Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
A quarterly publication of GP Liaison Centre, National University Hospital. MCI (P) 122/03/2016
médico
Home Care @ NCIS
IN THIS ISSUE+Early Phase Clinical Trials
Limb Salvage in Musculoskeletal Oncology
Stereotactic Ablative Radiotherapy (SABR) Programme
A Holistic Approach to Conquer Myeloma
National University Cancer Institute, Singapore (NCIS)
JUL - SEP 2016
New features inside this
issue
02 médico JUL - SEP 2016
WHAT’SINSIDE
+
A Publication of NUH GP Liaison Centre (GPLC)
Advisor Editors Editorial MemberA/ProfGohLeeGan AmarantaLim YvonneLin KarinLim
We will love to hear your feedback on MédicoPleasedirectallfeedbackto:TheEditor,MédicoGPLiaisonCentre,NationalUniversityHospital,1EKentRidgeRoad,NUHSTowerBlock,Level6,Singapore119228
Tel:67725079 Email:[email protected]:67778065 Website:www.nuh.com.sg/nuh_gplc
Co.Reg.No.198500843R
Theinformationinthispublicationismeantpurelyforeducationalpurposesandmaynotbeusedasasubstituteformedicaldiagnosisortreatment.Youshouldseektheadviceofyourdoctororaqualifiedhealthcareproviderbeforestartinganytreatment,or,ifyouhaveanyquestionsrelatedtoyourhealth,physicalfitnessormedicalcondition(s).
Copyright(2016).NationalUniversityHospital,Singapore
Allrightsreserved.NopartofthispublicationmaybereproducedwithoutpermissioninwritingfromNationalUniversityHospital.
In Focus03 TheNationalUniversityCancerInstitute,
Singapore(NCIS)
First Look04 HomeCare@NCIS–TheCareContinuum
Insights 07 EarlyPhaseClinicalTrials–TheNCIS
DevelopmentalTherapeuticsUnit
12 LimbSalvageinMusculoskeletalOncology
18 Tips
Treatment Room19 StereotacticAblativeRadiotherapy(SABR)
Programme–Treatingour100thPatient andBeyond
Landscape23 AHolisticApproachtoConquerMyeloma
In Addition26 NCISHealthResourceCentre&Patient
SupportGroups
Specialist in Focus28 ProfessorChngWeeJoo
30 Happenings @ NUH
The NUHS group
18
12
TheNCISbringstogethertheexpertiseofthedepartmentsofHaematology,Radiation,Paediatric,Gynaecologic,Surgical,NursingandPharmacyOncologytoprovidemulti-disciplinarycancercareforpatientsthroughourspecialisedoutpatientclinicsspanningacrossLevels8to10attheNUHMedicalCentre(NUHMC).ItistheonlyfacilityinSingaporethattreatsbothadultandpaediatriconcologypatientswithinthesamepremises.OtherservicesincludeaPharmacy,aHealthResourceCentre(whichhelpspatientslearnandcopebetterwiththedisease)andtheNCISConcierge(whichassistsinternationalpatients).
The National University Cancer Institute, Singapore (NCIS)
Our Outpatient FacilitiesTheCancer Centreishometospecialistoutpatientclinicsprovidingexpertadviceandcareforcancerconditions.Ithasover40outpatientconsultroomsincludingtwoVIPconsultroomsforVIPpatients,withaseparateareafortheirentourageorsecurity.
TheChemotherapy Centreprovidesinfusionandoraltherapytreatingadultoncologypatientsinanoutpatientsettingandiscurrentlyequippedwithcapacityforupto44treatmentchairs.
TheViva-University Children’s Cancer Centreisaone-stopcentrehousingallpaediatriccancerpatients.Withateamofdedicatedandspecialisedpaediatriconcologynurses,thecentreiscommittedtomeetingthestandardofcarerequiredformanagingpatientsundergoingchemotherapyandbonemarrowtransplant.
University Orthopaedics, Hand and Reconstructive Microsurgery Cluster 03
TheStem Cell Therapy CentrecatersspecificallytopatientsdiagnosedwithbenignandmalignantbloodcancersandHaematopoeticStemCellTransplantneeds.
TheRadiation Therapy Centreisanoutpatientcentreprovidingradiationtherapytreatmentandspecialistconsultationforthemanagementandcareofbothadultandpaediatriccancers.ItcurrentlyhousesthreeLinearAcceleratormachinesandabrachytherapymachine,withadditionalcapacityforfutureexpansion.
TheBreast Care Centreisaone-stopcentreprovidingdedicateddiagnosisandtreatmentfordiseasesofthebreastwithservicessuchasbreastimaging,breastsurgery,aswellasbreastpreservationandbreastreconstruction.
National University Cancer Institute, Singapore (NCIS) 03
In Focus
04 médico JUL - SEP 2016
Home Care @ NCIS –The Care ContinuumEnsuring patients’ smooth transition from hospital stay to normal life at home is a key focus the National University Cancer Institute, Singapore (NCIS) has heavily invested in. As such, informal home care was established in 2001 by Professor John Wong (Director of NCIS then) and Mdm Zarinah Hairom, Assistant Director of Nursing, to provide home care for cancer patients. At that time, it was only provided for special cases due to limited resources. In January 2014, the first official home care team at the NCIS was set up with the aid of government funding. The first patient was served on 22 January 2014. This programme was then named NCIS Transitional Care, also known as Caring Across Cancer Care [CA3C] P2, highlighting the continuity of cancer care from the point of diagnosis till end of life. Today, the team consists of three full-time dedicated haematology-oncology trained nurses working closely with multi-disciplinary team members.
First Look
National University Cancer Institute, Singapore (NCIS) 05
visitsforcancerpatients.Servicesprovidedincludebloodtests,intravenoushydration,centrallinecare,antibioticlocksforcentrallines,postchemotherapycoping,medicationdelivery,woundcareandremovalofCADDpumppostchemotherapy.
TheservicesofferedundertheCA3CP2catertothedifferentneedsofourpatientsduringthevariousstagesoftheircancerjourney.
Services under the CA3C P2 programme
• post-cancertherapysymptommanagement• patient,familyandcaregivereducation• psychosocialandspiritualsupport• medicationreconciliationandadministration• referralstocommunityresources• centralvenouscathetercare• woundandstomacare• bloodsampling• homebasedtreatment
FeasibilityandsafetyoftheCA3CP2programmewereanalysedbasedon82patientswithdifferentcancers,specifically:lymphoma(31.7%),coloncancer(14.6%)andlungcancer(9.8%).Therewereatotalof341homevisitsconductedoveraperiodofeightmonthswithnoadverseeventsreported.
InDecember2014,thegovernmentinitiatedanewmodelofcare,theFrequentAdmitter(FA)programme,tofundhomevisitsforpatientswithatleastthreehospitalisationsforthepastoneyear,fromthedateofenrolmentintotheFAprogramme.TheaimoftheFAprogrammeistoreduceunplannedreadmissionstohospital.Withthisnewinitiative,weareabletoreachouttomorepatients,allowingthemtobenefitfromhomecareserviceswhilereducingtheirunplannedreadmissions.Todate,79patientshavebeingrecruitedintotheFAprogramme.Arecentanalysisfoundthat56.7%ofpatientsintheFAprogrammeexperiencedatleastoneadmissioninsevenmonthscomparedto78.4%inacontrolgroup.PatientsintheFAprogrammewereadmittedforshorterdurations(11daysversus23days),thusspendinglesseronhospitalisationcosts($5,023versus$11,186).Allthesewerestatisticallysignificant.
