1. health and fitness
2. disease
3. cancer

www.singhealth.com.sg
Jul-Sep 14
A SingHealth Newsletter for Medical Practitioners MCI (P) 143/11/2013
Focus: Cancer
The Changing
Landscape of
Lung Cancer
in Singapore
Managing
Polypharmacy in
Elderly Patients
with Cancer
Managing the
Adverse Effects
of Radiation
Therapy
SingHealth Academic Healthcare Cluster
• Singapore General Hospital • KK Women’s and Children’s Hospital • Sengkang Health • 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
Appointments: 6436 8288
Email: [email protected]
Focus: Cancer
Jul-Sep 2014
The Changing Landscape of Lung Cancer
in Singapore
While Asian never-smokers
with lung cancer are
predominantly females, the
proportion of males in this
category is not insignificant.
Assoc Prof Darren Wan-Teck Lim, Dr Eng-Huat Tan
Senior Consultants, Division of Medical Oncology, National Cancer Centre Singapore
Academic Medical Program (Oncology), Duke-NUS Graduate Medical School
The Burden of Lung Cancer in
Singapore
Lung cancer is one of the most common malignancies in the world.1 It is the
leading cause of cancer deaths in both
men and women in Singapore.2 Nonsmall cell lung cancer (NSCLC) makes
up the majority (85-90%) of lung cancer
cases.3 Prognosis is generally poor, with
an overall 5-year survival of 15%. Most
patients present with advanced disease, in which setting median survival is
between 8 to 10 months.
Lung Cancer in Asia is
Different from the West
The composition of lung cancer in Singapore and the rest of Asia differ from
the West in various aspects. Firstly, the
number of ever-smokers and neversmokers are discordant. Ever-smokers
comprise 92% of patients in the United
States of America (USA), but the proportion of ever smokers is significantly
lower in the Asian populations in South
Korea, Japan and Singapore, at approximately 70%.5,6
Data from the Singapore Cancer Registry mapped between 1968 to 2007
demonstrates a consistent incidence
of lung cancer among women (now the
third most common cancer in females
after breast and colorectal cancer) and
a reduction in incidence of lung cancer
among men.4 Fewer males with lung
cancer, and the relatively low proportion of smoking-related lung cancer
subtypes overall, speak to the salutary
results of a successful anti-smoking
public policy over the last 4 decades.
The difference in smoking status between Asian and Western women with
lung cancer is even more marked. A
Polish study revealed 19% of female
lung cancer patients to be non-smokers
in contrast with 62-82% of female lung
cancer patients in Singapore.7-9 Studies
conducted in Japan and Korea similarly
showed a significantly higher proportion of never smokers amongst females
when compared to US (76-89% versus
10%).5,6
The proportion of Asian male neversmokers is also significantly higher when
compared with US (11-16% versus 5-6%).
The proportion of male never-smokers in
Singapore is similar to the Korean and
Japanese population at 15%.7
Secondly, there is some evidence that
response to chemotherapy is superior
in Asian patients compared with Caucasian or Western patients. In a multi-centre study of combination chemotherapy
in Australia and Singapore, two thirds
(65%) of Asian patients demonstrated
objective response to chemotherapy,
compared with only one third of Caucasian patients (31%).10
Moreover, there is growing evidence
that Asian ethnicity (specifically East
Asian) predicts for a better survival outcome when compared to Caucasians.
Data from cancer registries in Korea, Japan and the US revealed Asian ethnicity
to be an independent factor predicting
for better survival, even after taking
smoking status into account.
Table 1: Some differences between lung cancer in Asia and the West
NSCLC in East Asians
NSCLC in Caucasians
Proportion of never-smokers
30%
8%
Proportion of female never-smokers
75%
10%
Proportion of male never-smokers
15%
5%
Proportion of EGFR mutants amongst never- or light smokers
60%
38%
Sensitivity to cytotoxic chemotherapy
65%
31%
2
Never-smokers with Lung
Cancer is an East Asian
Disease
The cause of lung cancer in Asian
non-smokers remains unknown. While
Asian never-smokers with lung cancer
are predominantly females, the proportion of males in this category is not
insignificant, with more than 10% of
male lung cancer patients being neversmokers.
The importance of never-smoking status in lung cancer came to prominence
with the development of a new class
of targeted agents to treat lung cancer in the late 1990s. Unlike classical
chemotherapy, which exerts its antineoplastic effect primarily by inducing
cellular damage, these agents act by
blocking specific signalling pathways
that drive cellular growth, proliferation
and survival processes essential to the
growth and sustenance of malignancy,
and recognised biological hallmarks of
cancer. They antagonise the action of
specific enzymes, called kinases, that
propagate the growth and proliferation
signals downstream of the cellular receptor through phosphorylation of the
amino acid tyrosine – hence the name
tyrosine kinase inhibitor (TKI).
The first TKIs used in lung cancer were
targeted against the epidermal growth
factor receptor (EGFR), a cell surface
receptor associated with cell proliferation and survival, and noted to be
overexpressed in pathologic evaluations of multiple malignancies, including lung cancer.
Laboratory and early clinical trials
showed some degree of activity of
these EGFR TKIs against NSCLC. However, initial phase II and III clinical trials
in unselected advanced NSCLC showed
modest activity only, with no discernible improvement when these agents
were added to chemotherapy.11-14
Nevertheless, the EGFR TKI erlotinib
was found to have sufficient activity
in unselected patients with NSCLC in
the salvage setting when compared to
placebo, and received global approval
for use.15
Our group at the National Cancer Centre Singapore (NCCS) first reported the
much higher response rate to EGFR
TKI amongst the never-smokers.16 Further light on the distinctiveness of East
Asian NSCLC was shed with the landmark discovery of the EGFR mutations
in tumours of patients who responded
well to EGFR TKI.17-19
These mutations, detected with the
use of readily available molecular
tests, are the molecular aberrations
conferring these receptors’ heightened activity even in the absence of a
triggering ligand, and represent an excellent biomarker for activity of the TKI
directed against EGFR, as opposed
to mere EGFR overexpression on im-
munohistochemical evaluation of the
pathological specimen.
The landmark Iressa Pan Asia Study
revealed superiority of the EGFR TKI
Iressa (gefitinib) over conventional chemotherapy in Asian never- or ex-light
smokers with lung cancer.20 Several
studies that followed demonstrated
EGFR mutations to be significantly
more common in NSCLC patients in
East Asia, especially amongst the never-smokers; the frequency of EGFR mutations in never- or ex-light smokers in
Asia is approximately 60%, compared
to 38% of European never-smokers.
This finding seems to imply that the
likelihood of mutations affecting the
EGFR in NSCLC is influenced both by
the smoking status and ethnicity, explaining the observation that EGFR
TKIs have a greater impact on survival
outcome in Asian patients when compared to Caucasians. These studies also
confirmed the EGFR mutation to be a
robust biomarker of sensitivity to the
EGFR TKI; with 70% of patients with
EGFR mutations responding to EGFR
TKIs, as opposed to less than 5% of patients without EGFR mutations.
Thus, being an East Asian, female nonsmoker (the phenotype) can be used as
a good (if not perfect) clinical surrogate
for the underlying EGFR mutation (genotype) to select for sensitivity to EGFR
TKIs.
3
Medical
Update
Appointments: 6436 8288
Email: [email protected]
Focus: Cancer
Jul-Sep 2014
The Changing Landscape of Lung Cancer
in Singapore
While Asian never-smokers
with lung cancer are
predominantly females, the
proportion of males in this
category is not insignificant.
Assoc Prof Darren Wan-Teck Lim, Dr Eng-Huat Tan
Senior Consultants, Division of Medical Oncology, National Cancer Centre Singapore
Academic Medical Program (Oncology), Duke-NUS Graduate Medical School
The Burden of Lung Cancer in
Singapore
Lung cancer is one of the most common malignancies in the world.1 It is the
leading cause of cancer deaths in both
men and women in Singapore.2 Nonsmall cell lung cancer (NSCLC) makes
up the majority (85-90%) of lung cancer
cases.3 Prognosis is generally poor, with
an overall 5-year survival of 15%. Most
patients present with advanced disease, in which setting median survival is
between 8 to 10 months.
Lung Cancer in Asia is
Different from the West
The composition of lung cancer in Singapore and the rest of Asia differ from
the West in various aspects. Firstly, the
number of ever-smokers and neversmokers are discordant. Ever-smokers
comprise 92% of patients in the United
States of America (USA), but the proportion of ever smokers is significantly
lower in the Asian populations in South
Korea, Japan and Singapore, at approximately 70%.5,6
Data from the Singapore Cancer Registry mapped between 1968 to 2007
demonstrates a consistent incidence
of lung cancer among women (now the
third most common cancer in females
after breast and colorectal cancer) and
a reduction in incidence of lung cancer
among men.4 Fewer males with lung
cancer, and the relatively low proportion of smoking-related lung cancer
subtypes overall, speak to the salutary
results of a successful anti-smoking
public policy over the last 4 decades.
The difference in smoking status between Asian and Western women with
lung cancer is even more marked. A
Polish study revealed 19% of female
lung cancer patients to be non-smokers
in contrast with 62-82% of female lung
cancer patients in Singapore.7-9 Studies
conducted in Japan and Korea similarly
showed a significantly higher proportion of never smokers amongst females
when compared to US (76-89% versus
10%).5,6
The proportion of Asian male neversmokers is also significantly higher when
compared with US (11-16% versus 5-6%).
The proportion of male never-smokers in
Singapore is similar to the Korean and
Japanese population at 15%.7
Secondly, there is some evidence that
response to chemotherapy is superior
in Asian patients compared with Caucasian or Western patients. In a multi-centre study of combination chemotherapy
in Australia and Singapore, two thirds
(65%) of Asian patients demonstrated
objective response to chemotherapy,
compared with only one third of Caucasian patients (31%).10
Moreover, there is growing evidence
that Asian ethnicity (specifically East
Asian) predicts for a better survival outcome when compared to Caucasians.
Data from cancer registries in Korea, Japan and the US revealed Asian ethnicity
to be an independent factor predicting
for better survival, even after taking
smoking status into account.
Table 1: Some differences between lung cancer in Asia and the West
NSCLC in East Asians
NSCLC in Caucasians
Proportion of never-smokers
30%
8%
Proportion of female never-smokers
75%
10%
Proportion of male never-smokers
15%
5%
Proportion of EGFR mutants amongst never- or light smokers
60%
38%
Sensitivity to cytotoxic chemotherapy
65%
31%
2
Never-smokers with Lung
Cancer is an East Asian
Disease
The cause of lung cancer in Asian
non-smokers remains unknown. While
Asian never-smokers with lung cancer
are predominantly females, the proportion of males in this category is not
insignificant, with more than 10% of
male lung cancer patients being neversmokers.
The importance of never-smoking status in lung cancer came to prominence
with the development of a new class
of targeted agents to treat lung cancer in the late 1990s. Unlike classical
chemotherapy, which exerts its antineoplastic effect primarily by inducing
cellular damage, these agents act by
blocking specific signalling pathways
that drive cellular growth, proliferation
and survival processes essential to the
growth and sustenance of malignancy,
and recognised biological hallmarks of
cancer. They antagonise the action of
specific enzymes, called kinases, that
propagate the growth and proliferation
signals downstream of the cellular receptor through phosphorylation of the
amino acid tyrosine – hence the name
tyrosine kinase inhibitor (TKI).
The first TKIs used in lung cancer were
targeted against the epidermal growth
factor receptor (EGFR), a cell surface
receptor associated with cell proliferation and survival, and noted to be
overexpressed in pathologic evaluations of multiple malignancies, including lung cancer.
Laboratory and early clinical trials
showed some degree of activity of
these EGFR TKIs against NSCLC. However, initial phase II and III clinical trials
in unselected advanced NSCLC showed
modest activity only, with no discernible improvement when these agents
were added to chemotherapy.11-14
Nevertheless, the EGFR TKI erlotinib
was found to have sufficient activity
in unselected patients with NSCLC in
the salvage setting when compared to
placebo, and received global approval
for use.15
Our group at the National Cancer Centre Singapore (NCCS) first reported the
much higher response rate to EGFR
TKI amongst the never-smokers.16 Further light on the distinctiveness of East
Asian NSCLC was shed with the landmark discovery of the EGFR mutations
in tumours of patients who responded
well to EGFR TKI.17-19
These mutations, detected with the
use of readily available molecular
tests, are the molecular aberrations
conferring these receptors’ heightened activity even in the absence of a
triggering ligand, and represent an excellent biomarker for activity of the TKI
directed against EGFR, as opposed
to mere EGFR overexpression on im-
munohistochemical evaluation of the
pathological specimen.
The landmark Iressa Pan Asia Study
revealed superiority of the EGFR TKI
Iressa (gefitinib) over conventional chemotherapy in Asian never- or ex-light
smokers with lung cancer.20 Several
studies that followed demonstrated
EGFR mutations to be significantly
more common in NSCLC patients in
East Asia, especially amongst the never-smokers; the frequency of EGFR mutations in never- or ex-light smokers in
Asia is approximately 60%, compared
to 38% of European never-smokers.
This finding seems to imply that the
likelihood of mutations affecting the
EGFR in NSCLC is influenced both by
the smoking status and ethnicity, explaining the observation that EGFR
TKIs have a greater impact on survival
outcome in Asian patients when compared to Caucasians. These studies also
confirmed the EGFR mutation to be a
robust biomarker of sensitivity to the
EGFR TKI; with 70% of patients with
EGFR mutations responding to EGFR
TKIs, as opposed to less than 5% of patients without EGFR mutations.
Thus, being an East Asian, female nonsmoker (the phenotype) can be used as
a good (if not perfect) clinical surrogate
for the underlying EGFR mutation (genotype) to select for sensitivity to EGFR
TKIs.
3
Medical
Update
Appointments: 6436 8288
Email: [email protected]
Focus: Cancer
The Road Ahead
The last decade has witnessed the
transformation of lung cancer from
a dead end into a road map – from
being a homogeneous disease of
universally dismal prognosis, into a
collection of molecularly disparate
diseases with differing outcomes and
ever-widening therapeutic options,
that is leading the way in redefining
our approach to cancer diagnostics
and therapeutics.
The EGFR pathway in lung cancer
Epidermal Growth Factor
Epidermal Growth Factor
Receptor
Mutation resulting in
ligand independent
constitutive activation
Tyrosine kinase inhibitor
(e.g. gefitinib erlotinib)
cytoplasm
Cell growth, survival and proliferation
While 50% of the lung adenocarcinoma
in East Asia comprises patients with
EGFR mutations, additional subsets
with well-defined molecular aberrations
that are targetable have also been discovered.21-23
In recent years, a small subset (5-8%)
of NSCLC has been found to harbour a
specific chromosomal translocation that
results in the rearrangement of particular
genes (in this case, the anaplastic lymphoma kinase [ALK] gene, a gene that
encodes the ALK kinase). The aberrant
juxtaposition of the ALK gene with another gene usually distant from it results
in the formation of a fusion gene (and
thence, protein) that drives cell proliferation and survival, promoting the development of lung cancer. In a landmark
trial, patients with ALK positive NSCLC
were shown to derive significant clinical
benefit from Crizotinib, a TKI inhibiting
the ALK protein.24 This ALK-driven subset of lung cancer also displays a slight
preponderance in East Asian patients.
Data from the NCCS and Singapore
General Hospital (SGH) over the last 3
years, during which time molecular profiling has been performed routinely in
4
lung cancer diagnosis, shows that the
local molecular landscape is very similar
to the rest of Asia, with an EGFR mutation rate of 56% and an ALK translocation rate of 8%.
Jul-Sep 2014
priately selected patients responding
to therapy, and median survival in this
group now exceeding 2 years.
Changing Paradigms,
Improved Outcomes
Combination cytotoxic chemotherapy
has been the standard of care for advanced NSCLC for decades. However,
even with the use of third generation
chemotherapeutic agents and spectacular enhancements in supportive care,
improvements in overall outcome were
marginal at best, with median survival in
advanced disease remaining at 1 year.25-27
Just as therapy is personalised to particular molecular subsets, it has been
found that specific histological subtypes predict for response to, and benefit from, particular cytotoxic agents.
To this end, the histological subtype
of adenocarcinoma has been shown to
predict for better responses and overall survival to the novel cytotoxic agent
Pemetrexed, a drug that prevents DNA
synthesis and cell division by antagonising folate, an important cofactor in the
synthesis of nucleotides.29
Happily, this dismal prognosis is finally
changing with improved understanding of the biological heterogeneity of
the disease, and appropriately tailoring
therapy to disparate disease subsets.28
The recognition of EGFR-mutated
and ALK-translocated subsets of lung
cancer, coupled with the introduction
of orally bioavailable, conveniently
dosed agents that specifically target
these molecular aberrations, have led
to spectacular improvements in clinical outcome, with up to 70% of appro-
The introduction of such molecularly
and histologically tailored therapeutics
into the treatment armamentarium has
resulted in improvements in lung cancer survival tracked in 5,320 lung cancer
patients treated in the NCCS from 2000
to 2012. Overall survival benefits were
not surprisingly best observed among
lung adenocarcinomas, with the inflection point of survival improvements occurring soon after the introduction of
Pemetrexed and EGFR tyrosine kinase
inhibitors into routine use.
