
Sub-specialty
Pulmonary Medicine,
Asthma, Endobronchial
Ultrasound and Allergy
- 22 -
Sub-specialty
General Internal
Medicine and
Infectious Diseases
Pathology
Histopathology,
Cytology
Dept
Sub-specialty
Uro-Oncology, Robotic
& Laparoscopic Surgery
Appointments
Promotions, Consultants
Dr Sng
Wei-Ee Karen
Senior Consultant
Dr Harikrishnan
Kothandan
Consultant
Dr Aaron Lee
Kwang Yang
Consultant
Dept
Dept
Dept
Sub-specialty
Anaesthesia
Sub-specialty
Sub-specialty
Dr Leong
Kwok Wah
Consultant
Dr Chew Min Hoe
Consultant
Dr Lee Haur Yueh
Consultant
Dept
Colorectal Surgery
Dept
Dept
Dr Farhad
Fakhrudin
Vasanwala
Consultant
Dr Sathish Kumar
Gopalakrishnan
Consultant
Dept
Haematology
Plastic, Reconstructive
& Aesthetic Surgery
Cleft & Craniofacial
Surgery, Aesthetic
Surgery
Anaesthesiology
Anaesthesiology
Anaesthesiology
Anaesthesia
Dermatology
Sub-specialty
Anaesthesia
Dr Soh Wah
Ek Abel
Consultant
Dept
Endocrinology
Sub-specialty
Diabetes, General
Endocrinology
Family Medicine
Continuing Care
Dept
Sub-specialty
Sub-specialty
Bone Marrow
Transplantation
Dr Ng Yuk Hui
Consultant
Dr Leo Kah Woon
Consultant
Dr Chiong Yi
Consultant
Dept
Dept
Dept
Otolaryngology
Sub-specialty
Rhinology
Family Medicine
Plastic, Reconstructive
& Aesthetic Surgery
Sub-specialty
Reconstructive
Microsurgery, Aesthetic
Dr Tan Chieh Suai
Consultant
Dr Chew Huck Chin
Consultant
Dept
Dept
Renal Medicine
Sub-specialty
General Nephrology
Respiratory & Critical
Care Medicine
Sub-specialty
Intensive Care,
Emergency Medicine,
General Pulmonary
- 23 -
Rehabilitation
Medicine
Appointments
Promotions, Associate Consultants
Dr Ng Tong Yong
Associate Consultant
Dr Shariq Ali Khan
Associate Consultant
Dept
Dept
Sub-specialty
Sub-specialty
Pathology
Anaesthesiology
General
Microbiology, Virology
Dr Chan Ju Min Shaun Xavier
Associate Consultant
Dept
Dept
Sub-specialty
Sub-specialty
Perioperative Medicine and
Ambulatory Anaesthesia
Dept
Colorectal Surgery
Neuro-Anaesthesia
Dr Hairil Rizal Bin Abdullah
Associate Consultant
Anaesthesiology
Dr Fu Wan Pei
Cherylin
Associate Consultant
Diagnostic Radiology
Interventional Radiology,
Body Imaging
Appointments, Consultant
Dr Parag Ratnakar Salkade
Associate Consultant
Dr Too Chow Wei
Associate Consultant
Dr Hakan Aydin
Consultant
Dept
Dept
Dept
Diagnostic Radiology
Diagnostic Radiology
Pathology
KK Women’s and Children’s Hospital GP Hotline: 6294 4050, Email: [email protected]
Appointments
Dr Rajeshwar Rao
Senior Consultant
Promotions
Dr Arun Kumar
Pugalenthi
Consultant
Dr Toh Han Wei
Luke
Consultant
Paediatrics
(Allergy Service)
Dept
Dept
Dr Ang Seng Bin
Consultant Family
Physician
Dr Thia Wee Hong
Edwin
Consultant
Dr Tan Woon Hui
Natalie
Consultant
Dept
Dept
Dept
Dr Indra Ganesan
Consultant
Dr Mok Yee Hui
Consultant
Dr Evan Woo
Consultant
Dept
Dept
Dept
Dept
Family Medicine
Service
Paediatrics
(Nephrology Service)
Paediatrics
(Respiratory Medicine)
Maternal Fetal
Medicine
Paediatric Subspecialties
(Children's Intensive
Care Unit)
- 24 -
Diagnostic and
Interventional Imaging
Paediatrics
(Infectious Disease
Services)
Plastic, Reconstructive
& Aesthetic Surgery
Appointments
New Appointments
Prof Chay Oh Moh
Campus Director,
Education Office
Senior Consultant
A/Prof Anette
S Jacobsen
Associate Dean;
Senior Consultant
Dept
Dept
Paediatrics
(Respiratory Medicine)
Paediatric Surgery
A/Prof Chan
Mei Yoke