Astudywasalsoconductedtoassesspatientsandtheircaregivers’responsestothehomecareprogramme.Thestudyrevealedthatpatientsandtheircaregiversvaluedthehomecareservicebecauseofthefollowingbenefits:- Theyareabletoregaincontroloftheirdailyroutine- Theyfeelreassuredandmoreconfidentincaringforthemselves- Theyareabletocopebetterwiththephysiologicalandemotional
strainsassociatedwithcancer
InAugust2014,theNCISHomeCare–adedicatedhomecareprogrammeapplicabletoallcancerpatients–wasofficiallylaunched.ThisopenedupthehomecareservicetoawiderrangeofpatientswhopreviouslymaynothavequalifiedfortheCA3CP2andFAprogrammes.SimilartotheCA3CP2andFAprogrammes,thisprogrammecamewithafixedchargepayablebypatients.Todate,theNCIShomecareprogrammehasmade165home
First Look
Figure1:NCIShomecarenurseadministeringBortezomibtherapytoapatient.
Movingforward,theNCISHomeCareProgrammeaimstoprovidedisease-specifichomecare.OneoftheservicesincludesadministeringBortezomibinthecomfortofmyelomapatients’homes.Bortezomibisastandardtreatmentformyelomapatients,whichwasconventionallydoneatouroutpatienttreatmentcentre.Theprogrammehassofarbeenpositivelyreceivedwithover20patientsbeingenrolledandmorethan170homevisitshavebeenmade.
06 médico JUL - SEP 2016
Nurse ClinicianDivision of Oncology Nursing, NCIS
DrDoraLangcompletedhertertiaryeducationandspecialiseddiplomainoncologyatNanyangPolytechnicin2000and2003respectively.SheobtainedherbasicnursingdegreeinLaTrobeUniversityin2003.In2012,shereceivedherPhDwiththeDean’scommendationforDoctoralThesisExcellence.ShewasawardedtheYongSiewYoonFellowshipawardfrom2013-2016todevelophomecareservices.
DrDoraLang
Figure2:NCIShomecarenurseconductingahomevisit.
First Look
Supplementingthecurrenthomecareservicesisafreecounsellinghotline,CancerLine,whichismanagedbyourteamoftrainedoncologynurses.CancerLineisthefirstpointofcontactforpatientswhentheyneedhelpathome.Itprovidescounsellingandadviceforthepublicaswellaspatientswhoexperiencesideeffectspost-treatment.Ourhomecareteamalsoworkscloselywithourhaematologistsandoncologists,medicalsocialworkers,nursenavigators,nursecounsellorsandalliedhealthprofessionalstoprovideourpatientswithanindividualisedandholisticcareplan.
AsthehomecareprogrammeintheNCIScontinuestoevolveandexpand,weaimtoprovidemorebespoketreatmentprogrammestoourpatientswhilestayingaffordable.Webelievethatcaregoesbeyondourpatients’homes–thebirthplaceoflove,hopeanddreams–andwearegladtobeapartoftheirlives.
*ThisarticlewasfirstpublishedinSPARKbyNCIS,January2016issue.
National University Cancer Institute, Singapore (NCIS) 07
EarlyPhaseClinicalTrials–
The NCIS Developmental Therapeutics Unit
Insights
08 médico JUL - SEP 2016
dosage;2)thedrugsweretootoxicandshouldneverhavebeendevelopedinthefirstplace;3)thedrugsdidnotactuallyhaveanyproofofmechanismi.e.therewasnoevidencethatthedrugactuallyhititsintendedmoleculartargetincancercells;and4)drugswentontobedevelopedinlaterphaseIIandIIIstudiesdespitethelackofdemonstrableefficacywhenthemoleculartargetwas“hit”inearlyphase(phaseI)studiesi.e.therewasnoearlyproofofconcept.
Giventhehighcostsassociatedwiththeconductoflaterphasetrials,especiallyrandomisedphaseIIorIIItrials,itisnowincreasinglycommonpracticeformanycompaniestodiscontinuedevelopmentoftheircompoundsiftheycannotestablishproof-of-mechanismbytheendofphaseItesting.Therefore,inadditiontoassessingtoxicityandtolerability,manyphaseItrialshavenowassumedtheroleof“gate-keepers”indrugdevelopment,andarenowanevenmorecrucialfirst-stepinthebenchtobedsidetranslationaldrugdevelopmentprocess.Consequently,thereisagrowingconsensusamongstcancerexpertsandthepharmaceuticalindustrythatearlyphaseorphaseIclinicaltrialsarenowafundamentalcomponentintheprocessoftranslatingthepreclinicaldataontheanti-cancereffectsofadruginthelaboratoryintorealtimeclinicaluseforcancerpatients.Inthecurrenteraofprecisionmedicineincorporatingmolecular-targetedtherapy,“go-no-go”decisionsareoftenmadeearlieroninthedrugdevelopmentalprocessthanduring
HOW ARE CANCER DRUGS DEVELOPED FOR PATIENTS?Drugdevelopmentgenerallyinvolvesfourphases:PhaseI,II,IIIandIV.ThetraditionalscopeofphaseIclinicaltrialsaretoevaluatesafetyandtoxicityandtodefıneoptimaldosinginhumansforfutureeffıcacy(phaseII)trialsofnovelagentsorcombinationsofagentsafterappropriatepre-clinicaltestingofsafety,toxicologyandpharmacology.Duetothefactthatmanyofthesenovelcompoundsorcombinationsofcompoundsmaybetestedforthefirsttimeinhumans(i.e.first-in-humanstudies)withunknownclinicalefficacyandtoxicity,theseearlyphasetrialsusuallyenrolpatientswithadvanceddiseasewhohavelimitedorexhaustedstandardtreatmentoptions.Nonetheless,allcurrentlyavailablestandard-of-caretreatmentsforcancerhavealsoinitiallybeendevelopedthroughphaseIclinicalstudies.
Oncetheoptimaldoseofthedrugisestablished,thedevelopmentofthedrugmovesintophaseIIwhereuptoseveralhundredpeoplewiththedisease/conditionwillberecruitedtolookattheeffectivenessandfurtherassessthesideeffectsofthedrug.AfterphaseII,ifthedrughasshownsufficientefficacy,thedevelopmentofthecompoundmovestophaseIIIwherethedrugwillbetestedbycomparingitsefficacyagainstthecurrentstandardofcaredrug.PhaseIIIstudiescaninvolvehundredstothousandsofpatientsandmaytakeyearstocomplete.IfphaseIIIstudiessuccessfullydemonstrateanimprovementinefficacy/outcomeforthenewdrugwhencomparedagainstanolderdrug,thenthenewdrugwillbecomethenewstandardofcareandsubsequentlybeconsideredandapprovedforusebythedruglicensingauthoritiessuchastheFoodandDrugAdministration(FDA)intheUnitedStatesandEuropeanMedicinesAgency(EMA)inEurope.Oncelicensed,thedrugdevelopmentprocessmovesintophaseIVwherefurthersafetyandefficacyevaluationwillbecarriedoutaspatientsstartbeingtreatedwiththenewcompoundasanewstandardofcare.