Relevant to our population, the entity of
non-smoking related lung cancers has
become better recognised and treated,
with median survival in this group of patients even in the setting of advanced
disease now exceeding 2 years. While
the progress made has been nothing
short of staggering, there remain unmet needs for tobacco-related lung
cancers and lung cancers with hitherto
unknown targetable molecular aberrations – the prognosis for these patients
remains unfavourable.
Even within the well-defined disease
subsets of the non-smoking related
lung cancers, there is data to suggest
the importance of additional molecular
abnormalities, above and beyond the
dominant ones like EGFR mutation and
ALK translocation, that may affect overall prognosis.30
To further our understanding of these
complexities so as to even further enhance outcomes, the Lung Cancer
Consortium Singapore (LCCS) has
been established. Started in 2000, the
LCCS originated as a project within
NCCS to streamline and coordinate research into lung cancer, involving clini-
cal investigators and basic scientists
from hospitals and research institutes
across Singapore.
In collaboration with the Genome Institute of Singapore, the LCCS was
awarded the National Medical Research
Council Translational and Clinical Research Program Grant for 2013 to study
the progenitor origins of lung cancer,
lung cancer heterogeneity and drug resistance. Additionally, next generation
sequencing for targeted genomic of tumour samples is also being performed
extensively under the auspices of the
Academia at SingHealth.
It is hoped that this concerted translational research effort in Singapore will
enable us to build upon recent successes to further enhance the outlook for
patients with lung cancer in Singapore.
In collaboration with the Genome Institute of
Singapore, the Lung Cancer Consortium (LCCS) was
awarded the National Medical Research Council
Translational and Clinical Research Program Grant for
2013 to study the progenitor origins of lung cancer,
lung cancer heterogeneity and drug resistance.
Learning Summary and Practice Points
1. Smoking cessation remains an important cornerstone of primary prevention of lung cancer.
2. Small cell lung cancer and squamous cell lung cancer rates have dropped
in tandem with smoking cessation programs.
3. Adenocarcinoma is now the dominant subtype of lung cancer in Singapore.
4. Adenocarcinoma with a predominance of never-smokers is a separate clinical and biological entity.
5. Specific molecular alterations in adenocarcinoma can be targeted with oral
small molecule kinase inhibitors.
6. Modern chemotherapeutics benefit adenocarcinoma more than squamous
cell.
7. This has led to overall survival improvement in lung cancer in Singapore
compared to 10 years ago.
8. Further investigations should be considered in never-smokers who present
with chronic airway-related symptoms.
GP CONTACT
GPs can call for appointments through
the Specialist Outpatient Clinic at
6436 8288.
Please visit www.singhealth.com.sg/
medical-news for the references used
for this article.
5
Medical
Update
Appointments: 6436 8288
Email: [email protected]
Focus: Cancer
The Road Ahead
The last decade has witnessed the
transformation of lung cancer from
a dead end into a road map – from
being a homogeneous disease of
universally dismal prognosis, into a
collection of molecularly disparate
diseases with differing outcomes and
ever-widening therapeutic options,
that is leading the way in redefining
our approach to cancer diagnostics
and therapeutics.
The EGFR pathway in lung cancer
Epidermal Growth Factor
Epidermal Growth Factor
Receptor
Mutation resulting in
ligand independent
constitutive activation
Tyrosine kinase inhibitor
(e.g. gefitinib erlotinib)
cytoplasm
Cell growth, survival and proliferation
While 50% of the lung adenocarcinoma
in East Asia comprises patients with
EGFR mutations, additional subsets
with well-defined molecular aberrations
that are targetable have also been discovered.21-23
In recent years, a small subset (5-8%)
of NSCLC has been found to harbour a
specific chromosomal translocation that
results in the rearrangement of particular
genes (in this case, the anaplastic lymphoma kinase [ALK] gene, a gene that
encodes the ALK kinase). The aberrant
juxtaposition of the ALK gene with another gene usually distant from it results
in the formation of a fusion gene (and
thence, protein) that drives cell proliferation and survival, promoting the development of lung cancer. In a landmark
trial, patients with ALK positive NSCLC
were shown to derive significant clinical
benefit from Crizotinib, a TKI inhibiting
the ALK protein.24 This ALK-driven subset of lung cancer also displays a slight
preponderance in East Asian patients.
Data from the NCCS and Singapore
General Hospital (SGH) over the last 3
years, during which time molecular profiling has been performed routinely in
4
lung cancer diagnosis, shows that the
local molecular landscape is very similar
to the rest of Asia, with an EGFR mutation rate of 56% and an ALK translocation rate of 8%.
Jul-Sep 2014
priately selected patients responding
to therapy, and median survival in this
group now exceeding 2 years.
Changing Paradigms,
Improved Outcomes
Combination cytotoxic chemotherapy
has been the standard of care for advanced NSCLC for decades. However,
even with the use of third generation
chemotherapeutic agents and spectacular enhancements in supportive care,
improvements in overall outcome were
marginal at best, with median survival in
advanced disease remaining at 1 year.25-27
Just as therapy is personalised to particular molecular subsets, it has been
found that specific histological subtypes predict for response to, and benefit from, particular cytotoxic agents.
To this end, the histological subtype
of adenocarcinoma has been shown to
predict for better responses and overall survival to the novel cytotoxic agent
Pemetrexed, a drug that prevents DNA
synthesis and cell division by antagonising folate, an important cofactor in the
synthesis of nucleotides.29
Happily, this dismal prognosis is finally
changing with improved understanding of the biological heterogeneity of
the disease, and appropriately tailoring
therapy to disparate disease subsets.28
The recognition of EGFR-mutated
and ALK-translocated subsets of lung
cancer, coupled with the introduction
of orally bioavailable, conveniently
dosed agents that specifically target
these molecular aberrations, have led
to spectacular improvements in clinical outcome, with up to 70% of appro-
The introduction of such molecularly
and histologically tailored therapeutics
into the treatment armamentarium has
resulted in improvements in lung cancer survival tracked in 5,320 lung cancer
patients treated in the NCCS from 2000
to 2012. Overall survival benefits were
not surprisingly best observed among
lung adenocarcinomas, with the inflection point of survival improvements occurring soon after the introduction of
Pemetrexed and EGFR tyrosine kinase
inhibitors into routine use.
Relevant to our population, the entity of
non-smoking related lung cancers has
become better recognised and treated,
with median survival in this group of patients even in the setting of advanced
disease now exceeding 2 years. While
the progress made has been nothing
short of staggering, there remain unmet needs for tobacco-related lung
cancers and lung cancers with hitherto
unknown targetable molecular aberrations – the prognosis for these patients
remains unfavourable.
Even within the well-defined disease
subsets of the non-smoking related
lung cancers, there is data to suggest
the importance of additional molecular
abnormalities, above and beyond the
dominant ones like EGFR mutation and
ALK translocation, that may affect overall prognosis.30
To further our understanding of these
complexities so as to even further enhance outcomes, the Lung Cancer
Consortium Singapore (LCCS) has
been established. Started in 2000, the
LCCS originated as a project within
NCCS to streamline and coordinate research into lung cancer, involving clini-
cal investigators and basic scientists
from hospitals and research institutes
across Singapore.
In collaboration with the Genome Institute of Singapore, the LCCS was
awarded the National Medical Research
Council Translational and Clinical Research Program Grant for 2013 to study
the progenitor origins of lung cancer,
lung cancer heterogeneity and drug resistance. Additionally, next generation
sequencing for targeted genomic of tumour samples is also being performed
extensively under the auspices of the
Academia at SingHealth.
It is hoped that this concerted translational research effort in Singapore will
enable us to build upon recent successes to further enhance the outlook for
patients with lung cancer in Singapore.
In collaboration with the Genome Institute of
Singapore, the Lung Cancer Consortium (LCCS) was
awarded the National Medical Research Council
Translational and Clinical Research Program Grant for
2013 to study the progenitor origins of lung cancer,
lung cancer heterogeneity and drug resistance.
Learning Summary and Practice Points
1. Smoking cessation remains an important cornerstone of primary prevention of lung cancer.
2. Small cell lung cancer and squamous cell lung cancer rates have dropped
in tandem with smoking cessation programs.
3. Adenocarcinoma is now the dominant subtype of lung cancer in Singapore.
4. Adenocarcinoma with a predominance of never-smokers is a separate clinical and biological entity.
5. Specific molecular alterations in adenocarcinoma can be targeted with oral
small molecule kinase inhibitors.
6. Modern chemotherapeutics benefit adenocarcinoma more than squamous
cell.
7. This has led to overall survival improvement in lung cancer in Singapore
compared to 10 years ago.
8. Further investigations should be considered in never-smokers who present
with chronic airway-related symptoms.
GP CONTACT
GPs can call for appointments through
the Specialist Outpatient Clinic at
6436 8288.
Please visit www.singhealth.com.sg/
medical-news for the references used
for this article.
5
Medical
Update
Appointments: 6436 8288
Email: [email protected]
Focus: Cancer
Managing Polypharmacy in
Elderly Patients with Cancer
Dr Alexandre Chan, Specialist Pharmacist (Oncology Pharmacy),
Department of Pharmacy, National Cancer Centre Singapore
Associate Professor, Department of Pharmacy, Faculty of Science,
National University of Singapore
Introduction
Cancer incidence increases with age in
tandem with chronic medical disorders
such as cardiovascular disease, cerebrovascular disease, arthritis, and diabetes.
Therefore, not only are comorbidities
common in older people who are newly
diagnosed with cancer, but many of
these patients also take drugs for primary or secondary disease prophylaxis
and treatment, and possibly also take
other self-prescribed medicines.
In this review, we examine the clinical
implications of polypharmacy in elderly
patients diagnosed with cancer, and
present practical recommendations for
drug management of such patients.
Definition of polypharmacy
Polypharmacy has many definitions but
commonly refers to the use of several
drugs concurrently for the treatment of
one or more coexisting diseases. Experts suggest that use of a strict definition of polypharmacy (e.g. five or more
drugs) as an indicator of drug-related
problems is counterproductive in clinical practice, especially for patients with
more than one comorbid disorder for
whom treatment has a clear benefit,
which might often be the case in older
patients with cancer.
Other terms used to define polypharmacy in the published work are unnecessary medications or potentially inappropriate medications, as defined by
Beer’s criteria which has two categories
of inappropriateness: the first is specific
drugs or drug classes that can be inappropriate because they are ineffective
6
or have a high risk when a suitable alternative exists; and the second is drugs
that are inappropriate in older adults
with specific medical disorders.
The medication appropriateness index
differs from Beer’s criteria, and has ten
elements, including indication, effectiveness, dosage, directions, drug-drug
interactions, and drug-disease interactions to assess the degree of appropriateness of a specific drug along a three
point scale.
Consequences of
polypharmacy
A potentially serious outcome of polypharmacy is the likelihood of drug interactions, which increases with the
number of drugs in the prescription.
Such interactions arise when the way
a drug acts in the body changes when
taken with other drugs, herbs, foods, or
when taken by patients with some medical disorders. Drug interactions are the
cause of 20-30% of all adverse drug reactions and are said to be clinically relevant in up to 80% of elderly patients.
In addition to polypharmacy, other risk
factors for drug interactions include
advanced age, malnutrition and malabsorption, the presence of hepatic and
renal diseases, and patient’s specific
pharmacogenetic characteristics.
Anticancer drugs are inherently toxic,
possess complex pharmacological profiles, and narrow therapeutic indices. A
systematic review reported that about
a third of ambulatory cancer patients
were exposed to potentially interacting
pairs of drugs, most commonly warfarin
and anti-epileptics.
Typically, chemotherapeutic drugs are
used in multi-drug combination regimens, which can necessitate additional
drugs for supportive care, such as antiemetics, anti-bacterials, anti-fungals,
anti-virals, and corticosteroids, all of
which have been implicated in drug
interactions with chemotherapy. Drug
interactions might also occur between
anticancer drugs and other medications
taken for cancer-related symptoms or
pre-existing medications for unrelated
comorbid disorder.
Another possible outcome of polypharmacy is the increase in healthcare costs
that can result from duplicate or inappropriate medications. Even minor drug interactions can lead to increased clinic visits, additional medications to treat new
symptoms, or repeat blood tests. Serious
adverse events resulting from polypharmacy might lead to emergency department visits and hospital admissions.
Management of
polypharmacy
Assessment of elderly patients with
cancer
Optimisation of treatment in elderly patients needs a collaborative approach
including primary care and specialist
doctors, and other health professionals
such as clinical pharmacists and nurses.
An integral part of the comprehensive
geriatric assessment of older patients
with newly diagnosed cancer is a medication review of all prescription, overthe-counter, and herbal products.
Jul-Sep 2014
In some countries, routine medication
reconciliation, in which a complete list of
a patient’s medications is communicated to the next care provider, is recommended on referral, hospital admission,
hospital transfer, and hospital discharge.
Drug histories
The ideal comprehensive medication
history includes an interview that has
questions about over-the-counter and
complementary and alternative medicines (CAMs), inspection of drug containers or lists, or both, and contact
with community pharmacies or family
doctors. This interaction will need close
teamwork between patients, doctors,
and pharmacists.
Various methods have been used to
determine all of a patient’s current
medications including prescription,
over-the-counter, and CAMs, identify
any that are inappropriate, and elicit
whether any adverse effects have been
experienced. Although most of these
techniques are used in primary care or
hospital inpatient settings, the brownbag method has also been used in the
geriatric cancer setting. This method
involves the patient bringing all of
their medicines, prescribed and nonprescribed, into the clinic with them to
be reviewed by a doctor, pharmacist,
nurse, or trained pharmacy technician
or physician’s assistant.
Weingart and colleagues developed
a medication reconciliation process,
and compared the process with usual
care in an ambulatory oncology clinic
with a patient-clinician partnership intervention. This intervention required
all patients to review and update their
own printed medication lists (provided
from electronic records, some of which
were shared with primary care doctors).
In this study, clinicians or nurse practitioners either corrected the discrepancies themselves, or handed them on to
pharmacists.
Compared with usual care, the intervention was reported to reduce medi-
cation list errors by 90%, and showed
that medication reconciliation can be
achieved in the ambulatory setting.
The operational challenge of implementing these processes in the busy
outpatient setting, though, cannot be
overstated.
Management of drug interactions in
patients with cancer
Once a patient’s complete medication
list has been established, either all patients or those at high risk for drug interactions need to be screened. Many
resources are available to check for
interactions between a patient’s treatment drugs and proposed anticancer
and supportive medications.
(See Appendix 1: Potential drug interactions between common drugs used in
elderly patients and oncologic agents.)
However, investigation of individual
references can be time-consuming and
is not a practical solution at the time
of prescription or dispensing of drugs.
In addition, substantial shortcomings
with alerts issued by computerised prescribing or dispensing systems were
noted in a comparison of nine software
systems commonly used in the primary
care setting in Australia. Such alerts
are a basic form of electronic decision
support in clinical software, usually in
the form of a pop-up message that
appears when interacting drugs are
prescribed or dispensed. Inconsistencies in drug interaction detection and
information were identified that led to
inadequate assistance for the prescriber or dispenser.
As the use of computerised prescribing systems expands, it is essential to
ensure clinically relevant information
is provided. Issuing of trivial warnings
can increase the risk of so-called alert
fatigue, desensitise users to prompts
and alerts, and potentially lead to users
switching the alerts off. Environmental
barriers (restricted access to computers or internet connections) can also
make electronic databases somewhat
user-unfriendly. This effect is particularly relevant to health professionals who
practice in an institution without a good
networking framework.
Increased awareness by health professionals of clinically meaningful drug
interactions could indirectly improve
recognition and prevention. Suggested
methods include case discussion at
medical rounds, improvement of teaching to students, and involvement of
the pharmacy team to discuss patients’
medications.
However, innovative techniques are
also needed to assist the cancer team.
Drug interaction alerts in electronic prescription and dispensary systems need
to inform users about clinical effects,
mechanisms, management, and timeframes with the flexibility that electronic
resources provide.
So-called tiering of electronic alerts to
show only serious interactions has been
used successfully in the inpatient setting to improve compliance with alert
recommendations, and could be used
in other settings. A technique for investigation of drug interactions specifically
in patients receiving chemotherapy
might prove a practical solution, especially in elderly patients on more than
one medication.
Pharmacists in Singapore have created
a programme designed to systematically assess the quality of anticancer drug
interaction information databases, and
has pilot-tested it on four databases.
The programme assesses the reliability
and usability of a database, and also assesses the accuracy of drug interaction
information.
Although direct correlation between
high quality online drug information
and positive treatment outcomes has
yet to be established, it seems intuitive.
Research is being done to assess the
feasibility of an online database to cater
for the detection of interactions related
to chemotherapy regimens.
7
Medical
Update
Appointments: 6436 8288
Email: [email protected]
Focus: Cancer
Managing Polypharmacy in
Elderly Patients with Cancer
Dr Alexandre Chan, Specialist Pharmacist (Oncology Pharmacy),
Department of Pharmacy, National Cancer Centre Singapore
Associate Professor, Department of Pharmacy, Faculty of Science,
National University of Singapore
Introduction
Cancer incidence increases with age in
tandem with chronic medical disorders
such as cardiovascular disease, cerebrovascular disease, arthritis, and diabetes.