Head, HaematoOncology Service;
Senior Consultant
Dept
Paediatric Subspecialties
A/Prof Ng
Kee Chong
Chairman, Division
of Medicine;
Head and Senior
Consultant
A/Prof Tan
Teng Hong
Head, Cardiology
Service;
Senior Consultant
Dr Chan
Yoke Hwee
Deputy Chairman,
Division of Medicine;
Senior Consultant
Dept
Paediatric
Subspecialties
Dept
Dept
Dr Helen Chen
Head & Senior
Consultant
Dr Lim Boon
Leong Kevin
Chairman, Division
of Surgery;
Senior Consultant
Dr Ong Say How
Head, Child &
Adolescent Mental
Wellness Service;
Senior Consultant
Emergency Medicine
Dept
Psychological Medicine
(Mental Wellness
Service)
National
Neuroscience
Institute GP Hotline: 6321 4402,
Dept
Orthopaedic Surgery
Singapore
National Eye
Centre GP Hotline: 6322 9399,
Email: [email protected]
Email: [email protected]
Promotion
Promotion
Dr Yip Chun Wai
Consultant
Dept
Neurology
Sub-specialty
General Nephrology
Adj A/Prof
Tina Wong
Senior Consultant
Dept
Glaucoma Service
- 25 -
Paediatric Subspecialties
(Children's Intensive
Care Unit)
Dept
Psychological
Medicine (Mental
Wellness Service)
Dr Shephali Tagore
Director, O&G
International Medical
Programs;
Consultant
Dept
Maternal Fetal
Medicine
Courses
SingHealth Duke-NUS Scientific Congress 2012
In line with the theme “Defining Tomorrow’s Medicine”, which is SingHealth’s vision, an exciting line-up of
speakers will present thought-provoking discussions in a variety of different areas, including the application of
genomics to medicine, latest advances in the management of chronic diseases, interdisciplinary management
in complex maxillo-facial reconstructions, and bioethical challenges faced by clinicians and researchers in
academia-industry collaborations. In addition, workshops on integrated care, obstetrics, allied health and
nursing will also be conducted before and after the main Congress.
Date
3 – 4 August 2012 (Friday to Saturday)
Time
Day 1 (Friday)
9 am – 6 pm
(Registration is from 8 am – 9 am)
Day 2 (Saturday)
8.30 pm – 4 pm
(Registration is from 8 am – 8.30 am)
Venue
Raffles City Convention Centre, Singapore
Contact
SingHealth Duke-NUS Scientific Congress 2012
Event Secretariat
Tel: 6377 8644
Email: shsdn.scientificcongress.singhealth.com.sg
Registration is required.
*For more information on the Congress programme,
visit www.singhealthacademy.edu.sg/sdc
Pre-Congress Workshops
Singapore General Hospital
Hematolymphoid Pathology
Course 2012
Date
30 Jul – 2 Aug 2012 (Monday to Thursday)
Venue
SGH Department of Pathology
Recent Advances in Stroke
Rehabilitation Workshop
Date
2 Aug 2012, Thursday
Venue
SingHealth Academy
Obstetric Emergencies
Training Workshop
Date
2 Aug 2012, Thursday
Venue
KKH Simulation Centre
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Courses
6th Gynaecological & Early Pregnancy
Ultrasound Workshop
The objective of the workshop is to gain an understanding of ultrasound
physics, technology and basic skills to perform and interpret images with
emphasis on first trimester pregnancy failure. Topics include practical
guidelines in the diagnosis of pregnancy failure, classification of miscarriage
by ultrasound, ectopic pregnancy as well as normal and abnormal variations
observed during the first trimester. A sonographic approach to endometrial
diagnosis and practical guide to the diagnosis and management of adnexal pathology is also included.