WHy ARE EARLy PHASE TRIALS (PHASE I TRIALS) SO IMPORTANT?Agreaterunderstandingofthebiologicalnetworksandpathwaysimplicatedinthedevelopmentofcancerhasledtotheidentificationofmanypotentially“druggable”therapeutictargetsandacorrespondingincreaseinthenumberofcompoundssuitableforclinicalinvestigation.Disappointingly,despitetherapidexpansionofavailabledrugcandidatesforearlyphasetesting,failuresintranslatingthepromiseofthesecompoundstoclinicalrealityremainprevalent[1,2].In2004,dataaccumulatedfromawholehostofindustrysponsoredphaseItrialsbetween1991-2000showedthatonlylessthan5%ofcancerdrugstestedinphaseIendupobtainingmarketingauthorisation[1].Mostexpertsareoftheopinionthattheshortcomingsincancerdrugdevelopmentcomedowntoseveralfactors:1)atthepre-clinicalphase(i.e.laboratorydevelopment,pre-humantestingphase)manycompoundswerenotproperlyassessedwiththeappropriatepre-clinicaldiseasemodelsandhenceweresubsequentlyfoundtobeineffectiveevenattheoptimal
Insights
National University Cancer Institute, Singapore (NCIS) 09
thephaseIItoIIIinterface[3].Notablesuccessesinthedevelopmentofnovelanti-cancertherapeuticagentsemployingtheapproachofincreasedfocusonphaseIdrugdevelopmentincludethedrugceritinibinlungcancerwhichwaslicensedbasedonthestrengthofthescientificandclinicaldatagarneredfromawell-designedandexecutedphaseIstudy.
A STATE-OF-THE-ART FACILITy FOR EARLy PHASE TRIALS: THE NCIS DEVELOPMENTAL THERAPEUTICS UNIT (DTU)
SettingupaformalDTUwasavitalstepinviewoftheneedtomaintainourcurrenthighstandardsforrunningearlyphasetrialsattheNCIS,and,giventheanticipatedincreaseinresourcesrequiredtorunmultipleclinicalstudiesofthisnature,onethatwillalsoensureourabilitytoaccommodatefurtherexpansionofourearlyphasetrialportfolio.Thesetrialsarehighlyintensiveforbothpatientsandtheclinicalteamrunningthestudygiventherequirementsforfrequentvisitstothehospitalformonitoringandtestingbefore,duringandafterthestudy.Thesevisitsoftenincludeovernightstaysinthehospitalforrepeatedbloodteststoassessdrugmetabolism(pharmacokineticassessments)overa24-hourperiod,andpre-/post-treatmenttumourbiopsiesorbloodteststoassessthebiologicaleffectofthedrugonspecificmoleculartargetsinthesetissues(pharmacodynamicsstudies).Additionally,itisalsoimperativethatadequatefacilitiesandappropriatelytrainedstaffarealwaysavailabletoevaluateandmanageanyissuesencounteredbyearlyphasetrialpatientsinatimelymanner.
THE NCIS DTU: A MULTI-DISCIPLINARy TEAM AT THE CUTTING EDGE OF CANCER CARETheNCISDTUcomprisesateamofclinicians,nurses,alliedhealthprofessionalsandscientists,whoworkinamulti-disciplinaryteamtoensuretheutmoststandardsofsafetyinconductingearlyphasetrials.TheDTUteamcurrentlyrunsadedicatedcliniceveryMondayandThursdayandmeetweeklytodiscusstheclinicalprogressofeachDTUpatientonstudyandany
Figure1:TheNCISDevelopmentalTherapeuticsUnit(DTU).
Insights
Sinceitsinception,theNCIShasdevelopedasignificanttrackrecordandreputationforrunningearlyphasestudiesintheregion,duelargelytotheearlyeffortsofAssociateProfessorGohBoonCher,HeadandSeniorConsultantoftheDepartmentofHaematology-Oncology,NCIS.HispioneeringworkinearlyphasedrugdevelopmentinSingaporewasmadepossiblebythedevelopmentofanextensiveadministrativeinfrastructureprovidedbytheHaematology-OncologyResearchGroup(HORG).TheearlyphasedrugdevelopmentunithassincegrownfromstrengthtostrengthandhasfurtherbenefitedfromtheformalestablishmentofourDevelopmentalTherapeuticsUnit(DTU)in2014,incorporatingdedicatedstate-of-the-artinpatientandoutpatientfacilitiesforearlyphaseclinicaltrialsaidedbyfundingfromtheYongSiewYoon(YSY)NCISgrant.GiventhelackofAsianpatientsrecruitedtophaseItrialswhicharegenerallycarriedoutinwesterncountries,theNCISalsorecognisedtheneedtoestablishaphaseIunitthatwouldspecificallyaddressthequestionofidentifyingoptimaldrugdosesinAsianpatients.
10 médico JUL - SEP 2016
othertrialrelatedissues.ThroughtheYSYgrant,wehavealsobeenabletodevelopatrainingfellowshipprogrammeincancerdrugdevelopmentintheDTU.OurcurrentfellowisDrValerieHeongwhowasworkingasaconsultantmedicaloncologistinMelbourne,AustraliabeforedecidingtotakeuptheYSYfellowshipindrugdevelopmentattheNCISlastyear.Importantly,theestablishmentoftheNCISDTUhasalreadyhelpedattractinterestfromdrugcompaniesseekingacademicpartnerswhohavetheappropriateinfrastructureinplacetosupportearlyphasetrialsinAsia.Thishasinturnbenefitedourpatientsbygivingthemaccesstocutting-edgeanti-cancerdrugs.CurrentlyavailableclinicaltrialsofnovelcompoundsintheDTUareshownintheTable1.
• P-TEFbinhibitor(Bayer)• Trastuzumab+NK-celltherapyforHER2amplified/
overexpressedtumours• BalancedPI3Kα/βinhibitor(Bayer)• Exportin1(XPO1)inhibitor–selectiveinhibitorofnuclearexport
(Selinexor,Karyopharm)• PDL-1+MEKinhibitor(Roche)• Pan-fibroblastgrowthfactorreceptor(FGFR)inhibitor(Bayer)• AKT1inhibitor(AstraZeneca)intumourswithAKT1mutations• ASLAN001:HER1/2/4inhibitor+carboplatinandpaclitaxel• PLK1inhibitor(Tekmira)• Wnt/Porcinhibitor(ExperimentalTherapeuticsCentre/D3
A*STARSingapore)
Table1:DTUPhaseItrials2015.
Figure2:MembersoftheHaematology-OncologyResearchGroup(HORG).
Insights
National University Cancer Institute, Singapore (NCIS) 11
Allourmedicaloncologistsontheteamarealsoleadingexpertsinspecifictumourtypes(seeTable2)andhenceprovideaddedclinicalandscientificinsightintothemanagementofeachpatientreferredtotheDTU.
Consultant Tumour subspecialty
GohBoonCher HeadandNeckCancers
ChngWeeJoo HaematologicalCancers
LeeSooChin BreastCancerandCancerGenetics
YongWeiPeng GastrointestinalCancers
CheeChengEan GastrointestinalCancers
AndreaWong BreastandCentralNervousSystemCancers
DavidTan GynaecologicalCancers
Table2:ListofDTUConsultantMedicalOncologists.