Therefore, not only are comorbidities
common in older people who are newly
diagnosed with cancer, but many of
these patients also take drugs for primary or secondary disease prophylaxis
and treatment, and possibly also take
other self-prescribed medicines.
In this review, we examine the clinical
implications of polypharmacy in elderly
patients diagnosed with cancer, and
present practical recommendations for
drug management of such patients.
Definition of polypharmacy
Polypharmacy has many definitions but
commonly refers to the use of several
drugs concurrently for the treatment of
one or more coexisting diseases. Experts suggest that use of a strict definition of polypharmacy (e.g. five or more
drugs) as an indicator of drug-related
problems is counterproductive in clinical practice, especially for patients with
more than one comorbid disorder for
whom treatment has a clear benefit,
which might often be the case in older
patients with cancer.
Other terms used to define polypharmacy in the published work are unnecessary medications or potentially inappropriate medications, as defined by
Beer’s criteria which has two categories
of inappropriateness: the first is specific
drugs or drug classes that can be inappropriate because they are ineffective
6
or have a high risk when a suitable alternative exists; and the second is drugs
that are inappropriate in older adults
with specific medical disorders.
The medication appropriateness index
differs from Beer’s criteria, and has ten
elements, including indication, effectiveness, dosage, directions, drug-drug
interactions, and drug-disease interactions to assess the degree of appropriateness of a specific drug along a three
point scale.
Consequences of
polypharmacy
A potentially serious outcome of polypharmacy is the likelihood of drug interactions, which increases with the
number of drugs in the prescription.
Such interactions arise when the way
a drug acts in the body changes when
taken with other drugs, herbs, foods, or
when taken by patients with some medical disorders. Drug interactions are the
cause of 20-30% of all adverse drug reactions and are said to be clinically relevant in up to 80% of elderly patients.
In addition to polypharmacy, other risk
factors for drug interactions include
advanced age, malnutrition and malabsorption, the presence of hepatic and
renal diseases, and patient’s specific
pharmacogenetic characteristics.
Anticancer drugs are inherently toxic,
possess complex pharmacological profiles, and narrow therapeutic indices. A
systematic review reported that about
a third of ambulatory cancer patients
were exposed to potentially interacting
pairs of drugs, most commonly warfarin
and anti-epileptics.
Typically, chemotherapeutic drugs are
used in multi-drug combination regimens, which can necessitate additional
drugs for supportive care, such as antiemetics, anti-bacterials, anti-fungals,
anti-virals, and corticosteroids, all of
which have been implicated in drug
interactions with chemotherapy. Drug
interactions might also occur between
anticancer drugs and other medications
taken for cancer-related symptoms or
pre-existing medications for unrelated
comorbid disorder.
Another possible outcome of polypharmacy is the increase in healthcare costs
that can result from duplicate or inappropriate medications. Even minor drug interactions can lead to increased clinic visits, additional medications to treat new
symptoms, or repeat blood tests. Serious
adverse events resulting from polypharmacy might lead to emergency department visits and hospital admissions.
Management of
polypharmacy
Assessment of elderly patients with
cancer
Optimisation of treatment in elderly patients needs a collaborative approach
including primary care and specialist
doctors, and other health professionals
such as clinical pharmacists and nurses.
An integral part of the comprehensive
geriatric assessment of older patients
with newly diagnosed cancer is a medication review of all prescription, overthe-counter, and herbal products.
Jul-Sep 2014
In some countries, routine medication
reconciliation, in which a complete list of
a patient’s medications is communicated to the next care provider, is recommended on referral, hospital admission,
hospital transfer, and hospital discharge.
Drug histories
The ideal comprehensive medication
history includes an interview that has
questions about over-the-counter and
complementary and alternative medicines (CAMs), inspection of drug containers or lists, or both, and contact
with community pharmacies or family
doctors. This interaction will need close
teamwork between patients, doctors,
and pharmacists.
Various methods have been used to
determine all of a patient’s current
medications including prescription,
over-the-counter, and CAMs, identify
any that are inappropriate, and elicit
whether any adverse effects have been
experienced. Although most of these
techniques are used in primary care or
hospital inpatient settings, the brownbag method has also been used in the
geriatric cancer setting. This method
involves the patient bringing all of
their medicines, prescribed and nonprescribed, into the clinic with them to
be reviewed by a doctor, pharmacist,
nurse, or trained pharmacy technician
or physician’s assistant.
Weingart and colleagues developed
a medication reconciliation process,
and compared the process with usual
care in an ambulatory oncology clinic
with a patient-clinician partnership intervention. This intervention required
all patients to review and update their
own printed medication lists (provided
from electronic records, some of which
were shared with primary care doctors).
In this study, clinicians or nurse practitioners either corrected the discrepancies themselves, or handed them on to
pharmacists.
Compared with usual care, the intervention was reported to reduce medi-
cation list errors by 90%, and showed
that medication reconciliation can be
achieved in the ambulatory setting.
The operational challenge of implementing these processes in the busy
outpatient setting, though, cannot be
overstated.
Management of drug interactions in
patients with cancer
Once a patient’s complete medication
list has been established, either all patients or those at high risk for drug interactions need to be screened. Many
resources are available to check for
interactions between a patient’s treatment drugs and proposed anticancer
and supportive medications.
(See Appendix 1: Potential drug interactions between common drugs used in
elderly patients and oncologic agents.)
However, investigation of individual
references can be time-consuming and
is not a practical solution at the time
of prescription or dispensing of drugs.
In addition, substantial shortcomings
with alerts issued by computerised prescribing or dispensing systems were
noted in a comparison of nine software
systems commonly used in the primary
care setting in Australia. Such alerts
are a basic form of electronic decision
support in clinical software, usually in
the form of a pop-up message that
appears when interacting drugs are
prescribed or dispensed. Inconsistencies in drug interaction detection and
information were identified that led to
inadequate assistance for the prescriber or dispenser.
As the use of computerised prescribing systems expands, it is essential to
ensure clinically relevant information
is provided. Issuing of trivial warnings
can increase the risk of so-called alert
fatigue, desensitise users to prompts
and alerts, and potentially lead to users
switching the alerts off. Environmental
barriers (restricted access to computers or internet connections) can also
make electronic databases somewhat
user-unfriendly. This effect is particularly relevant to health professionals who
practice in an institution without a good
networking framework.
Increased awareness by health professionals of clinically meaningful drug
interactions could indirectly improve
recognition and prevention. Suggested
methods include case discussion at
medical rounds, improvement of teaching to students, and involvement of
the pharmacy team to discuss patients’
medications.
However, innovative techniques are
also needed to assist the cancer team.
Drug interaction alerts in electronic prescription and dispensary systems need
to inform users about clinical effects,
mechanisms, management, and timeframes with the flexibility that electronic
resources provide.
So-called tiering of electronic alerts to
show only serious interactions has been
used successfully in the inpatient setting to improve compliance with alert
recommendations, and could be used
in other settings. A technique for investigation of drug interactions specifically
in patients receiving chemotherapy
might prove a practical solution, especially in elderly patients on more than
one medication.
Pharmacists in Singapore have created
a programme designed to systematically assess the quality of anticancer drug
interaction information databases, and
has pilot-tested it on four databases.
The programme assesses the reliability
and usability of a database, and also assesses the accuracy of drug interaction
information.
Although direct correlation between
high quality online drug information
and positive treatment outcomes has
yet to be established, it seems intuitive.
Research is being done to assess the
feasibility of an online database to cater
for the detection of interactions related
to chemotherapy regimens.
7
Medical
Update
Recommendations and
conclusions
Recognition of polypharmacy is the
first step towards prevention. Rational
discontinuation of drugs in older adults
is a logical component in the management of polypharmacy, and is recommended as part of a comprehensive
geriatric assessment in such patients
with cancer. Discussion with the patient
and consideration of overall quality of
life is essential.
The selection of appropriate pharmacotherapy for elderly patients is a challenging and complex process, even
when cancer is not involved, and although a framework for incorporation
of drug discontinuation into the prescribing process has been proposed, it
is not yet standard practice.
Stopping of medications started by
other practitioners, even when used
for primary or secondary prevention
and associated with higher risk than will
likely benefit, might not occur despite
perceived opportunities. Reasons for
the lack of discontinuation can include
restricted communication between the
primary and specialist care team, and
difficulties explaining reasons to patients. There is presently no consensus
among oncologists or specific guidelines for management or reduction of
polypharmacy in older people with cancer who have treatment in the ambulatory setting.
Steps in the medication discontinuation process include proper planning,
communication with the patients (and
family or carer) and other clinicians, and
monitoring of the patient for beneficial
or harmful effects. Drugs from cardiovascular and central nervous system
classes can be associated with adverse
drug withdrawal events, and might
need a tapering off of doses over days
to weeks.
The application of knowledge from
studies of geriatric medicine to the cancer setting suggest that this process
might benefit from a multidisciplinary
team approach to prescribe the best
drugs, including a geriatrician, healthcare professionals with skills in geriatrics such as nurses and pharmacists,
8
Appointments: 6436 8288
Email: [email protected]
Focus: Cancer
Comprehensive Geriatric Assessment
Functional
Status
(ECOG-PS,
ADL, IADL,
GUG Test)
Cognitive
Status
Affective
Status
(Clock
drawing test,
MMSE)
(GDS)
Nutritional
Status
CGA
Jul-Sep 2014
Appendix 1: Potential drug interactions between common drugs used in elderly patients
and oncologic agents
Oncologic Agent
(Brief description)
Concomitant
Drug
Potential
Clinical Effect
Management
Recommendation
Capecitabine (oral antimetabolite, used in multiple solid
tumours)
Warfarin
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Phenytoin
Increased phenytoin concentrations, potential toxic effects
Monitor phenytoin concentrations or consider use of noninteracting epileptic drug
Mercaptopurine (oral antimetab- Allopurinol
olite, used in certain leukemias
and lymphomas)
Increased mercaptopurine conReduce dose of mercaptopurine
centrations, potential for BM and 25-33%
liver toxic effects
Erlotinib (oral tyrosine kinase
inhibitor against the epidermal
growth factor receptor, used in
lung adenocarcinoma)
Carbamazepine,
primidone, and
phenytoin
Decreased concentrations of
erlotinib, potential for reduced
anticancer effect
Avoid concurrent use or consider
a cautious increase of erlotinib
dose as tolerated at 2-week intervals with close monitoring for
effect and tolerability
Ciprofloxacin
Increased erlotinib concentrations, potential for increased
toxic effects
Monitor for adverse effects from
erlotinib and reduce dose as
needed
Carbamazepine
Decreased concentration of
gefitinib, potential for reduced
anticancer effect
Avoid concurrent use or consider
an increase of gefitinib dose with
close monitoring for effect and
tolerability
Warfarin
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Imatinib (tyrosine kinase inhibitor against the bcr-abl and c-kit
oncoproteins, used in chronic
myeloid leukemia and gastrointestinal stromal tumours)
St John’s Wort
(Hypericum perforatum)
Decreased concentrations of
anticancer drug
Advise patient against use while
on chemotherapy
Sunitinib (tyrosine kinase inhibitor against vascular endothelial
growth factor receptor, used in
kidney cancer)
Carbamazepine,
primidone, phenytoin
Decreased concentrations of
sunitinib, potential for reduced
anticancer effect
Avoid concurrent use or consider
an increase of sunitinib dose with
close monitoring for effect and
tolerability
Tamoxifen (selective oestrogen
receptor modulator, used in
breast cancer)
Fluoxetine, paroxetine
Reduced conversion of tamoxifen to its active metabolite and
reduced anticancer effect
Avoid combination
Warfarin
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Carboplatin (intravenous platinum agent, used in lung and
ovarian cancer)
Warfarin
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Cisplatin (intravenous platinum
agent, used in multiple solid
tumours)
Phenytoin
Decreased phenytoin concentra- Monitor concentration or
tion, potential for loss of seizure consider use of non-interacting
control
epileptic drug
Etoposide (intravenous or oral
topoisomerase 2 inhibitor, used
in multiple tumours)
Warfarin
Increased anticoagulant effect
Comorbidity
(CCI)
(BMI, DNI)
Pharmacy
and increasingly an oncologist with
geriatric training. Pharmacists can advise prescribers about the tapering of
particular medications, and educate patients about the process.
Other methods for management of
polypharmacy include educational interventions and computerised decision
support, which can improve the appropriateness of prescribing in elderly
patients in different settings, most often hospitals or long-term care facilities
rather than ambulatory cancer centres.
The use of electronic drug databases
can help identify high risk drugs, drug
classes, dosages, and schedules. However, these resources have limitations,
especially when pharmacy-based support is not readily available.
Geriatric
Syndromes
To conclude, more and more elderly
patients with cancer will encounter
polypharmacy. Healthcare providers
need to be vigilant if they are to curb
the negative outcomes of polypharmacy in all elderly patients, but perhaps
especially in those diagnosed with
cancer.
This vigilance is most likely to be
achieved through the involvement of
multidisciplinary teams, and especially
geriatric oncology or senior adult oncology programmes. In the electronic
age where health information technology is integrated to solve drug-related
disorders in clinical practice, clinicians
and researchers need to continue to
develop new strategies to overcome
the challenges of polypharmacy.
Gefitinib (oral tyrosine kinase
inhibitor against the epidermal
growth factor receptor, used in
lung adenocarcinoma)
Monitor INR closely and adjust
warfarin dose as needed
9
Medical
Update
Recommendations and
conclusions
Recognition of polypharmacy is the
first step towards prevention. Rational
discontinuation of drugs in older adults
is a logical component in the management of polypharmacy, and is recommended as part of a comprehensive
geriatric assessment in such patients
with cancer. Discussion with the patient
and consideration of overall quality of
life is essential.
The selection of appropriate pharmacotherapy for elderly patients is a challenging and complex process, even
when cancer is not involved, and although a framework for incorporation
of drug discontinuation into the prescribing process has been proposed, it
is not yet standard practice.
Stopping of medications started by
other practitioners, even when used
for primary or secondary prevention
and associated with higher risk than will
likely benefit, might not occur despite
perceived opportunities. Reasons for
the lack of discontinuation can include
restricted communication between the
primary and specialist care team, and
difficulties explaining reasons to patients. There is presently no consensus
among oncologists or specific guidelines for management or reduction of
polypharmacy in older people with cancer who have treatment in the ambulatory setting.
Steps in the medication discontinuation process include proper planning,
communication with the patients (and
family or carer) and other clinicians, and
monitoring of the patient for beneficial
or harmful effects. Drugs from cardiovascular and central nervous system
classes can be associated with adverse
drug withdrawal events, and might
need a tapering off of doses over days
to weeks.
The application of knowledge from
studies of geriatric medicine to the cancer setting suggest that this process
might benefit from a multidisciplinary
team approach to prescribe the best
drugs, including a geriatrician, healthcare professionals with skills in geriatrics such as nurses and pharmacists,
8
Appointments: 6436 8288
Email: [email protected]
Focus: Cancer
Comprehensive Geriatric Assessment
Functional
Status
(ECOG-PS,
ADL, IADL,
GUG Test)
Cognitive
Status
Affective
Status
(Clock
drawing test,
MMSE)
(GDS)
Nutritional
Status
CGA
Jul-Sep 2014
Appendix 1: Potential drug interactions between common drugs used in elderly patients
and oncologic agents
Oncologic Agent
(Brief description)
Concomitant
Drug
Potential
Clinical Effect
Management
Recommendation
Capecitabine (oral antimetabolite, used in multiple solid
tumours)
Warfarin
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Phenytoin
Increased phenytoin concentrations, potential toxic effects
Monitor phenytoin concentrations or consider use of noninteracting epileptic drug
Mercaptopurine (oral antimetab- Allopurinol
olite, used in certain leukemias
and lymphomas)
Increased mercaptopurine conReduce dose of mercaptopurine
centrations, potential for BM and 25-33%
liver toxic effects
Erlotinib (oral tyrosine kinase
inhibitor against the epidermal
growth factor receptor, used in
lung adenocarcinoma)
Carbamazepine,
primidone, and
phenytoin
Decreased concentrations of
erlotinib, potential for reduced
anticancer effect
Avoid concurrent use or consider
a cautious increase of erlotinib
dose as tolerated at 2-week intervals with close monitoring for
effect and tolerability
Ciprofloxacin
Increased erlotinib concentrations, potential for increased
toxic effects
Monitor for adverse effects from
erlotinib and reduce dose as
needed
Carbamazepine
Decreased concentration of
gefitinib, potential for reduced
anticancer effect
Avoid concurrent use or consider
an increase of gefitinib dose with
close monitoring for effect and
tolerability
Warfarin
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Imatinib (tyrosine kinase inhibitor against the bcr-abl and c-kit
oncoproteins, used in chronic
myeloid leukemia and gastrointestinal stromal tumours)
St John’s Wort
(Hypericum perforatum)
Decreased concentrations of
anticancer drug
Advise patient against use while
on chemotherapy
Sunitinib (tyrosine kinase inhibitor against vascular endothelial
growth factor receptor, used in
kidney cancer)
Carbamazepine,
primidone, phenytoin
Decreased concentrations of
sunitinib, potential for reduced
anticancer effect
Avoid concurrent use or consider
an increase of sunitinib dose with
close monitoring for effect and
tolerability
Tamoxifen (selective oestrogen
receptor modulator, used in
breast cancer)
Fluoxetine, paroxetine
Reduced conversion of tamoxifen to its active metabolite and
reduced anticancer effect
Avoid combination
Warfarin
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Carboplatin (intravenous platinum agent, used in lung and
ovarian cancer)
Warfarin
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Cisplatin (intravenous platinum
agent, used in multiple solid
tumours)
Phenytoin
Decreased phenytoin concentra- Monitor concentration or
tion, potential for loss of seizure consider use of non-interacting
control
epileptic drug
Etoposide (intravenous or oral
topoisomerase 2 inhibitor, used
in multiple tumours)
Warfarin
Increased anticoagulant effect
Comorbidity
(CCI)
(BMI, DNI)
Pharmacy
and increasingly an oncologist with
geriatric training. Pharmacists can advise prescribers about the tapering of
particular medications, and educate patients about the process.