Ultrasound is a quick and non-invasive test that is useful in the assessment of a patient’s gynaecological complaints and is increasingly
becoming an indispensable diagnostic tool in daily clinical applications. Through the morning lectures, participants will be able to revise
the first principles of performing ultrasound scans and be alerted to the common pitfalls. The quiz will comprise images from common
gynaecological conditions, followed by a hands-on session on patients.
Date
11 August 2012, Saturday
Time
Lectures
9 am – 1.15 pm
Practical
2 pm – 4 pm
(Registration starts at 8.45 am)
*Lunch is at 1.15 pm
Venue
Lectures
Post Graduate Medical Institute (PGMI)
Block 4, Level 1, Singapore General Hospital
Practical
Obstetrics & Gynaecology Centre
Block 5, Level 1, Singapore General
Hospital
CME Points
Application in process
Fees
Morning lectures
$110 (SingHealth staff),
$120 (non-SingHealth staff)
Full day session
$220 (SingHealth staff),
$240 (non-SingHealth staff)
*Full day session is limited to 24 pax
Contact
Ms Jessica Leong
SGH Postgraduate Medical Institute
Singapore General Hospital
Tel: 6321 4071 / 6326 5284
Fax: 6223 9789
Email: [email protected]
Registration is required.
Updates on Corneal Surgery and External Eye Diseases
for Family Physicians
This is a two-hour course that will provide family physicians with updates and practical information on corneal diseases,
corneal surgery and contact lenses. Topics such as the management of dry eyes, ocular allergy, infective keratitis and other
corneal diseases, external eye diseases, corneal transplantation techniques, types of contact lens management and contact
lens complications will be covered.
Course Director
Prof Donald Tan
Date
11 August 2012, Saturday
Fees
Waived
Course Co-ordinator
Adj Assoc Prof Jodhbir S. Mehta
Time
2 pm – 4 pm
*Lunch starts at 1pm
Contact
Training and Education Development
Singapore National Eye Centre
Singapore 168751
Fax: 6226 3395
Email: [email protected]
Course Faculty
Dr Anshu Arundhati
Dr Cordelia Chan
Dr Lim Li
Dr Ti Seng Ei
Adj Assoc Prof Louis Tong
Venue
Level 4, Auditorium,
Tower Block,
Singapore National Eye Centre
CME Points
2 points
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Registration is required.
Courses
12th Advanced
Neuroradiology Course
The course aims to refresh and add value as well as
innovation to the clinical realm and highlight advances
in the practice of Neuroradiology and Head and Neck
Radiology. The specially invited international and local
faculty will share their expert knowledge and insights with
the audience and on the newest developments in their field.
Obstetric Anaesthesia
Symposium 2012
The symposium will cover a wide range of topics, with a
special focus on the discussion of cutting-edge advances made
in the field of obstetric anaesthesia. Guest speakers A/Prof
Brendan Carvalho and Dr Roshan Fernando will share their
vast experience and research in obstetric anaesthesia and pain
management. Problem-Based Learning discussions will allow
participants to have a chance at assessing their skills in diagnosis
and management of clinical scenarios in obstetric patients.
Date
29 – 30 September 2012 (Saturday to Sunday)
Course highlights:
• Neuro-Interventional Updates
• Imaging Cerebrovascular Reserve
• Paediatric Spine: Development, Imaging and
Neurosurgical Perspective
• Fetal MRI
• Sellar and Parasellar Imaging and Pathology
• Head and Neck Imaging
• Neuroradiology Resident Review Course
Date
18 – 19 October 2012
(Thursday to Friday)
Time
To be advised
Venue
TTSH Theatrette (Level 1)
Tan Tock Seng Hospital, Singapore
Time
8 am – 5 pm (Saturday)
8.30 am – 12.30 pm (Sunday)
CME Points
Application in process
Venue
KKH Auditorium (Training Centre)
Level 1, Women’s Tower
Fees
Doctors
$250 (on or before 1 Sept), $280 (after 1 Sept)
CME Points
Application in process
Other healthcare professionals
$180 (on or before 1 Sept), $210 (after 1 Sept)
Fees
Private Doctors / Specialists
$170 (until 31 Aug), $220 (from 1 Sept)
Trainees
$100 (on or before 1 Sept), $120 (after 1 Sept)
Medical Officers / Trainees / Residents
$110 (until 31 Aug), $160 (from 1 Sept)
Nurses
$70 (until 31 Aug), $110 (from 1 Sept)
Contact
Tel: 6394 8746
(Monday to Friday, 8.30 am to 5.30 pm)
Contact
Course Secretariat
12th Advanced Neuroradiology Course
c/o Department of Neuroradiology
National Neuroscience Institute @ TTSH
Tel: 6357 7018/7033
Fax: 6358 1259
Email: [email protected]
Registration is required.
