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MEDICAL www.singhealth.com.sg 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 - 26 - 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 - 27 - 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. - 28 - 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] - 29 - 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] - 30 - 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. - 31 - 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. - 32 - Members of the SingHealth Group