Other methods for management of
polypharmacy include educational interventions and computerised decision
support, which can improve the appropriateness of prescribing in elderly
patients in different settings, most often hospitals or long-term care facilities
rather than ambulatory cancer centres.
The use of electronic drug databases
can help identify high risk drugs, drug
classes, dosages, and schedules. However, these resources have limitations,
especially when pharmacy-based support is not readily available.
Geriatric
Syndromes
To conclude, more and more elderly
patients with cancer will encounter
polypharmacy. Healthcare providers
need to be vigilant if they are to curb
the negative outcomes of polypharmacy in all elderly patients, but perhaps
especially in those diagnosed with
cancer.
This vigilance is most likely to be
achieved through the involvement of
multidisciplinary teams, and especially
geriatric oncology or senior adult oncology programmes. In the electronic
age where health information technology is integrated to solve drug-related
disorders in clinical practice, clinicians
and researchers need to continue to
develop new strategies to overcome
the challenges of polypharmacy.
Gefitinib (oral tyrosine kinase
inhibitor against the epidermal
growth factor receptor, used in
lung adenocarcinoma)
Monitor INR closely and adjust
warfarin dose as needed
9
Medical
Update
Appointments: 6436 8288
Email: [email protected]
Focus: Cancer
Appendix 1: Potential drug interactions between common drugs used in elderly patients
and oncologic agents
Oncologic Agent
(Brief description)
Concomitant
Drug
Potential
Clinical Effect
Management
Recommendation
Increased phenytoin concentrations, potential toxic effects
Monitor phenytoin concentrations or consider use of a noninteracting anti-epileptic drug
Warfarin
Increased anticoagulant effects
Monitor INR closely and adjust
warfarin dose as needed
Gemcitabine (intravenous
antimetabolite, used in multiple
tumours)
Warfarin
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Irinotecan (intravenous topoisomerase I inhibitor, used in
gastrointestinal tumours)
St John’s Wort
(Hypericum perforatum)
Decreased concentrations of
anticancer drug
Advise patient against use while
on chemotherapy
Methotrexate (intravenous anti
metabolite, used in multiple
tumours)
NSAIDs
Reduced methotrexate clearance, potential for increased
toxic effects
Avoid combination
Sulfamethoxazole
and trimethoprim
combination
Reduced methotrexate clearance, potential for increased
toxic effects
Avoid combination
Paclitaxel (intravenous mitotic
Warfarin
spindle poison, used in lung and
breast cancers)
Warfarin
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Vincristine (intravenous mitotic
Itraconazole
spindle poison, used in lymphomas)
Increased vincristine induced
neurotoxic effects
Avoid combination
Fluorouracil (intravenous antime- Phenytoin
tabolite, used in gastrointestinal
and breast cancers)
Practical recommendations
for drug management in elderly patients with cancer
Potentially inappropriate medications
include drug classes that can potentially be discontinued (in collaboration with a patient’s primary care doctor), such as:
• Tricyclic antidepressants
• Sedating antihistamines
• Long-acting benzodiazepines
associated with increased
sedation
• Analgesics including dextropropoxyphene or tramadol
• Some non-steroidal anti-inflammatory drugs, including indomethacin
10
Be alert for, and consider changing
drugs that are commonly used by patients with cancer, and are associated
with high frequency of adverse drug
events, such as:
• Anticoagulants (specifically
warfarin)
• Benzodiazepines
Assess drugs that are used for primary
or secondary prevention for appropriateness in terms of long-term benefit
in patients with metastatic cancer3 (in
collaboration with the patient’s primary care doctor), such as:
• Antihypertensives
• Lipid-lowering drugs
• Antiplatelet drugs
• Anticoagulants
Jul-Sep 2014
Managing the Adverse Effects of
Radiation Therapy
What the General Practitioner Should Know
Dr Wong Ru Xin, Registrar, Division of Radiation Oncology,
National Cancer Centre Singapore
This article strives to share with general practitioners, the
frontline warriors in our healthcare system, on the recognition and management of acute toxicities of radiotherapy as
it is not uncommon for patients to present to primary healthcare with these issues. Should some long-term patients be
lost to specialised follow-up, prompt recognition of chronic
toxicities and timely re-referral back to the radiation oncologist will benefit patients greatly.
A linear accelerator delivery external beam
radiation.
GP CONTACT
GPs can call for appointments through
the Specialist Outpatient Clinic at
6436 8288.
For references used for this article,
please visit www.singhealth.com.sg/
medical-news
A patient with multichannel brachytherapy
implants.
A computer tomographic cross section image
of the breast implants.
An introduction to
Radiation Therapy (RT)
Radiation therapy (RT) is the medical
use of ionising radiation to attempt to
control or kill malignant cells, although
there are non-malignant indications
too. Commonly utilised radiation modalities are photon and electron beams,
and elsewhere in the world, some specialised centres use protons, carbon
ions and other heavy elements. Radiation can be delivered externally with
linear accelerators, or internally (known
as brachytherapy).
Radiation beams cause ionisation in
DNA molecules and subsequently double-stranded breakages. When cells are
unable to repair these damages, they
die. Unfortunately, both healthy and
tumour cells receive radiation, but the
former are better equipped to repair
these damages.
Therapeutic index is a term denoting
the balance between the probability of
tumour control and normal tissue damage. The higher the dose of radiation,
the higher the probability of cure, but
side effects become more severe. The
radiation oncologist is always keeping
the therapeutic index in mind, adhering to the principles of ‘Primum non
nocere’. In patients whose intent of
treatment is curative, high doses are required. In palliative patients, doses are
lowered to preserve quality of life.
Conventional treatment
(6 weeks overall time)
Response (%)
100
80
Tumour
60
40
Late oedema
20
0
30
40
50
60
70
80
90
Radiation dose (Gy)
Graph showing laryngeal cancer response to
radiation. As radiation dose increases, the
chance of tumour response increases, but so
does the probability of late oedema. Image
source: Bentzen and Overgaard 1996
11
Medical
Update
Appointments: 6436 8288
Email: [email protected]
Focus: Cancer
Appendix 1: Potential drug interactions between common drugs used in elderly patients
and oncologic agents
Oncologic Agent
(Brief description)
Concomitant
Drug
Potential
Clinical Effect
Management
Recommendation
Increased phenytoin concentrations, potential toxic effects
Monitor phenytoin concentrations or consider use of a noninteracting anti-epileptic drug
Warfarin
Increased anticoagulant effects
Monitor INR closely and adjust
warfarin dose as needed
Gemcitabine (intravenous
antimetabolite, used in multiple
tumours)
Warfarin
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Irinotecan (intravenous topoisomerase I inhibitor, used in
gastrointestinal tumours)
St John’s Wort
(Hypericum perforatum)
Decreased concentrations of
anticancer drug
Advise patient against use while
on chemotherapy
Methotrexate (intravenous anti
metabolite, used in multiple
tumours)
NSAIDs
Reduced methotrexate clearance, potential for increased
toxic effects
Avoid combination
Sulfamethoxazole
and trimethoprim
combination
Reduced methotrexate clearance, potential for increased
toxic effects
Avoid combination
Paclitaxel (intravenous mitotic
Warfarin
spindle poison, used in lung and
breast cancers)
Warfarin
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Increased anticoagulant effect
Monitor INR closely and adjust
warfarin dose as needed
Vincristine (intravenous mitotic
Itraconazole
spindle poison, used in lymphomas)
Increased vincristine induced
neurotoxic effects
Avoid combination
Fluorouracil (intravenous antime- Phenytoin
tabolite, used in gastrointestinal
and breast cancers)
Practical recommendations
for drug management in elderly patients with cancer
Potentially inappropriate medications
include drug classes that can potentially be discontinued (in collaboration with a patient’s primary care doctor), such as:
• Tricyclic antidepressants
• Sedating antihistamines
• Long-acting benzodiazepines
associated with increased
sedation
• Analgesics including dextropropoxyphene or tramadol
• Some non-steroidal anti-inflammatory drugs, including indomethacin
10
Be alert for, and consider changing
drugs that are commonly used by patients with cancer, and are associated
with high frequency of adverse drug
events, such as:
• Anticoagulants (specifically
warfarin)
• Benzodiazepines
Assess drugs that are used for primary
or secondary prevention for appropriateness in terms of long-term benefit
in patients with metastatic cancer3 (in
collaboration with the patient’s primary care doctor), such as:
• Antihypertensives
• Lipid-lowering drugs
• Antiplatelet drugs
• Anticoagulants
Jul-Sep 2014
Managing the Adverse Effects of
Radiation Therapy
What the General Practitioner Should Know
Dr Wong Ru Xin, Registrar, Division of Radiation Oncology,
National Cancer Centre Singapore
This article strives to share with general practitioners, the
frontline warriors in our healthcare system, on the recognition and management of acute toxicities of radiotherapy as
it is not uncommon for patients to present to primary healthcare with these issues. Should some long-term patients be
lost to specialised follow-up, prompt recognition of chronic
toxicities and timely re-referral back to the radiation oncologist will benefit patients greatly.
A linear accelerator delivery external beam
radiation.
GP CONTACT
GPs can call for appointments through
the Specialist Outpatient Clinic at
6436 8288.
For references used for this article,
please visit www.singhealth.com.sg/
medical-news
A patient with multichannel brachytherapy
implants.
A computer tomographic cross section image
of the breast implants.
An introduction to
Radiation Therapy (RT)
Radiation therapy (RT) is the medical
use of ionising radiation to attempt to
control or kill malignant cells, although
there are non-malignant indications
too. Commonly utilised radiation modalities are photon and electron beams,
and elsewhere in the world, some specialised centres use protons, carbon
ions and other heavy elements. Radiation can be delivered externally with
linear accelerators, or internally (known
as brachytherapy).
Radiation beams cause ionisation in
DNA molecules and subsequently double-stranded breakages. When cells are
unable to repair these damages, they
die. Unfortunately, both healthy and
tumour cells receive radiation, but the
former are better equipped to repair
these damages.
Therapeutic index is a term denoting
the balance between the probability of
tumour control and normal tissue damage. The higher the dose of radiation,
the higher the probability of cure, but
side effects become more severe. The
radiation oncologist is always keeping
the therapeutic index in mind, adhering to the principles of ‘Primum non
nocere’. In patients whose intent of
treatment is curative, high doses are required. In palliative patients, doses are
lowered to preserve quality of life.
Conventional treatment
(6 weeks overall time)
Response (%)
100
80
Tumour
60
40
Late oedema
20
0
30
40
50
60
70
80
90
Radiation dose (Gy)
Graph showing laryngeal cancer response to
radiation. As radiation dose increases, the
chance of tumour response increases, but so
does the probability of late oedema. Image
source: Bentzen and Overgaard 1996
11
Medical
Update
Focus: Cancer
Radiation therapy has evolved much
over the last few decades, moving
from the old era of 2-dimensional treatment, to 3-dimensional and currently,
the state-of-the-art intensity modulated
radiotherapy (IMRT) which utilises computer planning systems to help deliver
highly conformal photon beams.
Radiosurgery describes a technique
of using high doses of ionising radiation in a stereotactic manner and this
is increasingly being used for small localised tumours. Due to its highly targeted nature, acute and chronic side
effects with radiosurgery are much less
manifested.
Effects of radiation therapy
Among individual patients, the effect of
the same dose of radiation varies. Different tissues also react differently to
radiation. TD50 (toxic dose 5/5) is the
dose which results in 5% of injury over
the next 5 years. To illustrate the difference between organs, the human eye
lens has a TD5/5 of 10Gy, while the vagina 90Gy.
Other than radiation dose, volume of organ irradiated also determines severity
of response. In organs such as the spinal
cord, where the functional subunits are
arranged serially, a high dose of radiation to a small volume can result in catastrophe, as a damaged link can disrupt
the entire chain. In organs like the lungs
and liver, where the subunits are parallel,
a large volume of tissues must be irradiated before toxicities arise.
Also, toxicities are divided into acute
and chronic. For example, in treatment of head and neck cancer, after 2-3
weeks of radiotherapy, dermatitis occurs which promptly recovers 1-2 weeks
upon cessation of treatment. However,
months and years after radiation, late
effects such as hypopigmentation of
skin, hair loss, telangiectasia and even
ulceration can happen.
In the next few paragraphs, I will delve
into common cancers and their acute
and chronic side effects, as well as their
management. These patients may
present to the general practitioner
and treatments are often simple and
widely available in most pharmacies.
12
Head and neck cancers
Appointments: 6436 8288
Email: [email protected]
in severe cases, pilocarpine, which is a
parasympathomimetic, can be given for
relief. The patient is more prone to dental caries and mandibular osteoradionecrosis may complicate extractions.
Hypothyroidism and panhypopituitarism may occur. Stiffening of soft tissues
can cause trismus, neck hardening and
dysphagia. Cranial nerve neuropathies
may happen too.
Acute mucositis during RT.
Rarer complications include temporal
lobe necrosis and carotid blowout. With
the advent of newer technologies and
more conformal radiation delivery, these
side effects are not as overt as before.
Jul-Sep 2014
In patients whose axilla are irradiated,
the risk of upper limb lymphoedema is
higher. There is also an increased risk
of cardiovascular events with older RT
techniques but these days, efforts are
made to minimise radiation doses to
the left anterior descending artery.
Lung cancer
Lung cancer can be treated with radical
RT. During and shortly after treatment,
patients may experience dry cough,
odynophagia due to oesophagitis and
mild skin irritation over the chest wall.
Simple symptomatic aids like cough
suppressants, analgesia, dietary modifications and emollients usually do the
trick.
Breast cancer
However, in a small proportion of patients, radiation pneumonitis may develop and symptoms include dyspnoea,
cough and fever. This is a subacute condition and can happen up to 6 months
post-treatment. In mild cases, corticosteroids do the trick but sometimes
patients will require temporary oxygen
supplementation to tide them through.
Years down the road, lung fibrosis, oesophageal strictures and rib fractures
are possible although uncommon.
Dental changes.
Head and neck cancers are treated with
radiotherapy, with or without chemotherapy, upfront or as an adjuvant modality after surgery. These patients often have morbid toxicities during treatment. Acutely, common side effects are
mucositis, dermatitis, odynophagia,
altered taste, xerostomia, hoarseness
and oral thrush, etc.
For pain, analgesics are prescribed
according to the World Health Organization ladder progression. Patients
can consume liquid dietary substitutes
like Ensure™ should their usual food
be hard to swallow and a nasogastric
tube can aid in meeting dietary caloric
requirements. Gargling with sodium
bicarbonate and saliva substitutes like
Biotene® upkeep oral hygiene and alleviate xerostomia.
For dermatitis, simple washing with
plain water and application of emollients are advised. Fluconazole is recommended for the treatment of thrush,
which can exacerbate mucositis by itself.
As these acute toxicities recover shortly
after treatment, chronic ones may develop. Xerostomia may not improve and
vented with frequent douching and
patient-initiated dilatation. Lower limb
oedema is also possible especially
post-operatively due to lymph node
dissection and subsequent irradiation.
metastases, RT for painful bone lesions,
advanced lung cancers and in haemorrhagic conditions like advanced gynaecological and gastrointestinal cancers,
RT can ameliorate bleeding.
In prostate cancer treatment, long-term
side effects include sexual dysfunction,
urinary frequency and proctitis. Sexual
dysfunction is attributed not just to RT,
but due to synergism with androgen
ablation therapies, surgery and old age.
Phosphodiesterase type 5 inhibitors,
such as sildenafil (Viagra) and tadalafil
(Cialis), are effective for radiation-associated erectile dysfunction. Proctitis can
sometimes manifest as rectal bleeding,
and treatment includes endoscopic argon plasma coagulation, but if refractory, hyperbaric oxygen therapy may
improve healing responses.
Generally, palliative RT should not cause
severe side effects. Of note, whole brain
RT can cause nausea, fatigue, hair loss
and scalp changes. Again, simple antiemetics will suffice for nausea. In the
subacute and chronic setting, patients
may experience neurocognitive decline
also, although few patients survive to
experience this.
Radiotherapy for palliation
Radiotherapy is a useful tool for palliation. Only low doses are required to
control symptoms and hence side effects are less overt. Common palliative
procedures are whole brain RT for brain
Gynaecological, urological
and colorectal
malignancies
Radiotherapy of the pelvis is indicated for gynaecological, urological
and colorectal malignancies. Common
acute toxicities are nausea and diarrhoea, urinary frequency and urgency
and perineal skin break down.