Giventhatmanyofthecurrentlytestedcompoundstargetaspecificmolecularpathwayaberrationincancercells,patientsinourDTUearlyphasetrialsarealsoofferedmolecularprofilingoftheirtumoursviaourintegratedmolecularanalysisofcancer(IMAC)programmetoidentifythese“actionable”molecularaberrationsinthetumourcellssothat,basedontheirtumourmolecularprofile,patientscanbematchedtothemostappropriatedruginearlyphaseclinicaltrials.OurmolecularprofilingprogrammeinDTUiscurrentlyledbyDrDavidTanandisfundedbyaNationalResearchCouncilofSingapore(NMRC)TransitionAwardandtheNCIScentregrant.Throughthisprogramme,wehavesuccessfullymatchedpatientswithactionablemutationsintheirrefractorycancercompoundswithdurableresponsesalreadynoted.
FINDING AND DEVELOPING THE NExT GENERATION OF ANTI-CANCER DRUGSThenexteraofoncologicaltherapywillinevitablyevolvefromabetterunderstandingofthemolecularaberrationsincancersalliedwithtechnologiesthatwillfacilitatearapidandcomprehensivecharacterisationoftheuniquebiologicalfeaturesofeachcancerpatient’stumour.Thechallengeforoncologistsistoleverageonthiswealthofscientificinformationtodevelopmoreeffectivetherapeuticoptionsforpatientsviawell-designedandexpertlyexecutedearlyphasestudies.TheNCISDTUisnowfullyequippedtoembracethischallengeandleadthedevelopmentofnewdrugsinthefightagainstcancer.
References:1. KolaI,LandisJ.Canthepharmaceuticalindustryreduceattritionrates?NatRevDrug
Discov2004;3:711-715.2. KurzrockR,BenjaminRS.Risksandbenefitsofphase1oncologytrials,revisited.NEnglJ
Med2005;352:930-932.3. LoongHH,SiuLL.SelectingthebestdrugsforphaseIclinicaldevelopmentandbeyond.Am
SocClinOncolEducBook2013;469-473.
ConsultantDepartment of Haematology-Oncology, NCIS
DrDavidTanisaconsultantmedicaloncologistandclinicianscientistattheNCIS.HeisalsoanAssistantProfessorattheYongLooLinSchoolofMedicine,NUS.DrTangraduatedwithanintercalatedBScinExperimentalPathologyandMBBSwithDistinctionfromGuy’s,King’sandStThomas’SchoolofMedicine,UniversityofLondon.HeundertooktrainingininternalmedicineatHammersmith,Guy’sandStThomas’HospitalsinLondon,andobtainedhisMRCP(UK)in2005.HewasaCancerResearchUKClinicalResearchFellowattheInstituteofCancerResearch,London,whereheobtainedhisPhD,andtrainedinMedicalOncologyattheRoyalMarsdenHospital,London.HealsocompletedafellowshipinDrugDevelopmentandGynaecologicOncologyatthePrincessMargaretCancerCentre,UniversityofTorontobeforereturningtoSingapore.
DrDavidTan
Insights
Limb Salvage in Musculoskeletal Oncology
12 médico JUL - SEP 2016
Musculosketaloncology(MSO)isasub-specialtyofsurgicaloncologythatfocusesonthediagnosisandmulti-disciplinaryapproachtotreatmentofpatientswithbenignandmalignanttumoursofboneandsofttissues.
Thelastfewdecadeshaveseenrapidstridesintheevolutionofmusculoskeletaloncology.Whatwasonceoriginallyaspecialtythatinvolvedasingularorthopaedicsurgeonisnowaspecialtythatrequiresamulti-disciplinaryapproachcombiningtheexpertiseoforthopaedicsurgeons,plasticandhandsurgeons,paediatricandadultgeneralsurgeons,radiologists,radiationoncologists,paediatricandadultmedicaloncologists,andmusculoskeletalpathologists.
Red flags
History Physical Examination
Rapidlygrowinglesion Generalphysicalexamination
Nightpain Sizeofthelesion–morethan5cm
Presenceofconstitutionalsymptoms
Depthofthelesion–lesionsdeepertothesubcutaneouslayer
Personalorfamilyhistoryofcancer Enlargedlocoregionallymphnodes
Pasthistoryofchemo/radiotherapy Signsofmetastases
Inthepast,treatmentaimsinmusculoskeletaloncologywerecentredonsurvival(overallandeventfreesurvival)asthemainmeasurableoutcome.Theadventofbetterimagingmodalities,moreeffectivechemotherapy,improvedradiotherapytechniques,abetterunderstandingoftheanatomywithcontinuousrefinementinsurgicaltechniquesandadvancesinprosthesisdesign,biologicaltechniquesandmaterialshaveallowedforthefocusoftreatmenttoencompasslimbpreservation,jointpreservationandgrowthplatepreservationinpaediatricpatientswhereapplicable[1].Assuch,functionandqualityoflifeinthesepatientshavebecomeasignificantgoaloftreatmentinadditiontooverallandeventfreesurvival.
Limbsalvagesurgery,alsoknownaslimb-sparingsurgery,isahighlycomplexoperationdonetoremoveaboneorsofttissuetumourandavoidsamputationforpatientswithmalignanttumoursaffectingthelimbs.Thesearehighlyspecialisedprocedurescarriedoutintertiarycentreswithsub-specialtyexpertsinthefield.
Withtheevolutionofmusculoskeletaloncologyasasub-specialty,amputationrateshaveundoubtedlygonedowninmosttertiarycentrestreatingtheseconditions.We,asasurgicalfraternity,arecontinuouslypushingtheboundariesoflimbsalvagesurgeryaswecontinuetoevolve.Certain‘absolutecontraindications’tolimbsalvagesurgeryarenolongerrelevant.Forexample,pathologicalfracturesinpatientswithosteosarcomawereregarded
Insights
National University Cancer Institute, Singapore (NCIS) 13
asacontraindicationtolimbsalvagesurgeryandamputationwasfrequentlyperformedinthesepatients.Variousstudieshavesinceshownthattherearenodifferencesinoutcomesoflimbsalvagesurgeryandamputation,providedthatthesurgeryiscarriedoutintertiarycentreswithsub-specialtyexpertsperformingthesurgeries,andmargincontrolattemptsareaggressive[2,3,4].
Thetwocasestudiesbelowillustratelimbsalvagesurgeryintwodifferentpatients.Bothpatientsareinthepaediatricagegroupwithosteosarcomaastheprimarydiagnosis.Thereconstructionthathasbeenperformedinthefirstcaseisbiologicalwiththeuseofanallograftandthekneejointwaspreserved.Inthesecondcase,duetotheextentoftumour,thekneejointcouldnotbepreservedandaspeciallydesignedtumourendoprosthesiswasused.
Case Study 1MrAKKisan11yearoldboywhopresentsforincreasingrightthighpainandswellingfortwoweeks.Therewasnohistoryofrecenttraumatohisleg.Noconstitutionalsymptomsorsimilarlumpselsewherewerereported.X-rays(Figure1)thatweredonerevealedapoorlydefinedlyticlesionoverthelateralaspectofthedistalmeta-diaphysealregionoftheleftfemur.Ithadalargezoneoftransitionandassociatedperiostealreaction.