*For more information and updates, visit www.nni.com.sg
Registrations by 14 September 2012.
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Courses
Paediatric Airway Course
This is a two-day workshop which covers common and important aspects of paediatric airway disease that are relevant to
surgical as well as medical disciplines like paediatric medicine, emergency medicine and anaesthesia.
For the surgical disciplines like otolaryngology and paediatric surgery, a special emphasis on various aspects of paediatric
bronchoscopic procedure and technique will be demonstrated.
This will be further augmented with hands-on bronchoscopic techniques on rabbits and live surgery on paediatric patients.
Date
9 – 10 November 2012 (Friday to Saturday)
Time
9 am – 5 pm
Full course
Fees
(9-10 November 2012)
ENT specialists
S$1000
S$300
Residents**
S$500
S$150
S$75
General Practitioners / Specialists
Venue
Day 1: Hands-on Paediatric Endoscopy
Workshop (Friday)
SingHealth Experimental Medicine Centre
Block 9, Level 3
Singapore General Hospital
Day 2: Lectures and Live Surgeries (Saturday)
KKH Auditorium (Training Centre)
Level 1, Women’s Tower
KK Women’s and Children’s Hospital
CME Points
Application in process
Lectures only
(10 November 2012)
** Residents should include a letter of status from Head of Department
Contact
A/Prof Henry Tan
Department of Otolaryngology
KK Women's and Children's Hospital
Tel: 6394 1676
Fax: 6295 6339
Email: [email protected]
Paediatric Tracheostomy Workshop
(optional add-on)
Date
8 November 2012, Thursday
Time
8.20 am – 5 pm
(Registrations starts at 8.10 am)
Venue
KKH Auditorium (Training Centre)
Level 1, Women’s Tower
KK Women’s and Children’s
Hospital
Fees
Full course
(9-10 November 2012)
Lectures only
(10 November 2012)
Doctors
S$100
S$50
Nurses
S$80
S$40
* Morning lectures (maximum 70 pax), afternoon workshop (maximum 40 pax)
Contact
Ms Shermeen Quek
Division of Nursing
KK Women’s and Children’s Hospital
Tel: 6394 2395
Fax: 6394 1163
Email: [email protected]
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Recruitment
Doctors
As Singapore's leading referral centre for cardiovascular medicine, National Heart Centre Singapore, with 185 beds,
houses the largest cardiovascular specialty group in Singapore and has an international reputation for outstanding
clinical services, research and medical advances.
We seek passionate and talented doctors to join our existing team of cardiac specialists in the
following position:
DOCTORS
(Full-time, Part-time or Sessional)
You will conduct treadmill stress tests for outpatients. Flexible working arrangements on a full-time, part-time or sessional
basis can be worked out.
You must be a medical practitioner with a basic Medical Degree that is registrable with the Singapore Medical Council
and should preferably have experience in running treadmill stress tests.
Please send in your resume stating full personal particulars, educational and professional
qualifications, career history, present and expected salaries, contact number and email address to:
Human Resource Department, National Heart Centre Singapore
Mistri Wing, 17 Third Hospital Avenue, Singapore 168752
E-mail: [email protected], Website: www.nhcs.com.sg
(Only shortlisted candidates will be notified.)
Resident Physician (Primary Eye Care Physician)
The Singapore National Eye Centre (SNEC) Primary
Eyecare Clinic (PEC) is a new and cost-effective model of
community-based primary eye care. The PEC provides
continuity of care in monitoring and assessing patients
with diabetic retinopathy, glaucoma and other chronic
age-related eye conditions referred by the SNEC. The PEC
also provides preventive eye screening services.
We are offering Full-time and Locum positions
for Family Physicians / General Physicians who
would like to develop a further interest in eye
care besides their GP practice. It may also be
an ideal choice for GPs looking to move into
a second career focusing on primary eye care
practice working within normal operating
hours. Doctors who have retired and/or
seeking part-time work hours or flexible work
arrangements are welcome to apply.