From top to bottom: Limb lymphoedema due
to axillary clearance. Breast telangiectasia
after RT.
Some breast cancer patients require
adjuvant radiotherapy after surgery.
During radiation therapy, dermatitis is
a common manifestation. Akin to head
and neck dermatitis, emollients are advised. Low-dose topical steroids and
oral antihistamines can alleviate itch.
Long-term side effects include hardening of breast tissues and skin changes.
Nausea due to RT is usually amenable
to anti-emetics like maxolon or ondansetron. Loperamide and lomotil are
useful for diarrhoea due to radiation enteritis and colitis, and low residue diet
is advised during treatment. In the absence of infection, phenazopyridine is
appropriate for dysuria, oxybutynin for
urinary urgency, and flavoxate for bladder spasm. Perineal skin breakdown is
treated with the same agents for dermatitis of other sites. In addition, topical lignocaine gel can be used.
Specific to gynaecological cancers,
vaginal stricture can occur especially
after brachytherapy which can be pre-
Patchy alopecia after whole brain RT.
In RT for cervical and upper thoracic
spinal metastases, sometimes patients
may experience transient dysphagia
due to proximity of the oesophagus to
the vertebrae. In treating lumbar and
sacral metastases, patients may experience self-limiting diarrhoea. The same
principles to treating dysphagia in head
and neck cancer and diarrhoea in pelvic
RT apply.
Malignant transformations
Malignant transformation is a dreaded
complication, but fortunately rare. However, in younger cancer patients, the risk
is not negligible. In a large analysis of
the United States Surveillance, Epidemiology and End Results (SEER) registries,
it is estimated that RT causes an excess
of 5 cancers per 1000 patients. The relative risk for secondary malignancies is
higher with younger patients, and as
time progresses since treatment.
As with most treatments in the practice
of medicine, the balance between therapeutics and toxicity is a fine one. With
appropriate management, the tough
journey a patient takes en route to cure
can be made more tolerable.
*Photographs courtesy of Dr Wong Fuh
Yong, Consultant, Division of Radiation Oncology, National Cancer Centre Singapore,
and published with permission.
Skin hypopigmentation and telangiectasia
after spinal RT.
GP CONTACT
GPs can call for appointments through
the Specialist Outpatient Clinic at
6436 8288.
13
Medical
Update
Focus: Cancer
Radiation therapy has evolved much
over the last few decades, moving
from the old era of 2-dimensional treatment, to 3-dimensional and currently,
the state-of-the-art intensity modulated
radiotherapy (IMRT) which utilises computer planning systems to help deliver
highly conformal photon beams.
Radiosurgery describes a technique
of using high doses of ionising radiation in a stereotactic manner and this
is increasingly being used for small localised tumours. Due to its highly targeted nature, acute and chronic side
effects with radiosurgery are much less
manifested.
Effects of radiation therapy
Among individual patients, the effect of
the same dose of radiation varies. Different tissues also react differently to
radiation. TD50 (toxic dose 5/5) is the
dose which results in 5% of injury over
the next 5 years. To illustrate the difference between organs, the human eye
lens has a TD5/5 of 10Gy, while the vagina 90Gy.
Other than radiation dose, volume of organ irradiated also determines severity
of response. In organs such as the spinal
cord, where the functional subunits are
arranged serially, a high dose of radiation to a small volume can result in catastrophe, as a damaged link can disrupt
the entire chain. In organs like the lungs
and liver, where the subunits are parallel,
a large volume of tissues must be irradiated before toxicities arise.
Also, toxicities are divided into acute
and chronic. For example, in treatment of head and neck cancer, after 2-3
weeks of radiotherapy, dermatitis occurs which promptly recovers 1-2 weeks
upon cessation of treatment. However,
months and years after radiation, late
effects such as hypopigmentation of
skin, hair loss, telangiectasia and even
ulceration can happen.
In the next few paragraphs, I will delve
into common cancers and their acute
and chronic side effects, as well as their
management. These patients may
present to the general practitioner
and treatments are often simple and
widely available in most pharmacies.
12
Head and neck cancers
Appointments: 6436 8288
Email: [email protected]
in severe cases, pilocarpine, which is a
parasympathomimetic, can be given for
relief. The patient is more prone to dental caries and mandibular osteoradionecrosis may complicate extractions.
Hypothyroidism and panhypopituitarism may occur. Stiffening of soft tissues
can cause trismus, neck hardening and
dysphagia. Cranial nerve neuropathies
may happen too.
Acute mucositis during RT.
Rarer complications include temporal
lobe necrosis and carotid blowout. With
the advent of newer technologies and
more conformal radiation delivery, these
side effects are not as overt as before.
Jul-Sep 2014
In patients whose axilla are irradiated,
the risk of upper limb lymphoedema is
higher. There is also an increased risk
of cardiovascular events with older RT
techniques but these days, efforts are
made to minimise radiation doses to
the left anterior descending artery.
Lung cancer
Lung cancer can be treated with radical
RT. During and shortly after treatment,
patients may experience dry cough,
odynophagia due to oesophagitis and
mild skin irritation over the chest wall.
Simple symptomatic aids like cough
suppressants, analgesia, dietary modifications and emollients usually do the
trick.
Breast cancer
However, in a small proportion of patients, radiation pneumonitis may develop and symptoms include dyspnoea,
cough and fever. This is a subacute condition and can happen up to 6 months
post-treatment. In mild cases, corticosteroids do the trick but sometimes
patients will require temporary oxygen
supplementation to tide them through.
Years down the road, lung fibrosis, oesophageal strictures and rib fractures
are possible although uncommon.
Dental changes.
Head and neck cancers are treated with
radiotherapy, with or without chemotherapy, upfront or as an adjuvant modality after surgery. These patients often have morbid toxicities during treatment. Acutely, common side effects are
mucositis, dermatitis, odynophagia,
altered taste, xerostomia, hoarseness
and oral thrush, etc.
For pain, analgesics are prescribed
according to the World Health Organization ladder progression. Patients
can consume liquid dietary substitutes
like Ensure™ should their usual food
be hard to swallow and a nasogastric
tube can aid in meeting dietary caloric
requirements. Gargling with sodium
bicarbonate and saliva substitutes like
Biotene® upkeep oral hygiene and alleviate xerostomia.
For dermatitis, simple washing with
plain water and application of emollients are advised. Fluconazole is recommended for the treatment of thrush,
which can exacerbate mucositis by itself.
As these acute toxicities recover shortly
after treatment, chronic ones may develop. Xerostomia may not improve and
vented with frequent douching and
patient-initiated dilatation. Lower limb
oedema is also possible especially
post-operatively due to lymph node
dissection and subsequent irradiation.
metastases, RT for painful bone lesions,
advanced lung cancers and in haemorrhagic conditions like advanced gynaecological and gastrointestinal cancers,
RT can ameliorate bleeding.
In prostate cancer treatment, long-term
side effects include sexual dysfunction,
urinary frequency and proctitis. Sexual
dysfunction is attributed not just to RT,
but due to synergism with androgen
ablation therapies, surgery and old age.
Phosphodiesterase type 5 inhibitors,
such as sildenafil (Viagra) and tadalafil
(Cialis), are effective for radiation-associated erectile dysfunction. Proctitis can
sometimes manifest as rectal bleeding,
and treatment includes endoscopic argon plasma coagulation, but if refractory, hyperbaric oxygen therapy may
improve healing responses.
Generally, palliative RT should not cause
severe side effects. Of note, whole brain
RT can cause nausea, fatigue, hair loss
and scalp changes. Again, simple antiemetics will suffice for nausea. In the
subacute and chronic setting, patients
may experience neurocognitive decline
also, although few patients survive to
experience this.
Radiotherapy for palliation
Radiotherapy is a useful tool for palliation. Only low doses are required to
control symptoms and hence side effects are less overt. Common palliative
procedures are whole brain RT for brain
Gynaecological, urological
and colorectal
malignancies
Radiotherapy of the pelvis is indicated for gynaecological, urological
and colorectal malignancies. Common
acute toxicities are nausea and diarrhoea, urinary frequency and urgency
and perineal skin break down.
From top to bottom: Limb lymphoedema due
to axillary clearance. Breast telangiectasia
after RT.
Some breast cancer patients require
adjuvant radiotherapy after surgery.
During radiation therapy, dermatitis is
a common manifestation. Akin to head
and neck dermatitis, emollients are advised. Low-dose topical steroids and
oral antihistamines can alleviate itch.
Long-term side effects include hardening of breast tissues and skin changes.
Nausea due to RT is usually amenable
to anti-emetics like maxolon or ondansetron. Loperamide and lomotil are
useful for diarrhoea due to radiation enteritis and colitis, and low residue diet
is advised during treatment. In the absence of infection, phenazopyridine is
appropriate for dysuria, oxybutynin for
urinary urgency, and flavoxate for bladder spasm. Perineal skin breakdown is
treated with the same agents for dermatitis of other sites. In addition, topical lignocaine gel can be used.
Specific to gynaecological cancers,
vaginal stricture can occur especially
after brachytherapy which can be pre-
Patchy alopecia after whole brain RT.
In RT for cervical and upper thoracic
spinal metastases, sometimes patients
may experience transient dysphagia
due to proximity of the oesophagus to
the vertebrae. In treating lumbar and
sacral metastases, patients may experience self-limiting diarrhoea. The same
principles to treating dysphagia in head
and neck cancer and diarrhoea in pelvic
RT apply.
Malignant transformations
Malignant transformation is a dreaded
complication, but fortunately rare. However, in younger cancer patients, the risk
is not negligible. In a large analysis of
the United States Surveillance, Epidemiology and End Results (SEER) registries,
it is estimated that RT causes an excess
of 5 cancers per 1000 patients. The relative risk for secondary malignancies is
higher with younger patients, and as
time progresses since treatment.
As with most treatments in the practice
of medicine, the balance between therapeutics and toxicity is a fine one. With
appropriate management, the tough
journey a patient takes en route to cure
can be made more tolerable.
*Photographs courtesy of Dr Wong Fuh
Yong, Consultant, Division of Radiation Oncology, National Cancer Centre Singapore,
and published with permission.
Skin hypopigmentation and telangiectasia
after spinal RT.
GP CONTACT
GPs can call for appointments through
the Specialist Outpatient Clinic at
6436 8288.
13
Services
News
Jul-Sep 2014
The SingHealth Duke-NUS
Head and Neck Centre
Better care for patients with head and neck tumours
The newly-formed SingHealth Duke-NUS
Head and Neck Centre brings together specialists from Singapore General
Hospital (SGH) and National Cancer
Centre Singapore (NCCS) into a condition-based multidisciplinary centre to
provide holistic care for patients with
tumours of the head and neck region.
The centre brings together specialists
from General Surgery, Otolaryngology (ENT), Plastic, Reconstructive and
Aesthetic Surgery and allied health
specialists dedicated to the treatment of head and neck tumours and
their post-operative rehabilitation.
Patients can be seen at the newlyopened Head and Neck Centre located
at SGH, or NCCS.
At a Glance
Clinical Services:
Evaluation and treatment of confirmed or suspected head and
neck tumours:
• Thyroid and Parathyroid gland
swellings
• Salivary gland tumours
• Tumours of the oral cavity,
oropharynx, nasopharynx,
hypopharynx and larynx
• Nasopharyngeal carcinoma
• Skin tumours and sarcomas in
the head and neck region
• Sinonasal tract tumours
• Cervical lymphadenopathy
Thyroid and other Neck Lumps
Neck lumps are a complaint encountered by doctors in primary care. Differentiating benign neck swellings of the
thyroid and salivary glands from malignant ones is often difficult. Patients with
large thyroid goiters may also present with compressive symptoms. Our
14
clinics offer a one-stop service for the
evaluation and surgical management of
these patients.
TUMOURS OF THE UPPER AERODIGESTIVE TRACT (Oral cavity, Oropharynx, Nasopharynx, Hypopharynx
and Larynx) AND SKIN
Visible surgical scars are a major concern, especially in young women undergoing thyroid surgery. The use of robotic and endoscopic thyroid surgery
allows for thyroid surgery to be performed via an axillary approach, leaving the patient without an unsightly
scar in the neck.
Tumours of the base of tongue and
tonsils can be technically difficult to
reach and traditional surgical methods
required large incisions, including splitting of the lower jaw. Transoral Robotic
Surgery (TORS) allows for robotic arms
to reach and operate in these areas difficult to reach with conventional tools,
allowing for the same operation to be
done without a large incision.
Traditional operations to resect tumours of the nasopharynx require large
facial incisions and dissecting through
large volume of normal tissue that often
result in high post-operative morbidity.
The use of endoscopic and robotic surgery allows for minimally invasive yet
oncologic resection of these tumours
with reduced morbidity. The endoscopic approach also allows for resection of
selected sinus and nasal tumours and
allows for endonasal approaches to resection tumours of the skull base (done
in collaboration with neurosurgeons).
Tumours of the Upper Aerodigestive Tract
Many tumours of the upper aerodigestive tract often present insidiously.
Warning signs that may require further
evaluation include:
•
•
•
•
•
•
•
A non-healing ulcer in the mouth
A persistent red or white patch in
the mouth
Persistent hoarseness or a change
in the voice
Persistent pain in the neck, throat
or ears
Blood in the sputum
Difficulty chewing, swallowing of
moving the jaws or tongue
Changes of discolouration of a
mole, a non-healing skin ulcer
Early detection of these tumours at an
early stage offers the best outcomes for
these patients.
Multidisciplinary Team
Approach to Complex
Tumours
Part of the challenge of managing head
and neck tumours involves removing
the tumour completely while ensuring
the patient maintains acceptable function and cosmesis.
Our surgical oncology and plastics reconstructive teams work closely hand
in hand to achieve the best outcomes
for our patients. Cases are discussed
at a multidisciplinary tumour board
comprising of experts surgeons, medical oncologists, radiation oncologists,
speech therapists and other allied
health workers to ensure the best treatment decisions are made.
New Nanomedicine Brings Relief
to Glaucoma Patients
Scientists from Nanyang Technological University (NTU) and the Singapore Eye Research Institute (SERI) have
jointly developed a new nanomedicine
that will allow glaucoma patients to
do away with daily application of eye
drops.
The new nanomedicine, a sustainedrelease drug therapy, can provide
months of relief with a single application compared to just hours with conventional eye drops. The therapy has
been shown to be both safe and effective in the treatment of glaucoma and
has yielded exceptional results in a pilot study with six patients conducted
by the Singapore National Eye Centre
(SNEC).
Glaucoma is a leading cause of blindness in the world especially for the elderly and conventionally, the first line
of treatment is daily eye drops to lower
the high pressure in their eyes.
Co-lead scientist Associate Professor
Tina Wong, Head of the Ocular Therapeutics and Drug Delivery Research
Group at the Singapore Eye Research
Institute said that it is estimated that
at least ten per cent of blindness from
glaucoma is directly caused by poor
patient adherence to their prescribed
medications.
“Many patients find it difficult to adhere
to their doctor’s prescribed regime for
many reasons, such as forgetfulness,
finding it too troublesome, or they lack
understanding of the disease. The results in this clinical study will open up
a new treatment modality for glaucoma
other than taking daily eye drops, and
will greatly enhance patient compliance
and improve treatment outcomes,” said
Assoc Prof Wong, who is also Adjunct
Associate Professor with NTU’s School
of Materials Science and Engineering
and Senior Consultant Ophthalmologist with the Glaucoma Service, SNEC.
How it works
Nanomedicine is a drug delivered
to a specific “postal code”, that is
a part of the body where the medicine is needed, and is released
over a period of time. This makes
it highly effective and minimises
any side effects to patients.
For glaucoma patients, the new
nanomedicine is delivered to the
front of the eye via a painless injection. The nanoliposomal drug
delivery system is made up of
millions of nano-sized capsules
thousands of times smaller than a
speck of dust. The capsules contain Latanoprost, a well-known
anti-glaucoma drug approved
worldwide for daily use, which is
released slowly over the next six
months.
Liposomal latanoprost is now in the
midst of being commercialised. Larger
scale clinical trials are currently being
planned to pave the way for eventual
release to the market.
CONTACT SNEC
Appointment Hotline
Tel: 6322 9399
General Enquiries
Tel: 6227 7255
GP CONTACT
The Head and Neck Centre is located at
SGH Block 3 Level 1.
GPs can call for appointments through the GP Appointment Hotline at
6321 4402 (SGH) or 6436 8288 (NCCS).
For general enquiries, patients can call
6321 4377 (SGH) or 6436 8088 (NCCS).
15
Services
News
Jul-Sep 2014
The SingHealth Duke-NUS
Head and Neck Centre
Better care for patients with head and neck tumours
The newly-formed SingHealth Duke-NUS
Head and Neck Centre brings together specialists from Singapore General
Hospital (SGH) and National Cancer
Centre Singapore (NCCS) into a condition-based multidisciplinary centre to
provide holistic care for patients with
tumours of the head and neck region.
The centre brings together specialists
from General Surgery, Otolaryngology (ENT), Plastic, Reconstructive and
Aesthetic Surgery and allied health
specialists dedicated to the treatment of head and neck tumours and
their post-operative rehabilitation.