TheMRIscan(Figure2)showeda7.8x4.9x4.6cmaggressiveenhancinglesioninthemeta-diaphysealregionoftherightdistalfemur.Thelesionextendeduptohisphysealplatebutnotintoorbeyondtheepiphysealplate.Thelesionwaswithin2mmmarginsofthepoplitealarteryandvein,buttherewasnoinvolvementoftheneurovascularbundle.
Acomputertopography(CT)scanofthethoraxrevealednoevidenceofpulmonarymetastases.Thiscompletedourpreliminaryinvestigations.Anopenbiopsyconfirmedthatthiswasahighgradeosteosarcoma.Hiscasewasdiscussedattheweeklymulti-disciplinarytumourboardwheretheconsensuswasforkneejointsparingsurgeryfollowingneoadjuvantchemotherapy.MrAKKsubsequentlyunderwentthreemonthsofneoadjuvantchemotherapyfollowingwhichrestagingimagingwasdone.TheMRI(Figure4)ofhisthighrevealedsomeevidenceoftumourresponsetotheneoadjuvantchemotherapy(2.9x0.9vs3.8x2cm).
Figure1:APweightbearingkneeX-ray.
Figure3:Wholebodybonescan.
Figure2(a-c):MRI,Thigh,Right.
Figure4(a-c):RestagingMRI,Thigh,Right.
Awholebodybonescan(Figure3)revealednoscintigraphicevidenceofbonylesionselsewhere.
Insights
14 médico JUL - SEP 2016
Thiscorrelatedwiththefindingonthebonescanwherethepreviouslyseenbonylesioninthedistalrightfemurappearedlessintense.Similartothepreviousbonescan,noskiplesionwasseenelsewhere.
Figure5:Restagingwholebodybonescan.
Figure6(a–c):Rigoroustemplatingcarriedout.
Figure7:Intra-operativephotographoftheboneallograftafterthethawingprotocolandimmersioninantibioticsoakedsolution.
Figure8:Excisionofrightdistalfemursarcoma.
Figure9:internalfixationoftemplatedallograft.
TheCTthoraxagainshowednoevidenceofanypulmonarymetastases.Highlyprecisepreoperativeplanningandcomputerguidedtemplating(Figure6)wasnecessarytoobtainanaccuratelymatchedstructuralboneallograft.
Asuitablematchwasfoundfroma25yearolddonorfromtheUSA.Multipleteleconferencingcallswerenecessarytoensurethatthedimensionsandtheanatomicalconfigurationoftheallograftwereappropriateforthepatient.Theallograftwasflownoverwhilemaintainingacoldchainoftransportpriortothesurgery.
Therightdistalfemurresectionandjointsparingallograftbiologicalfixationwentasplanned.Excision(Figure8)wasperformed4cmproximaltotumourmargins(confirmedbyintraoperativefrozensection)andimmediatelydistaltothephysis(growthplate)underintraoperativeimagingguidance.
Internalfixation(Figure9)oftemplatedallograftwasthencarefullycarriedoutusingadoubleplatetechnique.
Insights
National University Cancer Institute, Singapore (NCIS) 15
Figure10:APweightbearingkneeX-ray.
Figure11(a-c):MRI,Thigh,Right.
Figure12(a-b):MRI,Knee,Right.
Figure13(a-c):RestagingMRI,Thigh,Right.
Postoperatively,histopathologicalmarginsoftheresectedspecimenwereconfirmedtobenegative.MrAKKrecoveredwellandiscompletingadjuvantchemotherapy.Heisnowtwomonthspost-surgery.Thedistalinterfaceofthehostboneallografthasshowngoodhealing.Heiscurrentlywalkingwithcrutchsupportandwillbeplannedforfullweightbearingambulationinonemonth’stime.Case Study 2MrZBDisa19yearoldmalewhoisaNationalServicemanwhopresentedforincreasingrightkneepainforonemonthaccompaniedbynightpain.X-rays(Figure10)thatweredonerevealedaperiostealreactionatthelateralcortexofthediaphysealregionoftherightdistalfemur.
ThebonescanandCTthoraxshowednoevidenceofdistantmetastasesorskippedlesions.Thiscompletedourpreliminaryinvestigations.Afrozensectionopenbiopsyoftherightdistalfemurconfirmedhighgradeconventionalosteosarcoma.Aftercompletinghisneoadjuvantchemotherapy,his
MRIscansoftherightthigh(Figure11)andknee(Figure12)showedadestructivelesioninthelateralaspectofthedistalmetaphysisoftherightfemur.Nofractureorskiplesionwasdetected.Therewasnoneurovascularinvolvementnoted.However,inthiscasethetumourwasextremelyclosetothekneejoint.
re-stagingimagingwasdone.TheMRIofhisrightthigh(Figure13)revealedasmallerextraosseoussofttissuecomponentandextentwhichsuggestedfavourabletreatmentresponsetotheneoadjuvantchemotherapy.
Thiswasconfirmedbythebonescan(Figure14)onwhichtherightdistalfemorallesionwasnotedtobelessintensethanthepreviousscan.
Figure14:Old(top)versusnew(bottom)bonescan.
Insights
Afterdiscussionatthetumourboard,thedecisionwasmadetoproceedwithdistalfemurresectionandjointreplacementusingatumourendoprosthesis,asthetumourwasadjacenttothejointandjoint-sparingsurgerywouldnotbepossible.TheoperationwasdoneinearlyJulyandwentasplanned.Intra-operatively,theneurovascularbundlewasfoundtetheredtothefemurbutwasnotencasedbytumour.Intra-operativefrozensectionconfirmedthatallresectionmarginswereclear.
16 médico JUL - SEP 2016
Figure15:Post-operativeclinicalphoto.
Figure16(a-b):Post-operativekneeX-ray.
Figure17(a-b):Post-operativefemurX-ray.
Figure18(a):LateralKneeX-rayinclinicearlierthisweek.
Figure18(b):Bonegrowingoverhydroxyapatitecoatingofthetumourendoprosthesis.
Post-operativeimaging(Figures16&17)showedastabletumourendoprosthesisthatwasappropriatelyalignedandhadnofurthercomplications.
Post-operatively,histopathologicalmarginsoftheresectedspecimenwereconfirmedtobenegative.Therewerenosignsofinfectionorneurovascularcompromise.MrZBD’sprogresswasmonitoredandhewasdischargedwithnofurthercomplications.MrZBDisnowninemonthspost-surgery.Hisx-raysdoneinclinicatninemonthspostsurgery
Insights
showedbonegrowingoverthehydroxyapatitecoatingofthetumourendoprosthesissuggestinggoodintegration.Aftergoingthroughphysiotherapy,MrZBDisnowambulatingindependentlyandisbacktoridingamotorcycle.