You will be responsible for carrying out eye screening,
monitoring and assessment of walk-in and referral
patients from SNEC and GPs.
Successful candidates will be offered:
Primary eye care training in screening, diagnosis and
assessment. Attractive remuneration and benefits.
Requirements
Basic medical degree recognised by the Singapore
Medical Council (SMC). Previous posting in
ophthalmology would be an advantage.
Interested applicants, please email your
curriculum vitae including details of work
experience, qualifications, present and
expected salaries and contact telephone
number to: [email protected]
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Courses
Public Forums
CancerWise Workshop –
Managing the Psychological Aspect
of Newly Diagnosed Cancer Patients
Learn to understand the reactions and feelings of newly diagnosed
cancer patients towards the cancer, coping strategies and adjustment
to life after cancer treatment.
When
28 July 2012, Saturday
1.30 pm – 4.00 pm
(Registration starts at 1 pm)
Fees
$5
Please call 6225 5655 or visit
www.nccs.com.sg to register.
Where
Function Room, Level 4
National Cancer Centre Singapore
11 Hospital Drive
Singapore 169610
* Strictly no admission for children
below 12 years old.
‘Staying In Control’ –
A Pelvic Floor Disorders Public Forum
This forum aims to raise awareness and understanding of Pelvic
Floor Disorders and the treatment options provided by SGH’s
Pelvic Floor Disorders Service. Pelvic Floor Disorders, comprising
functional conditions such as faecal incontinence, urinary
incontinence and pelvic organ prolapse syndromes, represent
some of the most distressing health problems in any society,
with the incidence increasing with age.
When
18 August 2012, Saturday
Fees
Free
English Session
1 pm – 2.30 pm
(Registration from 12 pm – 1 pm)
Pre-registration is required.
Please call us at 6321 4671 /
6326 6106 to register (please
provide name, NRIC, number
of attendees).
Mandarin Session
3 pm – 4.30 pm
(Registration from 2 pm – 3 pm)
*Free goodie bag per registrant (first
come first served only).
Where
HDB Hub Auditorium, Toa Payoh
Cancerwise
Workshop –
Pain Management
Learn more about what is pain, how it occurs, why
cancer causes pain as well as to assess pain.
When
25 August 2012, Saturday
1.30 pm – 4.00 pm
(Registration starts at 1 pm)
Where
Function Room, Level 4
National Cancer Centre Singapore
11 Hospital Drive
Singapore 169610
Fees
$5
Please call 6225 5655 or visit www.nccs.com.sg
to register.
*Strictly no admission for children below 12 years old.
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Courses
Bilingual Public Forum –
Liver Awareness Month
Topics such as common liver problems, risk factors (viruses, alcohol and
fat), signs and symptoms, early detection and prevention as well as
treatment options will be covered.
When
8 September 2012, Saturday
Fees
Free
Mandarin Session
9.15 am – 10.30 am
(Registration from 9 am to 9.15 am)
Please call 6225 5655 / 6236 9432 /
6236 9447 to register.
English Session
11.15 am – 12.30 pm
(Registration from 11 am to 11.15 am)
SOC FAST TRACK APPOINTMENT
CONTACT NUMBERS
6321 4402
*Registration is required as seats are limited. Strictly
no admission for children below 12 years old.
6294 4050
6436 8288
Where
The URA Centre
Function Hall, Level 5
45 Maxwell Road
Singapore 069118
6324 8798
6436 7848
6321 4402
National Neuroscience
Institute @ TTSH
9637 9718
6322 9399
Cancerwise Workshop –
Hepatitis B and its Link to Liver Cancer
Find out what is Hepatitis and the causes, signs and symptoms of
Hepatitis B. Learn the link between Hepatitis B and liver cancer, and
how to live with Hepatitis B.
When
15 September 2012, Saturday
1.30 pm – 4 pm
(Registration starts at 1 pm)
Where
Function Room, Level 4
National Cancer Centre Singapore
11 Hospital Drive
Singapore 169610
DIRECT WARD REFERRAL
CONTACT NUMBERS
6321 4822
6394 1183
Fees
$5
Please call 6225 5655 or
visit www.nccs.com.sg
to register.
*Strictly no admission for children
below 12 years old.
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Members of the SingHealth Group