Patients can be seen at the newlyopened Head and Neck Centre located
at SGH, or NCCS.
At a Glance
Clinical Services:
Evaluation and treatment of confirmed or suspected head and
neck tumours:
• Thyroid and Parathyroid gland
swellings
• Salivary gland tumours
• Tumours of the oral cavity,
oropharynx, nasopharynx,
hypopharynx and larynx
• Nasopharyngeal carcinoma
• Skin tumours and sarcomas in
the head and neck region
• Sinonasal tract tumours
• Cervical lymphadenopathy
Thyroid and other Neck Lumps
Neck lumps are a complaint encountered by doctors in primary care. Differentiating benign neck swellings of the
thyroid and salivary glands from malignant ones is often difficult. Patients with
large thyroid goiters may also present with compressive symptoms. Our
14
clinics offer a one-stop service for the
evaluation and surgical management of
these patients.
TUMOURS OF THE UPPER AERODIGESTIVE TRACT (Oral cavity, Oropharynx, Nasopharynx, Hypopharynx
and Larynx) AND SKIN
Visible surgical scars are a major concern, especially in young women undergoing thyroid surgery. The use of robotic and endoscopic thyroid surgery
allows for thyroid surgery to be performed via an axillary approach, leaving the patient without an unsightly
scar in the neck.
Tumours of the base of tongue and
tonsils can be technically difficult to
reach and traditional surgical methods
required large incisions, including splitting of the lower jaw. Transoral Robotic
Surgery (TORS) allows for robotic arms
to reach and operate in these areas difficult to reach with conventional tools,
allowing for the same operation to be
done without a large incision.
Traditional operations to resect tumours of the nasopharynx require large
facial incisions and dissecting through
large volume of normal tissue that often
result in high post-operative morbidity.
The use of endoscopic and robotic surgery allows for minimally invasive yet
oncologic resection of these tumours
with reduced morbidity. The endoscopic approach also allows for resection of
selected sinus and nasal tumours and
allows for endonasal approaches to resection tumours of the skull base (done
in collaboration with neurosurgeons).
Tumours of the Upper Aerodigestive Tract
Many tumours of the upper aerodigestive tract often present insidiously.
Warning signs that may require further
evaluation include:
•
•
•
•
•
•
•
A non-healing ulcer in the mouth
A persistent red or white patch in
the mouth
Persistent hoarseness or a change
in the voice
Persistent pain in the neck, throat
or ears
Blood in the sputum
Difficulty chewing, swallowing of
moving the jaws or tongue
Changes of discolouration of a
mole, a non-healing skin ulcer
Early detection of these tumours at an
early stage offers the best outcomes for
these patients.
Multidisciplinary Team
Approach to Complex
Tumours
Part of the challenge of managing head
and neck tumours involves removing
the tumour completely while ensuring
the patient maintains acceptable function and cosmesis.
Our surgical oncology and plastics reconstructive teams work closely hand
in hand to achieve the best outcomes
for our patients. Cases are discussed
at a multidisciplinary tumour board
comprising of experts surgeons, medical oncologists, radiation oncologists,
speech therapists and other allied
health workers to ensure the best treatment decisions are made.
New Nanomedicine Brings Relief
to Glaucoma Patients
Scientists from Nanyang Technological University (NTU) and the Singapore Eye Research Institute (SERI) have
jointly developed a new nanomedicine
that will allow glaucoma patients to
do away with daily application of eye
drops.
The new nanomedicine, a sustainedrelease drug therapy, can provide
months of relief with a single application compared to just hours with conventional eye drops. The therapy has
been shown to be both safe and effective in the treatment of glaucoma and
has yielded exceptional results in a pilot study with six patients conducted
by the Singapore National Eye Centre
(SNEC).
Glaucoma is a leading cause of blindness in the world especially for the elderly and conventionally, the first line
of treatment is daily eye drops to lower
the high pressure in their eyes.
Co-lead scientist Associate Professor
Tina Wong, Head of the Ocular Therapeutics and Drug Delivery Research
Group at the Singapore Eye Research
Institute said that it is estimated that
at least ten per cent of blindness from
glaucoma is directly caused by poor
patient adherence to their prescribed
medications.
“Many patients find it difficult to adhere
to their doctor’s prescribed regime for
many reasons, such as forgetfulness,
finding it too troublesome, or they lack
understanding of the disease. The results in this clinical study will open up
a new treatment modality for glaucoma
other than taking daily eye drops, and
will greatly enhance patient compliance
and improve treatment outcomes,” said
Assoc Prof Wong, who is also Adjunct
Associate Professor with NTU’s School
of Materials Science and Engineering
and Senior Consultant Ophthalmologist with the Glaucoma Service, SNEC.
How it works
Nanomedicine is a drug delivered
to a specific “postal code”, that is
a part of the body where the medicine is needed, and is released
over a period of time. This makes
it highly effective and minimises
any side effects to patients.
For glaucoma patients, the new
nanomedicine is delivered to the
front of the eye via a painless injection. The nanoliposomal drug
delivery system is made up of
millions of nano-sized capsules
thousands of times smaller than a
speck of dust. The capsules contain Latanoprost, a well-known
anti-glaucoma drug approved
worldwide for daily use, which is
released slowly over the next six
months.
Liposomal latanoprost is now in the
midst of being commercialised. Larger
scale clinical trials are currently being
planned to pave the way for eventual
release to the market.
CONTACT SNEC
Appointment Hotline
Tel: 6322 9399
General Enquiries
Tel: 6227 7255
GP CONTACT
The Head and Neck Centre is located at
SGH Block 3 Level 1.
GPs can call for appointments through the GP Appointment Hotline at
6321 4402 (SGH) or 6436 8288 (NCCS).
For general enquiries, patients can call
6321 4377 (SGH) or 6436 8088 (NCCS).
15
News
Jul-Sep 2014
Code Red to Save Pregnant Mothers
decades, such as obesity, smoking,
older age at pregnancy, diabetes and
hypertension, causing ischaemic heart
disease and myocardial infarction.
General health measures for the prevention of cardiac disease include:
weight management; cessation of
smoking; active management of associated diseases such as diabetes and hypertension; and increasing knowledge
of conditions in pregnancy that can
lead to significant morbidity.
A multidisciplinary team simulates a CODE RED activation for maternal cardiac arrest.
KK Women’s and Children’s Hospital
(KKH) is the first hospital in Singapore
to induct a dedicated CODE RED for
cardiac arrest in pregnant women into
its resuscitation protocols.
In the event of a maternal cardiac arrest, CODE RED is activated through
the hospital’s code announcement system. A multidisciplinary medical team
trained in maternal resuscitation and
obstetric emergency management
swiftly assembles at the patient’s location within the hospital. Armed with
resuscitation and surgical equipment,
the team assesses the patient and, if
needed, performs a timely perimortem
caesarean section (PMCS) to improve
the chances of successful resuscitation.
To enable swift and coordinated medical intervention, the code is reinforced
by specialised guidelines and rigorous
simulation training in maternal resuscitation for all medical personnel involved.
“When a pregnant woman goes into
cardiac arrest, the window of opportunity for intervention can be measured in
a matter of minutes,” says Dr Deepak
Mathur, Consultant, Department of
Women’s Anaesthesia, KKH, who led
the code implementation. “CODE RED
reduces the medical response time to
caesarean delivery for effective maternal and neonatal resuscitation, helping
to better survival and neurological outcomes for both mother and baby.”
16
While the global incidence of maternal
cardiac arrest and the effect of PMCS
on feto-maternal survival remains challenging to quantify, the experience of
PMCS at KKH, when performed in a
timely manner, is promising.
In the past 24 months, three patients
presented with maternal cardiac arrest,
of which two responded successfully to
prompt resuscitation involving a PMCS.
MATERNAL CARDIAC ARREST
Although the incidence of maternal cardiac arrest is rare, data from the Centre for Maternal and Child Enquiries
(CMACE), United Kingdom, indicates
that its incidence has increased from
1:30,000 to 1:20,000 pregnancies since
the 2000-2002 triennium.
The aetiology of maternal cardiac arrest is multifactorial. Cardiac arrest
in pregnancy may result from direct
causes, such as eclampsia, haemorrhage, thromboembolism and amniotic
fluid embolism; or indirect and unrelated conditions, such as cardiac disease,
sepsis, malignancy and trauma. Diminished maternal cardiovascular and respiratory reserve usually leads to rapid
deterioration during pregnancy, which
can result in poorer outcomes.
Cardiac diseases are the leading cause
of death in pregnancy in the developed world. These are attributable to
preventable lifestyle changes in recent
WARNING SIGNS OF
MATERNAL CARDIAC ARREST
General practitioners and patients
should have a low threshold for
seeking early specialist review
for conditions which predispose
pregnant women to potential situations that lead to cardiac arrest.
These include:
• Severe sepsis arising from genitourinary or respiratory infections
• Signs and symptoms suggestive of internal haemorrhage or
genital tract bleeding
• Cardiovascular conditions presenting in pregnancy with symptoms such as chest discomfort
or breathing difficulties
• Unexplained or significant headaches which should be considered serious unless proven otherwise
In addition, several pre-existing
conditions, such as heart disease
or intracranial aneurysms, may
decompensate during pregnancy,
due to the physiological alterations
that occur in a pregnant woman.
CONTACT KKH
General Enquiries
Tel: 6225 5554
Trauma-Focused CognitiveBehavioural Therapy for Children
Children experiencing emotional and
psychological difficulties related to trauma, such as the sudden loss of a loved
one, will be able to receive communitybased therapy through a programme
jointly piloted by Temasek Cares and the
Psychosocial Trauma Support Service
(PTSS) at KK Women’s and Children’s
Hospital (KKH).
The Temasek Cares KITS (Kids in Tough
Situations) Programme is a three-year
pilot started in February this year to
strengthen care and support for children
affected by traumatic events. 60 community-based social workers, therapists
and school counsellors will be trained
to provide trauma-focused cognitivebehavioural therapy (TF-CBT) to children
within their environment in school and
the community.
The KITS Programme is expected to
benefit 1,920 children and their caregivers. Outreach efforts will also be
made to 7,000 children and adolescents, teachers, community-based professionals, parents and members of the
COMMON TRAUMA SYMPTOMS
IN CHILDREN
Trauma symptoms and reactions in
children are influenced by many factors, such as the child’s developmental level, cultural factors, previous
trauma exposure, available personal
coping and social resources, and preexisting child and family problems.
Children often vary in the nature of
their responses to traumatic events.
Common reactions displayed by children after a traumatic event include:
• Feeling fearful, worried or sad
• Sleep problems or nightmares
• Changes in appetite, eating problems
• Difficulty with concentrating (e.g.
problems with schoolwork)
public to raise awareness about trauma
and its effects on children.
cover,” adds Prof Ng, who is also the
Director of the KITS Programme.
EVIDENCE-BASED TREATMENT FOR
CHILDREN AFFECTED BY TRAUMA
“The impact of trauma, left unaddressed, raises a child’s risk of developing behavioural problems and
academic difficulties, among other potential emotional and psychological issues,” says Associate Professor Ng Kee
Chong, Chairman of KKH’s Division of
Medicine and Head of the hospital’s
Department of Emergency Medicine
and PTSS. “Studies have proven that
children exposed to trauma are nearly
two times more likely to develop psychiatric disorders compared with those
who are not.”
“TF-CBT is an evidence-based approach involving not just the child, but
also the parents and sometimes other
caregivers in the family, and has been
proven effective when delivered in the
community. KKH will help to train community-based therapists and school
counsellors to identify and extend TFCBT to children within their environment in school and the community,”
said Ms Lim Xin Yi, Clinical Psychologist and Deputy Head of KKH’s Psychosocial Trauma Support Service. Ms
Lim is also the Project Head of the KITS
Programme.
“While children with severe symptoms
are currently being identified and referred for tertiary interventions, those
with mild to moderate symptoms often
remain undetected and unsupported,
especially in the community setting.
This vulnerable group needs timely
therapy to develop resilience and re-
• Having thoughts about the event
‘pop up’ at unexpected times
• Repeatedly talking or thinking about
the traumatic event
• Avoiding places or things associated
with the traumatic event
• Being easily startled or ‘edgy’
• Being irritable or aggressive
• Complaining of headaches, tummy
aches or other minor illnesses
• Refusing to go to school or to go out
Younger children may also display certain behaviours after a traumatic event,
which include:
• Clinging to parents or other adults
• Having regressive behaviours (e.g.
bedwetting, thumb-sucking)
• Fear of the dark or being alone
• Crying or throwing tantrums
The KITS Programme is partnered by the
Guidance Branch of the Ministry of Education, Singapore; the Clinical and Forensic Psychology Branch of the Ministry
of Social and Family Development, and
various voluntary welfare organisations
including PAVE, AMKFSC Community
Services, Fei Yue Family Service Centre
and Tampines Family Service Centre.
• Playing in a repeated way about
the event or accident
Early intervention by trained therapists
has an important role in facilitating the
recovery of children when traumatic
events occur, and building their resilience in the long term. Parents who
are concerned about their child’s emotional adjustment following a traumatic
event should seek medical advice from
their child’s physician.
CONTACT KKH
General Enquiries
Tel: 6225 5554
17
News
Jul-Sep 2014
Code Red to Save Pregnant Mothers
decades, such as obesity, smoking,
older age at pregnancy, diabetes and
hypertension, causing ischaemic heart
disease and myocardial infarction.
General health measures for the prevention of cardiac disease include:
weight management; cessation of
smoking; active management of associated diseases such as diabetes and hypertension; and increasing knowledge
of conditions in pregnancy that can
lead to significant morbidity.
A multidisciplinary team simulates a CODE RED activation for maternal cardiac arrest.
KK Women’s and Children’s Hospital
(KKH) is the first hospital in Singapore
to induct a dedicated CODE RED for
cardiac arrest in pregnant women into
its resuscitation protocols.
In the event of a maternal cardiac arrest, CODE RED is activated through
the hospital’s code announcement system. A multidisciplinary medical team
trained in maternal resuscitation and
obstetric emergency management
swiftly assembles at the patient’s location within the hospital. Armed with
resuscitation and surgical equipment,
the team assesses the patient and, if
needed, performs a timely perimortem
caesarean section (PMCS) to improve
the chances of successful resuscitation.
To enable swift and coordinated medical intervention, the code is reinforced
by specialised guidelines and rigorous
simulation training in maternal resuscitation for all medical personnel involved.
“When a pregnant woman goes into
cardiac arrest, the window of opportunity for intervention can be measured in
a matter of minutes,” says Dr Deepak
Mathur, Consultant, Department of
Women’s Anaesthesia, KKH, who led
the code implementation. “CODE RED
reduces the medical response time to
caesarean delivery for effective maternal and neonatal resuscitation, helping
to better survival and neurological outcomes for both mother and baby.”
16
While the global incidence of maternal
cardiac arrest and the effect of PMCS
on feto-maternal survival remains challenging to quantify, the experience of
PMCS at KKH, when performed in a
timely manner, is promising.
In the past 24 months, three patients
presented with maternal cardiac arrest,
of which two responded successfully to
prompt resuscitation involving a PMCS.
MATERNAL CARDIAC ARREST
Although the incidence of maternal cardiac arrest is rare, data from the Centre for Maternal and Child Enquiries
(CMACE), United Kingdom, indicates
that its incidence has increased from
1:30,000 to 1:20,000 pregnancies since
the 2000-2002 triennium.
The aetiology of maternal cardiac arrest is multifactorial. Cardiac arrest
in pregnancy may result from direct
causes, such as eclampsia, haemorrhage, thromboembolism and amniotic
fluid embolism; or indirect and unrelated conditions, such as cardiac disease,
sepsis, malignancy and trauma. Diminished maternal cardiovascular and respiratory reserve usually leads to rapid
deterioration during pregnancy, which
can result in poorer outcomes.
Cardiac diseases are the leading cause
of death in pregnancy in the developed world. These are attributable to
preventable lifestyle changes in recent
WARNING SIGNS OF
MATERNAL CARDIAC ARREST
General practitioners and patients
should have a low threshold for
seeking early specialist review
for conditions which predispose
pregnant women to potential situations that lead to cardiac arrest.
These include:
• Severe sepsis arising from genitourinary or respiratory infections
• Signs and symptoms suggestive of internal haemorrhage or
genital tract bleeding
• Cardiovascular conditions presenting in pregnancy with symptoms such as chest discomfort
or breathing difficulties
• Unexplained or significant headaches which should be considered serious unless proven otherwise
In addition, several pre-existing
conditions, such as heart disease
or intracranial aneurysms, may
decompensate during pregnancy,
due to the physiological alterations
that occur in a pregnant woman.
CONTACT KKH
General Enquiries
Tel: 6225 5554
Trauma-Focused CognitiveBehavioural Therapy for Children
Children experiencing emotional and
psychological difficulties related to trauma, such as the sudden loss of a loved
one, will be able to receive communitybased therapy through a programme
jointly piloted by Temasek Cares and the
Psychosocial Trauma Support Service
(PTSS) at KK Women’s and Children’s
Hospital (KKH).