National University Cancer Institute, Singapore (NCIS) 17
ConsultantDivision of Surgical Oncology (Musculoskeletal Surgery), NCIS Division of Musculoskeletal Oncology, Department of Orthopaedic Surgery, University Orthopaedics, Hand and Reconstructive Microsurgery Cluster, NUH
DrGurpalSinghisafellowship-trainedOrthopaedicsurgeonspecialisinginmusculoskeletaloncologyandtotaljointreplacementintheNationalUniversityHospital.DrSingh’sclinicalpracticeconsistsofmusculoskeletaltumours(benign,malignantandmetastaticbonedisease)withafocusonendoprostheticreconstructionandlimbsalvagesurgery,aswellasprimaryandrevisionjointreplacement.Hisacademicinterestsincludeosteolysis,periprosthetictissueresponsestoweardebrisfromfailedjointreplacements,infectionsandbiomaterialsinjointreplacement.DrSinghcollaboratesinternationallywithateamofmusculoskeletaloncologists,arthroplastysurgeonsandmaterialscientistsfromGermanyinanefforttocontinuouslyimprovebiomaterialsandincreasethelifespanofartificialjointprostheses,reduceinfectionratesandminimiseadversetissueresponsesfromthepatient’sbody.
DrGurpalSingh
*ThisarticlewasalsopublishedinSPARKbyNCIS,July2016issue.
[1] MasonGE,AungL,GallS,MeyersPA,ButlerR,KrügS,etal.Qualityoflifefollowingamputationorlimbpreservationinpatientswithlowerextremitybonesarcoma.FrontOncol.2013;3:210.
[2] PapagelopoulosPJ,MavrogenisAF,SavvidouOD,BenetosIS,GalanisECandSoucacosPN:Pathologicalfracturesinprimarybonesarcomas.Injury39:395-403,2008.
[3] EbeidW,AminSandAbdelmegidA:Limbsalvagemanagementofpathologicfracturesofprimarymalignantbonetumours.CancerControl12:57-61,2005.
[4] ScullySP,GhertMA,ZurakowskiD,ThompsonRCandGebhardtMC:Pathologicfractureinosteosarcoma:prognosticimportanceandtreatmentimplications.JBoneJointSurgAm84-A:49-57,2002
Insights
FINAL THOUGHTS
Thesearehighlycomplexsurgeriesandcomplicationsdooccur,particularlyinthecontextofongoingchemotherapyandimmunosuppressionofthesepatients.However,theprocessofsuccessfullytreatingmultiplepatientssuchasMrAKKandMrZBDisanextremelyrewardingone.Thespecialtyofmusculoskeletaloncologyhasseenvastamountsofrapidchangeinthelastdecadeandwearefortunatetobeabletobringthislevelofcaretoourpatients.Wehopetobeabletohelpmanymorepatientsbothlocallyandinternationally.
18 médico JUL - SEP 2016
Tips
A structured approach should be adopted when taking a family history of cancer. Include information of at least three generations on both the paternal and maternal side of the family; do not neglect the paternal family history when assessing for familial breast or ovarian cancers.
Young onset cancer (less than 40 years old for most solid tumours) or multiple primary cancers in a single individual should raise suspicion of a possible hereditary predisposition, even in the absence of family history.
Genetic testing can confirm the diagnosis of various hereditary cancer syndromes.
Advocate regular cancer screening to patients, especially for those who fall within the recommended age groups. Breast and Colorectal cancers are two of the top cancers in Singapore and both have established methods of screening.
Screening and preventive guidelines exist for many cancers and can result in early detection and reduction of cancer risk and mortality in high-risk individuals. It is important to close the loop with patients who have positive screening results. To make a patient referral, call 6773 7888 or email [email protected].
TIPSTIPS
National University Cancer Institute, Singapore (NCIS) 19
Treatment Room
Treating Our 100th Patient And Beyond
Stereotactic Ablative Radiotherapy (SABR) Programme –
20 médico JUL - SEP 2016
BRIGHT NEW HOPE FOR CANCER PATIENTS
On15thSeptember2015,theNCISRadiationTherapyCentretreatedits100thSABRpatient.FromsendingateamtoundergotrainingattworenownedSABRcentresintheUnitedStatesin2011andtreatingourfirstSABRpatientinthesameyear,totreatingour100thSABRpatient,ithasindeedbeenalongjourneyinattainingthissignificantmilestone.
Stereotacticablativeradiotherapy(SABR),previouslyknownasstereotacticbodyradiationtherapy(SBRT),isanewly-developedcancertreatmenttechnology.Utilisingspecialisedandhighlyadvancedequipment,softwareandprocedures,atumour’slocationispreciselydefined,anditssizeandshapedexactlymapped.Duringthetreatmentitself,thepatientispreciselypositioned,immobilised,andadministeredhigh-precision,high-dosageexternalradiationtherapy.Thetechnologyallowsintenselyfocusedandhighlyprecisetreatmentofthetargetarea,withminimaleffectonsurrounding,healthytissue.
SABRdiffersfromconventionalradiotherapyprimarilyintheprecisionofradiationdelivery.Multiple,convergingbeamanglesareusedtosafelydeliverhigh-potencydosages.Thisreducestreatmenttime,minimisesdelayordisruptionofsystemictherapy,andresultsingreaterconvenienceforthepatient.
CurrentlyattheNCIS,SABRisusedinthetreatmentoftumoursinthelungsandliver.
ADVANTAGES OF SABR
1. Treatmentoutcomesforeligibleandproperlyselectedpatientsarecomparabletosurgery,andcertainlysurpassconventionalexternalbeamradiationtherapytechniques.
2. Treatmentdurationisreducedtojustonetofivesessions,eachlastingabout30minutes.Totaltreatmentdurationinclusiveofpreparationisabouttwoweeks–upto80%reductioncomparedtoconventionalfractionation.
3. Sideeffectsmayberelatively
mildorabsent,dependingontumourlocation.Patientsexperiencelesslethargy,esophagitis,andriskofpneumonitis.
4. TheoverallcostofSABRis
slightlyhigherthanconventionaltreatment.However,forSingaporeans,asignificantproportionofthecostcanbesubsidisedbyMedisaveandMedishieldLife.
WHAT PATIENTS CAN ExPECT1. Evaluation and patient
selection Thepatient’shistorywillbe
reviewed,andhisorhercasewillbeevaluatedforSABRsuitability.Thefollowingfactorswillbeconsideredduringevaluation:
Patient factors* Physicalcondition,including
ECOGstatus,abilitytoliestillandtocomplywithinstructions
* Lungfunction(iftreating thelung)* Liverfunction(iftreating theliver)
Disease factors* Sizeandlocationoftumour* Extentandcontrolof systemicdisease* Diseaseprogression* Previouspatienthistoryof
radiotherapy
Figure1:PatientundergoingSABRtreatment.
Treatment Room
National University Cancer Institute, Singapore (NCIS) 21
Figure2:Optimisedtreatmentplanwithhighdosetothetumourandminimaldosetosurroundingtissues.
2. Patient Consent Thefullprocedure,includingpossiblerisks,discomfortsandalternative
treatmentoptions,willbeexplainedtothepatient.Afterthepatienthasfullyunderstoodtheprocedure,writtenconsenttoproceedwillbeobtained.
3. Four-dimensional Computed Tomography (4D CT) simulation A4DComputedTomography(CT)simulationwillbecarriedout.Once
completed,small,permanentmarkswillbemadeonthepatient’sbody.Thesewillhelpinaccuratelypositioningthepatientatthetimeoftreatment.
4. Planning Thepatient’s4DCTimagesareimportedtotheplanningsoftware,and
thetumourplanningtargetvolume(PTV)andnormal-tissueorgansarecontoured.Atreatmentplanisproduced,aimedatdeliveringthemaximumprescribedradiationdosetothePTV,withrapiddosefall-offtothesurroundingnormaltissues.
aredeliveredtothepatienteachSABRsession,additionalmeasuresareemployedtoensurepatientsafety.
6. Treatment Thepatientistakentothe
treatmentroom,andpositionedpreciselyasdeterminedduringthepreparatoryCTsimulationstep.Theimmobilisationdeviceandbodyreferencemarkingsareusedtoensureaccuratepositioningisachieved.
Oncethepatienthasbeenpositioned,butbeforetheactualtreatmentisadministered,a4DConeBeamComputedTomography(CBCT)scanisdone,forfinalconfirmationofthetumour’spositionanddimensions.
Duringthetreatmentitself,aSABRradiationoncologistwillbeatthetreatmentconsole,utilisingallavailableon-boardimagingtechnologiestodeliverthetreatmentincloseaccordancewiththeoriginaltreatmentplan.Heorshewillalsotakeintoaccountallpotentialpatient-specific,tumour-specific,andorgan-specificmotionduringtreatment,inrealtime.
Theentiretreatmenttakesabout30minutes.Thepatientisawakethroughouttheprocedure,andcanexpecttocompletethetreatmentwithoutpain.SABRpatientscanresumenormalactivitywithinaday.
5. Quality Assurance Aseriesofproceduresisnowconductedtoensurethequality,accuracy
andsafetyofproceduralplanning.ThisstepisessentialinthedeliveryofSABRasitensuresthequalityoftheapprovedplanandthesafetyofthedeliveryoftheintendedradiationdose.Themedicalphysicistperformspatient-specificqualityassurancebeforeeachpatientundergoeshisorherfirstSABRsession.Asveryhighdosesofradiation
Treatment Room
22 médico JUL - SEP 2016
7. Follow-up Oncetreatmentiscomplete,thepatientwillbescheduledforroutine
follow-upconsultations.Follow-upscansandinvestigationswillalsobearranged,toevaluateresultsandresponsetotreatment,aswellasanypossiblesideeffects.
8. Side Effects ThesideeffectsofSABRareminimalasthetreatmentisveryprecise
andaccurate.
Figure3:SerialCTscansshowinggradualresolutionofthetumourafterSABR.
Clinical Director & Senior ConsultantDepartment of Radiation Oncology, NCIS
AsstProfLeong’sinterestsareinstereotacticablativeradiotherapy(SABR),thoracicandgastrointestinalmalignancy.HereceivedhisSABRtrainingintheUnitedStatesofAmericaundertheMinistryofHealthHumanManpowerDevelopmentProgram(HMDP)in2011.Uponhisreturn,hesetuptheSABRprogrammeattheNCIS.HealsoorganisesSABRsymposiumsandworkshopstoeducateregionalradiationoncologistsonSABR.
AsstProfLeongChengNang
Treatment Room
*ThisarticlewasfirstpublishedinSPARKbyNCIS,January2016issue.
OUTCOMES
MrTan,our100thSABRpatient,wasa75yearoldchronicsmokerwhowasrecentlydiagnosedwithearlylungcancer.Hehadmultiplemedicalcomorbiditiesandlimitedlungfunctionduetohischronicsmokingandwasnotkeentoundergosurgery.BeforetheavailabilityoftheSABRprogramme,hewouldhavebeenofferedconventionalradiationtherapytreatmentwhichwouldhaveresultedininferiorlocalcontrolratescomparedtosurgery.Now,hehasathreeyearlocalcontrolrateof85-90%basedonlocalNCISSABRdata,whichiscomparabletosurgery.Significantly,thisoutcomeisachievedwithoutanyinvasiveproceduresandasolelyoutpatienttreatmentmodality.
Our101stpatientisMrGoh,apatientwithhepatocellularcarcinoma.Hewasheavilytreatedwithsurgery,TACE(transarterialchemoembolisation)andRFA(radiofrequencyablation)previously.Hewasreferredtousfortreatmentfornewhepatomas.Despitehavinglimitedliverreservesfromprevioushepatectomyandlocaltreatment,wewereabletotreathis
newhepatomaswithSABR.WeexpectMrGohtohavea90%oneyearlocalcontrolratebasedonNCISdataof20patientstreatedwithSABRtotheirliverlesions.LiverSABRisanewfrontierwithpromisingresultswhichyetmayofferanothereffectivemodalitytopatientswithhepatocellularcarcinomaormetastaticpatientswitholigometastasestotheliver.
Movingforward,inadditiontolungSABR,therewillbemorefocusonusingSABRtotreatothersiteslikeliverandspine.Wealsohopetoimprovetheaveragetimetakenfrompatient’sconsentoftreatmenttocompletionofSABRtreatment.
A Holistic Approach to Conquer Myeloma
National University Cancer Institute, Singapore (NCIS) 23
Landscape
A Holistic Approach to Conquer Myeloma
24 médico JUL - SEP 2016
Theoutlookofmyelomapatientshaschangedtremendouslyinthelastdecade.Overthelastdecade,anumberofnewdrugshavebeenapprovedfortreatmentofmyeloma.Thesenewtreatmentsarenotchemotherapyandhavebetterside-effectprofiles.Asaresult,patientswithmyelomaaremostlytreatedintheoutpatientsettingandhavesignificantlybetterqualityoflifeevenwhileontreatmentascomparedtointhepast.Thesedrugsarealsomuchmoreeffectivecomparedtochemotherapywithalmost100%ofnewlydiagnosedpatientsachievingaresponseandcloseto50%achievingcompleteresponse.Asaresult,theaveragesurvivalofpatientshasdoubledfromthreetofouryearspreviously,comparedtoseventoeightyears,today.
Despitegreatimprovementintreatment,somegapsstillremain.Withtheincreaseintreatmentoptions,themanagementofmyelomahasalsobecomeverycomplexandconfusingforthepatientsandphysicians.Thediseaseisstillincurablewithresistancebeingaproblem–hence,continueddevelopmentofpotentialnewtherapeuticsiscritical.
AttheNationalUniversityCancerInstitute,Singapore(NCIS),wetaketheapproachthattofurtherimproveontheoutcomeofpatientswithMM,weneedtotakeaholisticapproach,throughoptimisingcurrenttreatment,usingresourcesrationallyandprovidingvaluetopatients,increaseaccesstonewdrugsaspatientsrelapse,researchtofindnewtreatments,andpatientsupportandeducationtohelppatientsthroughtheirjourneywithmyeloma.
Optimising Clinical CareWeleadthedevelopmentofaconsensusguidelineforthetreatmentofmyelomainSingapore.Thiswillfacilitatestandardisedpracticeandalsoensurethatexpensivedrugsareusedrationallyinpatientsthatwillderivethemostbenefitfromit.
Tofurtherimprovequalityoflifeandtreatmentforpatients,wedevelopedtwonewprogrammesthatremaintheonlyoneofitskindinSingapore.Firstwestartedperformingoutpatient-basedstemcelltransplantformyelomapatientsin2012.PatientsreceivethechemotherapyandstemcellinfusionintheCancerCentreandarelookedafterathomebytheirfamily.Bydoingthis,thecostoftheprocedureisreducedby30%andthe
lengthofhospitalstayisreducedbymorethan50%.OneofthemostcommontreatmentsformyelomaisBortezomib,whichisgivenasasubcutaneousinjectiononceaweek.WeintroducedaprogrammewherewegavepatientstheirBortezomibtreatmentinthecomfortoftheirownhomestosavethemtravellingtime,waitingtime,andreducetheriskofinfections,atnoadditionalcosttothepatient.