The Temasek Cares KITS (Kids in Tough
Situations) Programme is a three-year
pilot started in February this year to
strengthen care and support for children
affected by traumatic events. 60 community-based social workers, therapists
and school counsellors will be trained
to provide trauma-focused cognitivebehavioural therapy (TF-CBT) to children
within their environment in school and
the community.
The KITS Programme is expected to
benefit 1,920 children and their caregivers. Outreach efforts will also be
made to 7,000 children and adolescents, teachers, community-based professionals, parents and members of the
COMMON TRAUMA SYMPTOMS
IN CHILDREN
Trauma symptoms and reactions in
children are influenced by many factors, such as the child’s developmental level, cultural factors, previous
trauma exposure, available personal
coping and social resources, and preexisting child and family problems.
Children often vary in the nature of
their responses to traumatic events.
Common reactions displayed by children after a traumatic event include:
• Feeling fearful, worried or sad
• Sleep problems or nightmares
• Changes in appetite, eating problems
• Difficulty with concentrating (e.g.
problems with schoolwork)
public to raise awareness about trauma
and its effects on children.
cover,” adds Prof Ng, who is also the
Director of the KITS Programme.
EVIDENCE-BASED TREATMENT FOR
CHILDREN AFFECTED BY TRAUMA
“The impact of trauma, left unaddressed, raises a child’s risk of developing behavioural problems and
academic difficulties, among other potential emotional and psychological issues,” says Associate Professor Ng Kee
Chong, Chairman of KKH’s Division of
Medicine and Head of the hospital’s
Department of Emergency Medicine
and PTSS. “Studies have proven that
children exposed to trauma are nearly
two times more likely to develop psychiatric disorders compared with those
who are not.”
“TF-CBT is an evidence-based approach involving not just the child, but
also the parents and sometimes other
caregivers in the family, and has been
proven effective when delivered in the
community. KKH will help to train community-based therapists and school
counsellors to identify and extend TFCBT to children within their environment in school and the community,”
said Ms Lim Xin Yi, Clinical Psychologist and Deputy Head of KKH’s Psychosocial Trauma Support Service. Ms
Lim is also the Project Head of the KITS
Programme.
“While children with severe symptoms
are currently being identified and referred for tertiary interventions, those
with mild to moderate symptoms often
remain undetected and unsupported,
especially in the community setting.
This vulnerable group needs timely
therapy to develop resilience and re-
• Having thoughts about the event
‘pop up’ at unexpected times
• Repeatedly talking or thinking about
the traumatic event
• Avoiding places or things associated
with the traumatic event
• Being easily startled or ‘edgy’
• Being irritable or aggressive
• Complaining of headaches, tummy
aches or other minor illnesses
• Refusing to go to school or to go out
Younger children may also display certain behaviours after a traumatic event,
which include:
• Clinging to parents or other adults
• Having regressive behaviours (e.g.
bedwetting, thumb-sucking)
• Fear of the dark or being alone
• Crying or throwing tantrums
The KITS Programme is partnered by the
Guidance Branch of the Ministry of Education, Singapore; the Clinical and Forensic Psychology Branch of the Ministry
of Social and Family Development, and
various voluntary welfare organisations
including PAVE, AMKFSC Community
Services, Fei Yue Family Service Centre
and Tampines Family Service Centre.
• Playing in a repeated way about
the event or accident
Early intervention by trained therapists
has an important role in facilitating the
recovery of children when traumatic
events occur, and building their resilience in the long term. Parents who
are concerned about their child’s emotional adjustment following a traumatic
event should seek medical advice from
their child’s physician.
CONTACT KKH
General Enquiries
Tel: 6225 5554
17
Research
Appointments
Jul-Sep 2014
Flu Jab Not Fully Embraced
Singapore GENERAL HOSPITAL
Education needed to encourage immunisation among
primary healthcare workers
Only 20 to 60 per cent of healthcare
workers in polyclinics here get vaccinated against the influenza virus annually. This, despite the increased risk of
infection they face with some 740,000
patients presenting at polyclinics each
year with acute respiratory infections.
The fear of pain from the needle and
the concern over adverse reactions
from vaccination were the main barriers
to immunisation according to a focus
group study conducted by a team from
SingHealth Polyclinics. Others included
the uncertainty of the vaccine’s efficacy
and the notion of having good immunity. Anecdotal reports of adverse events
afflicting others also served to discourage immunisation.
These findings, recently published in
the Proceedings of Singapore Healthcare, highlighted the need to increase
awareness and dispel misconceptions about the influenza vaccination
amongst these primary care workers.
“Adverse reactions are uncommon,
and while there will be a small amount
of pain, this must be balanced against
the benefits. The message to communicate is that vaccination not only confers them protection, but also prevents
transmission of the virus to patients,
other staff and family members,” shared
team leader Dr Hwang Siew Wai, Clinic
Director and Consultant, Bukit Merah
Polyclinic.
Dr Hwang also believes that approaching staff at an individual level or in small
groups is probably most effective. He
suggested using educational posters and screensavers to reinforce the
importance of receiving the influenza
vaccination, which remains the most
New Drug Trial for
Knee Osteoarthritis
The Singapore General Hospital is testing out a new drug
treatment for patients with knee osteoarthritis (OA) and is
looking for volunteers for the trial.
Appointments
Dr Wong Patrick
Consultant
Dr Fong Poh Ling
Associate Consultant
Dept
Dept
Dept
Respiratory & Critical Care Medicine
Dr Gudi
Alakananda Mihir
Associate Consultant
Orthopaedic
Surgery
Dept
Psychiatry
Pulmonary Medicine &
Critical Care Medicine
Promotions
Dr Zhu Haibei
Associate Consultant
Dept
Anaesthesiology
Dr Yeo Shen-Ann
Eugene
Associate Consultant
Dr Kam Juinn Huar
Associate Consultant
Dept
Hepatopancreatobiliary
and Transplant Surgery
Dept
Colorectal Surgery
Sub-specialty
While the study focused on polyclinics,
the findings and suggested interventions are equally applicable to other
primary care workers such as general practitioners and clinic assistants,
who are also at the frontline providing
healthcare to the community.
HPB and Transplant
Surgery
Dr Xie Wanying
Associate Consultant
Dr Chew Chee Ping
Associate Consultant
Dr Koo Oon Thien Kevin
Associate Consultant
Dept
Dept
Dept
Nuclear Medicine & PET
“Besides getting immunised annually,
they should also employ other preventive techniques such as wearing masks
and practising good hand hygiene,”
added Dr Hwang.
Anaesthesiology
Sub-specialty
important means of preventing and
controlling influenza.
The study also recognised that there
were some motivating factors such as
positive influence from other staff and
senior management, availability of incentives, accessibility as well as knowledge about the vaccine’s benefits.
Dr Tay Chee Kiang Melvin
Associate Consultant
Orthopaedic Surgery
Orthopaedic Surgery
Sub-specialty
Foot & Ankle Surgery
Dr Chan Su Pin Hazel
Associate Consultant
Dr Chen Xuanxuan
Associate Consultant
Dr Lim Kai Inn
Associate Consultant
Dr Ong Yee Yian
Associate Consultant
Dept
Dept
Dept
Dept
Dr Thor Timothy Anuntapon Chutatape
Associate Consultant
Dr Lao Zhentang
Associate Consultant
Dr Heah Hon Wei Harold
Associate Consultant
Dept
Dept
Dept
Anaesthesiology
Anaesthesiology
Anaesthesiology
Anaesthesiology
Haematology
Anaesthesiology
Otolaryngology (ENT)
KK WOMEN’S AND CHILDREN’S HOSPITAL
PROMOTIONS - SENIOR CONSULTANTS
Venue
Autoimmunity & Rheumatology Centre, Singapore General
Hospital
Dr Lim Sheow Lei
Senior Consultant
Assoc Prof Chan Kok Yen Jerry
Senior Consultant
Dept
Volunteers who are above 21 years old having pain, aching
or stiffness of the knee on most days for the past month and
moderate knee pain
Gynaecological Oncology
Dept
Requirements
Conducting
Language
• English
• Mandarin
Involvement
5 consultation visits, knee X-ray, blood/urine tests, removal of
fluid from knee and study drug. All at no cost to volunteers.
Dr Sandeep Shashikant Kulkarni
Senior Consultant
Dr Sng Ban Leong
Senior Consultant
Dept
Dept
Contact
18
Women’s Anaesthesia
Reproductive Medicine
Women’s Anaesthesia
Tel: 9616 0245 (From 9am to 5pm)
19
Research
Appointments
Jul-Sep 2014
Flu Jab Not Fully Embraced
Singapore GENERAL HOSPITAL
Education needed to encourage immunisation among
primary healthcare workers
Only 20 to 60 per cent of healthcare
workers in polyclinics here get vaccinated against the influenza virus annually. This, despite the increased risk of
infection they face with some 740,000
patients presenting at polyclinics each
year with acute respiratory infections.
The fear of pain from the needle and
the concern over adverse reactions
from vaccination were the main barriers
to immunisation according to a focus
group study conducted by a team from
SingHealth Polyclinics. Others included
the uncertainty of the vaccine’s efficacy
and the notion of having good immunity. Anecdotal reports of adverse events
afflicting others also served to discourage immunisation.
These findings, recently published in
the Proceedings of Singapore Healthcare, highlighted the need to increase
awareness and dispel misconceptions about the influenza vaccination
amongst these primary care workers.
“Adverse reactions are uncommon,
and while there will be a small amount
of pain, this must be balanced against
the benefits. The message to communicate is that vaccination not only confers them protection, but also prevents
transmission of the virus to patients,
other staff and family members,” shared
team leader Dr Hwang Siew Wai, Clinic
Director and Consultant, Bukit Merah
Polyclinic.
Dr Hwang also believes that approaching staff at an individual level or in small
groups is probably most effective. He
suggested using educational posters and screensavers to reinforce the
importance of receiving the influenza
vaccination, which remains the most
New Drug Trial for
Knee Osteoarthritis
The Singapore General Hospital is testing out a new drug
treatment for patients with knee osteoarthritis (OA) and is
looking for volunteers for the trial.
Appointments
Dr Wong Patrick
Consultant
Dr Fong Poh Ling
Associate Consultant
Dept
Dept
Dept
Respiratory & Critical Care Medicine
Dr Gudi
Alakananda Mihir
Associate Consultant
Orthopaedic
Surgery
Dept
Psychiatry
Pulmonary Medicine &
Critical Care Medicine
Promotions
Dr Zhu Haibei
Associate Consultant
Dept
Anaesthesiology
Dr Yeo Shen-Ann
Eugene
Associate Consultant
Dr Kam Juinn Huar
Associate Consultant
Dept
Hepatopancreatobiliary
and Transplant Surgery
Dept
Colorectal Surgery
Sub-specialty
While the study focused on polyclinics,
the findings and suggested interventions are equally applicable to other
primary care workers such as general practitioners and clinic assistants,
who are also at the frontline providing
healthcare to the community.
HPB and Transplant
Surgery
Dr Xie Wanying
Associate Consultant
Dr Chew Chee Ping
Associate Consultant
Dr Koo Oon Thien Kevin
Associate Consultant
Dept
Dept
Dept
Nuclear Medicine & PET
“Besides getting immunised annually,
they should also employ other preventive techniques such as wearing masks
and practising good hand hygiene,”
added Dr Hwang.
Anaesthesiology
Sub-specialty
important means of preventing and
controlling influenza.
The study also recognised that there
were some motivating factors such as
positive influence from other staff and
senior management, availability of incentives, accessibility as well as knowledge about the vaccine’s benefits.
Dr Tay Chee Kiang Melvin
Associate Consultant
Orthopaedic Surgery
Orthopaedic Surgery
Sub-specialty
Foot & Ankle Surgery
Dr Chan Su Pin Hazel
Associate Consultant
Dr Chen Xuanxuan
Associate Consultant
Dr Lim Kai Inn
Associate Consultant
Dr Ong Yee Yian
Associate Consultant
Dept
Dept
Dept
Dept
Dr Thor Timothy Anuntapon Chutatape
Associate Consultant
Dr Lao Zhentang
Associate Consultant
Dr Heah Hon Wei Harold
Associate Consultant
Dept
Dept
Dept
Anaesthesiology
Anaesthesiology
Anaesthesiology
Anaesthesiology
Haematology
Anaesthesiology
Otolaryngology (ENT)
KK WOMEN’S AND CHILDREN’S HOSPITAL
PROMOTIONS - SENIOR CONSULTANTS
Venue
Autoimmunity & Rheumatology Centre, Singapore General
Hospital
Dr Lim Sheow Lei
Senior Consultant
Assoc Prof Chan Kok Yen Jerry
Senior Consultant
Dept
Volunteers who are above 21 years old having pain, aching
or stiffness of the knee on most days for the past month and
moderate knee pain
Gynaecological Oncology
Dept
Requirements
Conducting
Language
• English
• Mandarin
Involvement
5 consultation visits, knee X-ray, blood/urine tests, removal of
fluid from knee and study drug. All at no cost to volunteers.
Dr Sandeep Shashikant Kulkarni
Senior Consultant
Dr Sng Ban Leong
Senior Consultant
Dept
Dept
Contact
18
Women’s Anaesthesia
Reproductive Medicine
Women’s Anaesthesia
Tel: 9616 0245 (From 9am to 5pm)
19
Appointments
Jul-Sep 2014
KK WOMEN’S AND CHILDREN’S HOSPITAL
KK WOMEN’S AND CHILDREN’S HOSPITAL
PROMOTIONS - CONSULTANTS
NEW Appointments
Dr Sita Padmini
Yeleswarapu
Consultant
Dr Kua Phek Hui Jade
Consultant
Dr Lee Jiah Min
Consultant
Dept
Emergency Medicine
Dept
Dept
Dr Tan Pih Lin
Consultant
Dr Soh Chee Cheong
Reuben
Consultant
Dr Mohammad Ashik
Bin Zainudin
Consultant
Dept
Dept
Child Development
Dept
Neonatology
Dr Tay Guan Tzu
Consultant
Dept
Orthopaedic Surgery
Dr Chong Siew Le
Consultant
Dept
Paediatrics
(Nephrology Service)
Minimally Invasive
Surgery Unit
Orthopaedic Surgery
Orthopaedic Surgery
Dr Wan Yuan Kwan
Sharon
Consultant
Dr Saumya Shekhar
Jamuar
Consultant
Dept
Dept
Paediatric Anaesthesia
Paediatrics
(Genetics Service)
Dr Liew Kein Meng
Wendy
Consultant
Dr Leong Wan Ling
Consultant
Dept
Women’s Anaesthesia
Dept
Paediatrics
(Neurology Service)
PROMOTIONS - ASSOCIATE CONSULTANTS
Dr Angela Yeo Siok
Hoong
Associate Consultant
Dr Lam Kei Yet
Associate Consultant
Dept
Orthopaedic Surgery
Paediatric Anaesthesia
Dr Marielle Valerie Fortier
Academic Vice Chair Clinical Services
Quality (RADSC ACP)
Assoc Prof Ong Chiou Li
Academic Deputy Chair (RADSC ACP)
Dept
Diagnostic and Interventional Imaging
Dept
Diagnostic and Interventional Imaging
National Heart Centre Singapore
Promotions
Assoc Prof Kenny Sin
Deputy Medical Director;
Head & Senior Consultant
Assoc Prof Lim Soo Teik
Deputy Medical Director;
Senior Consultant
Dept
Dept
Sub-specialty
Sub-specialty
Cardiothoracic Surgery
Cardiology
Cardiac Surgery (Adult),
Thoracic & Vascular Surgery
Interventional Cardiology
Asst Prof Chin Chee Tang
Senior Consultant
Dr Ho Kah Leng
Senior Consultant
Dr Tan Boon Yew
Senior Consultant
Dept
Dept
Dept
Sub-specialty
Sub-specialty
Sub-specialty
Cardiology
Interventional
Cardiology
Cardiology
Electrophysiology and
Pacing
Dept
Dept
Women’s Anaesthesia
Electrophysiology and
Pacing
Dr Calvin Chin
Consultant
Dr Angela Koh
Consultant
Dept
Dept
Sub-specialty
Sub-specialty
Cardiology
Dr Srividhya
Jayant Iyer
Associate Consultant
Cardiology
Echocardiography
Cardiology
Cardiac Imaging
National NEUROSCIENCE INSTITUTE
Promotions
NEW Appointments
Assoc Prof Yam Kwai Lam Philip
Senior Mentor
Dr Lim Yong Kuei Timothy
Head
Dept
Dept
Gynaecological Oncology
Gynaecological Oncology
Assoc Prof Deidre Anne De Silva
Senior Consultant
Dr Nagaendran Kandiah
Senior Consultant
Dept
Dept
Sub-specialty
Sub-specialty
Dr Rajinder Singh
Senior Consultant
Dr Tan Kevin
Senior Consultant
Dept
Dept
Sub-specialty
Sub-specialty
Neurology (SGH Campus)
Stroke
Neurology (TTSH Campus)
Stroke, General Neurology
20
Neurology (TTSH Campus)
Alzheimer’s Disease, Dementia, Cognitive
Neurology
Neurology (TTSH Campus)
Neuroimmunology, Neuroinfectious Disease
21
Appointments
Jul-Sep 2014
KK WOMEN’S AND CHILDREN’S HOSPITAL
KK WOMEN’S AND CHILDREN’S HOSPITAL
PROMOTIONS - CONSULTANTS
NEW Appointments
Dr Sita Padmini
Yeleswarapu
Consultant
Dr Kua Phek Hui Jade
Consultant
Dr Lee Jiah Min
Consultant
Dept
Emergency Medicine
Dept
Dept
Dr Tan Pih Lin
Consultant
Dr Soh Chee Cheong
Reuben
Consultant
Dr Mohammad Ashik
Bin Zainudin
Consultant
Dept
Dept
Child Development
Dept
Neonatology
Dr Tay Guan Tzu
Consultant
Dept
Orthopaedic Surgery
Dr Chong Siew Le
Consultant
Dept
Paediatrics
(Nephrology Service)
Minimally Invasive
Surgery Unit
Orthopaedic Surgery
Orthopaedic Surgery
Dr Wan Yuan Kwan
Sharon
Consultant
Dr Saumya Shekhar
Jamuar
Consultant
Dept
Dept
Paediatric Anaesthesia
Paediatrics
(Genetics Service)
Dr Liew Kein Meng
Wendy
Consultant
Dr Leong Wan Ling
Consultant
Dept
Women’s Anaesthesia
Dept
Paediatrics
(Neurology Service)
PROMOTIONS - ASSOCIATE CONSULTANTS
Dr Angela Yeo Siok
Hoong
Associate Consultant
Dr Lam Kei Yet
Associate Consultant
Dept
Orthopaedic Surgery
Paediatric Anaesthesia
Dr Marielle Valerie Fortier
Academic Vice Chair Clinical Services
Quality (RADSC ACP)
Assoc Prof Ong Chiou Li
Academic Deputy Chair (RADSC ACP)
Dept
Diagnostic and Interventional Imaging
Dept
Diagnostic and Interventional Imaging
National Heart Centre Singapore
Promotions
Assoc Prof Kenny Sin
Deputy Medical Director;
Head & Senior Consultant
Assoc Prof Lim Soo Teik
Deputy Medical Director;
Senior Consultant
Dept
Dept
Sub-specialty
Sub-specialty
Cardiothoracic Surgery
Cardiology
Cardiac Surgery (Adult),
Thoracic & Vascular Surgery
Interventional Cardiology
Asst Prof Chin Chee Tang
Senior Consultant
Dr Ho Kah Leng
Senior Consultant
Dr Tan Boon Yew
Senior Consultant
Dept
Dept
Dept
Sub-specialty
Sub-specialty
Sub-specialty
Cardiology
Interventional
Cardiology
Cardiology
Electrophysiology and
Pacing
Dept
Dept
Women’s Anaesthesia
Electrophysiology and
Pacing
Dr Calvin Chin
Consultant
Dr Angela Koh
Consultant
Dept
Dept
Sub-specialty
Sub-specialty
Cardiology
Dr Srividhya
Jayant Iyer
Associate Consultant
Cardiology
Echocardiography
Cardiology
Cardiac Imaging
National NEUROSCIENCE INSTITUTE
Promotions
NEW Appointments
Assoc Prof Yam Kwai Lam Philip
Senior Mentor
Dr Lim Yong Kuei Timothy
Head
Dept
Dept
Gynaecological Oncology
Gynaecological Oncology
Assoc Prof Deidre Anne De Silva
Senior Consultant
Dr Nagaendran Kandiah
Senior Consultant
Dept
Dept
Sub-specialty
Sub-specialty
Dr Rajinder Singh
Senior Consultant
Dr Tan Kevin
Senior Consultant
Dept
Dept
Sub-specialty
Sub-specialty
Neurology (SGH Campus)
Stroke
Neurology (TTSH Campus)
Stroke, General Neurology
20
Neurology (TTSH Campus)
Alzheimer’s Disease, Dementia, Cognitive
Neurology
Neurology (TTSH Campus)
Neuroimmunology, Neuroinfectious Disease
21
Recruitment
Courses
Jul-Sep 2014
Don’t Limit Your Challenges. Challenge Your Limits.
If you are a qualified doctor, a
challenging career awaits you at
SingHealth. We seek suitably qualified
candidates to join us as:
•Resident Physicians /
Family Physicians
•Registrars
Interested applicants to email CV
with full personal particulars, educational and professional qualifications
(including housemanship details),
career history, present and expected
salary, names of at least two professional references, contact numbers
and e-mail address together with a
non-returnable photograph.
Please email your CV to the respective institutions’ email addresses/
online career portals below with the
Reference Number MN1407.
Singapore Health Services (SingHealth),
Singapore’s largest Academic Healthcare
Cluster, is committed to providing affordable and accessible quality healthcare
to patients. With a total of 42 clinical
specialties, its network of 2 Hospitals, 5
National Specialty Centres, 9 Polyclinics and a Community Hospital delivers a
comprehensive range of multidisciplinary
and integrated medical care.
SingHealth is responsible for developing Sengkang Health, a new healthcare
system to deliver patient-centric care to
the community in the north-east of Singapore. By 2018, a general hospital and
a community hospital will be fully operational in Sengkang. Sengkang Health will
commence operations in Alexandra Hospital in 2015, prior to the completion of its
new hospitals. The collective strengths of
SingHealth and Duke-NUS, its partner in
research and medical education, pave the
way for the transformation of healthcare.
22
Singapore General Hospital
Departments seeking Resident
Physicians and Registrars:
• Anaesthesiology
• Colorectal Surgery
• Diagnostic Radiology
• Emergency Medicine
• Endocrinology
• Family Medicine and
Continuing Care
• Gastroenterology & Hepatology
• General Surgery
• Geriatric Medicine
• Haematology
• Hand Surgery
• Infectious Diseases
• Internal Medicine
• Neonatal and Developmental
Medicine
• Nuclear Medicine & PET
• Obstetrics & Gynaecology
• Orthopaedic Surgery
• Otolaryngology
• Plastic, Reconstructive &
Aesthetic Surgery
• Renal Medicine
• Rehabilitation Medicine
• Respiratory and Critical Care
Medicine
• Rheumatology & Immunology
• Urology
• Staff Clinic - Locum
Website: www.sgh.com.sg
Career Portal: www.sgh.com.sg/
subsites/sgh-careers/medical/pages/
career-opportunites.aspx
Email: [email protected]
KK Women’s and Children’s
Hospital
Departments seeking Resident
Physicians:
• Breast Surgery
• Cardiothoracic Surgery
• Obstetric Anaesthesia
Website: www.kkh.com.sg
Email: [email protected]
National Cancer Centre Singapore
Seeking Resident Physicians
Website: www.nccs.com.sg
Email: [email protected]
National Heart Centre Singapore
Departments seeking Registrars:
• Cardiothoracic Surgery
Website: www.nhcs.com.sg
Email: [email protected]
Singapore National Eye Centre
Seeking Resident Physicians and
Registrars
Website: www.snec.com.sg
Email: [email protected]
SingHealth Polyclinics
Departments seeking Resident
Physicians and Family Physicians:
• Polyclinic (Family Medicine)
Website: http://polyclinic.singhealth.
com.sg
Email: [email protected]
Sengkang Health
Departments seeking Resident
Physicians and Registrars:
• Anaesthesiology
• Diagnostic Radiology
• Endocrinology
• Emergency Medicine
• Gastroenterology
• General Surgery
• Geriatric Medicine
• Infectious Diseases
• Internal Medicine
• Neurology
• Orthopaedic Surgery
• Pathology
• Rehabilitation Medicine
• Renal Medicine
• Respiratory Medicine
Website: www.singhealth.com.sg/
AboutSingHealth/CorporateOverview/
sengkang-health/pages/home.aspx
Email: [email protected]
NNI Neuroscience Seminars for Family Physicians 2014
Stroke
This seminar will provide General Practitioners (GPs) practical knowledge and
skills of evidence-based, cost effective
treatment for stroke-related patients.
Date
27 September 2014 (Saturday)
Time
1.00pm to 3.45pm
Venue
NNI Exhibition Hall, Basement 1
(NNI is located within
Tan Tock Seng Hospital)
CME Points
Application in process
Fees
Free
Contact
The NNI GP Seminar Secretariat
National Neuroscience Institute
Tel: 6357 7163
Fax: 6256 4755
Email: [email protected]
Registration is required.
15th Singapore Stroke Conference
Evolving Stroke Frontiers
The 15th Stroke Conference, themed
“Evolving Stroke Frontiers” this year,
will focus on emerging trends such as
newer thrombolytics, endovascular
therapy trials and novel oral anticoagulation drugs. A broad range of additional topics such as rehabilitation, cognitive impairment and venous thromboembolism will also be featured in the
two-day conference.
Date
7 & 8 November 2014
(Friday & Saturday)
Time
Day 1 – 7.00am - 5.30pm
Day 2 – 8.00am - 1.00pm
Venue
The Academia
Singapore General Hospital
20 College Road
CME Points
Application in process
Contact
Email: [email protected]
Registration is required.
Registration Fee
Physicians and
Researchers
Trainees, Nurses,
Allied Health
Professionals and other
Medical Professionals
Early Registration
Registration AND Payment
must be made before
29 August 2014
S$100
S$80
Normal Registration
Registration AND Payment
must be made before
17 October 2014
S$150
S$100
On-site Registration
Registration AND Payment received after 17 October 2014
will be considered at On-site
Registration
S$200
S$120
2
Registration
Category
1
Note:
1
Associate Consultants, Consultants and Senior Consultants are considered as Physicians. Other
will be considered as Trainees.
2
Trainee/Student identification or proof of qualifying trainee/student status MUST accompany
the registration form to qualify for Trainee/Student fees. Proof of status is also required when
registering on-site.
23
Recruitment
Courses
Jul-Sep 2014
Don’t Limit Your Challenges. Challenge Your Limits.
If you are a qualified doctor, a
challenging career awaits you at
SingHealth. We seek suitably qualified
candidates to join us as:
•Resident Physicians /
Family Physicians
•Registrars
Interested applicants to email CV
with full personal particulars, educational and professional qualifications
(including housemanship details),
career history, present and expected
salary, names of at least two professional references, contact numbers
and e-mail address together with a
non-returnable photograph.
Please email your CV to the respective institutions’ email addresses/
online career portals below with the
Reference Number MN1407.
Singapore Health Services (SingHealth),
Singapore’s largest Academic Healthcare
Cluster, is committed to providing affordable and accessible quality healthcare
to patients. With a total of 42 clinical
specialties, its network of 2 Hospitals, 5
National Specialty Centres, 9 Polyclinics and a Community Hospital delivers a
comprehensive range of multidisciplinary
and integrated medical care.
SingHealth is responsible for developing Sengkang Health, a new healthcare
system to deliver patient-centric care to
the community in the north-east of Singapore. By 2018, a general hospital and
a community hospital will be fully operational in Sengkang. Sengkang Health will
commence operations in Alexandra Hospital in 2015, prior to the completion of its
new hospitals. The collective strengths of
SingHealth and Duke-NUS, its partner in
research and medical education, pave the
way for the transformation of healthcare.
22
Singapore General Hospital
Departments seeking Resident
Physicians and Registrars:
• Anaesthesiology
• Colorectal Surgery
• Diagnostic Radiology
• Emergency Medicine
• Endocrinology
• Family Medicine and
Continuing Care
• Gastroenterology & Hepatology
• General Surgery
• Geriatric Medicine
• Haematology
• Hand Surgery
• Infectious Diseases
• Internal Medicine
• Neonatal and Developmental
Medicine
• Nuclear Medicine & PET
• Obstetrics & Gynaecology
• Orthopaedic Surgery
• Otolaryngology
• Plastic, Reconstructive &
Aesthetic Surgery
• Renal Medicine
• Rehabilitation Medicine
• Respiratory and Critical Care
Medicine
• Rheumatology & Immunology
• Urology
• Staff Clinic - Locum
Website: www.sgh.com.sg
Career Portal: www.sgh.com.sg/
subsites/sgh-careers/medical/pages/
career-opportunites.aspx
Email: [email protected]
KK Women’s and Children’s
Hospital
Departments seeking Resident
Physicians:
• Breast Surgery
• Cardiothoracic Surgery
• Obstetric Anaesthesia
Website: www.kkh.com.sg
Email: [email protected]
National Cancer Centre Singapore
Seeking Resident Physicians
Website: www.nccs.com.sg
Email: [email protected]
National Heart Centre Singapore
Departments seeking Registrars:
• Cardiothoracic Surgery
Website: www.nhcs.com.sg
Email: [email protected]
Singapore National Eye Centre
Seeking Resident Physicians and
Registrars
Website: www.snec.com.sg
Email: [email protected]
SingHealth Polyclinics
Departments seeking Resident
Physicians and Family Physicians:
• Polyclinic (Family Medicine)
Website: http://polyclinic.singhealth.
com.sg
Email: [email protected]
Sengkang Health
Departments seeking Resident
Physicians and Registrars:
• Anaesthesiology
• Diagnostic Radiology
• Endocrinology
• Emergency Medicine
• Gastroenterology
• General Surgery
• Geriatric Medicine
• Infectious Diseases
• Internal Medicine
• Neurology
• Orthopaedic Surgery
• Pathology
• Rehabilitation Medicine
• Renal Medicine
• Respiratory Medicine
Website: www.singhealth.com.sg/
AboutSingHealth/CorporateOverview/
sengkang-health/pages/home.aspx
Email: [email protected]
NNI Neuroscience Seminars for Family Physicians 2014
Stroke
This seminar will provide General Practitioners (GPs) practical knowledge and
skills of evidence-based, cost effective
treatment for stroke-related patients.
Date
27 September 2014 (Saturday)
Time
1.00pm to 3.45pm
Venue
NNI Exhibition Hall, Basement 1
(NNI is located within
Tan Tock Seng Hospital)
CME Points
Application in process
Fees
Free
Contact
The NNI GP Seminar Secretariat
National Neuroscience Institute
Tel: 6357 7163
Fax: 6256 4755
Email: [email protected]
Registration is required.
15th Singapore Stroke Conference
Evolving Stroke Frontiers
The 15th Stroke Conference, themed
“Evolving Stroke Frontiers” this year,
will focus on emerging trends such as
newer thrombolytics, endovascular
therapy trials and novel oral anticoagulation drugs. A broad range of additional topics such as rehabilitation, cognitive impairment and venous thromboembolism will also be featured in the
two-day conference.
Date
7 & 8 November 2014
(Friday & Saturday)
Time
Day 1 – 7.00am - 5.30pm
Day 2 – 8.00am - 1.00pm
Venue
The Academia
Singapore General Hospital
20 College Road
CME Points
Application in process
Contact
Email: [email protected]
Registration is required.
Registration Fee
Physicians and
Researchers
Trainees, Nurses,
Allied Health
Professionals and other
Medical Professionals
Early Registration
Registration AND Payment
must be made before
29 August 2014
S$100
S$80
Normal Registration
Registration AND Payment
must be made before
17 October 2014
S$150
S$100
On-site Registration
Registration AND Payment received after 17 October 2014
will be considered at On-site
Registration
S$200
S$120
2
Registration
Category
1
Note:
1
Associate Consultants, Consultants and Senior Consultants are considered as Physicians. Other
will be considered as Trainees.
2
Trainee/Student identification or proof of qualifying trainee/student status MUST accompany
the registration form to qualify for Trainee/Student fees. Proof of status is also required when
registering on-site.
23
Courses
GP Forum for
Paediatric Health 2014
Reg. No.: 200002698Z
GPEP HOTLINE
6377 8550
Date
22 November 2014 (Saturday)
Time
1.00pm to 5.00pm
Venue
KKH Auditorium,
Training Centre,
Level 1, Women’s Tower
CME Points
Application in process
Fees
$10 per pax
(includes lunch, tea and
parking)
Contact
Tel: 6394 8746
Email: [email protected]
Registrations by
17 November 2014 (Monday).
For more details or to register,
please call 6394 8746 (Monday to
Friday, 8.30am to 5.30pm) or log
on to www.kkh.com.sg/events.
Strictly no refund of registration
fee. Seats are confirmed upon
full payment on a first-come-firstserved basis.
Time
Programme
1.00pm Registration and Lunch
2.00pm Updates on Management of
Childhood Myopia
Dr Quah Boon Long
Head and Senior Consultant
Ophthalmology Service
KK Women’s and Children’s
Hospital
2.30pm Eyelid and Orbital Disorders in
Children
Dr Sunny Shen
Visiting Consultant
Ophthalmology Service
KK Women’s and Children’s
Hospital
3.00pm Interactive Session
3.15pm Tea Break
3.45pm Common Sports Injuries in
Children
Dr Mohammad Ashik Zainuddin
Consultant
Department of Orthopaedic
Surgery
KK Women’s and Children’s
Hospital
4.15pm Congenital Heart Surgery for
Grown-up Children
Dr Masakazu Nakao
Associate Consultant
Cardiothoracic Surgery Service
KK Women’s and Children’s
Hospital
4.45pm Interactive Session
24
[email protected]
GP FAST TRACK
APPOINTMENT HOTLINES
6321 4402
6294 4050
6436 8288
6324 8798
6704 2222
6321 4402/
6357 7095
6322 9399
DIRECT WARD REFERRAL
CONTACT NUMBERS
6321 4822
6394 1180
SINGHEALTH ACADEMIC
healthcare cluster