Tofurtheroptimiseoutcomes,weprovideearlyaccesstodrugsforourpatientswithacarefullyselectedportfolioofclinicaltrialstocoverthemainindicationsinmyeloma.Intheprocess,ourpatientshavehadtheopportunitytobetreatedwithdrugsthathavebeenapprovedbytheFoodandDrugAdministration(FDA)intheUnitedStatesbutarenotavailableinSingaporecommercially.Overthelastfiveyears,theNCIShasbecomeoneofthemostwell-knownsitesfortheconductingofclinicaltrialsinmyelomaintheworld,culminatingthisyearasoneofthetoprecruitingcentresinatrialthatledtotheapprovalofanewdrugcalledCarfilzomib.
ResearchPatientswithhigh-riskdiseaseshaveasurvivaltimeoflessthan
Multiple myeloma (MM) is a type of bone marrow cancer characterised by the abnormal expansion of malignant plasma cells in the bone marrow. It is the second most common type of blood cancer and afflicts more than 100 patients in Singapore a year. It has rising incidence in Asia, the reason for which is still elusive. Patients tend to be above 55 years of age, and can present in very non-specific manners with fatigue, and bone aches. As these symptoms are rather common in the elderly population, a high index of suspicion is needed for early diagnosis of the condition. Myeloma eventually causes anaemia, lytic bone lesions, which may cause bone pain or pathological fractures, renal impairment and hypercalcaemia. The presence of these features without a clear aetiology should prompt a screen for myeloma to exclude the diagnosis.
Landscape
National University Cancer Institute, Singapore (NCIS) 25
twoyearsevenwiththecurrentbesttreatment.Therefore,thereisaneedtounderstandthenatureofthesehigh-riskdiseasesandtodeveloptherapeuticseffectiveagainstthesetumours.Anothertherapeuticproblemisdrugresistanceandrelapse.Wehavemadeheadwaysoverthelastfewyearsandsomeofourdiscoverieshavethepotentialtobetestedinpatients.
Patient Education and SupportMyelomapatientsoftenfeelisolatedandconfusedbythedifferenttreatmentsavailabletothem.Theyarealsoworriedbecausetheyknowthattheyhaveadiseasethatisnotyetcurableandtreatmentisexpensive.Itiscriticalthattheyhaveaccesstoasupportsystemofpeersastheygothroughtheirtreatmentjourney.Alsoimportantistheavailabilityofrelevantinformationaswellasaccesstoexpertopinion.Inthisregard,wehaveimplementedafewinitiatives.
1) Puttinginplaceanavigatorwhoactsasapointofcontactandhelpstocoordinatetheneedsofourmyelomapatientsandreducecomplexityandconfusiontothem.
2) Establishingapatientsupportgroupcomprisingofpatientsandcaregivers.Thegroupmeetsregularlytosharetheirexperiencesandlearnfromdifferentexperts.Onceayear,wewillhavealargerforum.Thisallowsthepatientstofeelthattheyarepartofalargercommunityandnotisolated.Thepatientshavebeenveryappreciativeandcontributedbacktothemyelomaresearchbyraisingabouthalfamillioninresearchfundstoaidmyelomaresearch.
3) Inaddition,toensurethataccesstoexpertandlatestinformationisavailableandup-to-date,wehavesetupawebsitewheretheseinformationwillbedisseminatedandpatientscanblogabouttheirexperienceandaskthedoctorsabouttheirsymptoms.Thisinteractiveapproachisaimedatreducinganxietyandequippingthepatientswithenoughknowledgetotakechargeoftheirillness.
Director, NCISSenior Consultant, Department of Haematology-Oncology, NCIS
ProfChngWeeJooobtainedhismedicaldegreefromtheUniversityofLeeds,UK,anddidhisinternalmedicineresidencyintheUnitedKingdom.HecompletedhisfellowshiptraininginhaematologyinSingaporebeforeobtaininganA*STARinternationalfellowshipin2004,inwhichhedidaresearchfellowshipinmultiplemyelomageneticsattheMayoClinic.Hiscurrentresearchisverytranslationalandinvolvestheuseofhigh-resolutionglobalgenomictechniquestounderstandbiology,identifydrugtargets,understanddrugresistanceandimprovediseaseprognosisinhaematologicalmalignancies,withtheultimateaimofimprovingpatientoutcomesandpersonalisingtreatment.Hisspecialtyinterestsincludelymphomaandmultiplemyeloma.
ProfessorChngWeeJoo
CONCLUSION
AttheNCIS,wehavetakenacomprehensiveandholisticapproachtomanagingpatientswithmyelomawiththepatientatthecentre,andclinical,researchandeducationalinitiativesfocusedonthem.WehopethatthisapproachtowardsTotalMyelomaCarewillprovidetheframeworktowardsasustainablestrategyforcontinualimprovementintheoutcomesofourmyelomapatients.
Landscape
26 médico JUL - SEP 2016
In Addition
NCIS Health Resource Centre & Patient Support Groups
Health Resource Centre (HRC)TheHRCispartofourholisticapproachinourtreatmentforcancerpatientsandtheircaregivers.Weprovideanavenueforthemtolearnmoreabouttheirconditionsandtoattendvarioussupportprogrammeswhichwillenablethemtobettercopewiththeirdisease.TheHRCiscurrentlyhometoaresourcelibraryshelvedwithover900titlesoffictionandnon-fictionbooks.
Oursupportivecareprogrammesandactivitiesaredesignedtoprovidepatientsandtheirfamilieswiththenecessaryinformationandskillstocopewithcancerandtheeffectsoftreatment.SomeoftheprogrammesthatarecurrentlybeingrunattheHRCincludecookingdemonstrations,yogaclassesandeducationaltalks.Forthelatestinformationonoursupportivecareprogrammes,dovisit www.ncis.com.sg.
Beyondjustprovidingclinicalcaretoourpatients,theNCISrecognisestheemotionaldistresscancerpatientsface.Weseektoembraceandempowerourpatientsthroughvarioussupportivecareprogrammesandactivitiessothattheycandrawstrengthandcomforttobettercopewiththeirbattleagainstcancer.
Cancerpatientsandsurvivorsengaginginartactivitiesaspartofasupportgroupevent.
National University Cancer Institute, Singapore (NCIS) 27
In Addition
Patient Support GroupsHereattheNCIS,wehaveanumberofsupportgroupswhichcancerpatientsandsurvivorscanjoin.Thesesupportgroupplatformsprovideaplaceforthemtosharecommonconcernsandemotionalsupport.Italsogivesthemanopportunitytoconnectandinteractwithotherswhosharesimilarexperiences.Someofoursupportgroupsarepatientdrivenwhileothersarefacilitatedbyoncologyspecialists.Patientsareencouragedtosharetheirexperiencesthroughregularactivitiesandmeetings.
Currentlythereareninesupportgroupswherepatientscanfindempathyinsharingsessions,interactivegroupactivities,aswellaseducationaltalks.• AcuteLeukaemiaWarriors
SupportGroup• BreastSupportGroup• GynaecologicOncologyPatients
TEALSupportGroup• HaematopoieticProgenitorCell
Transplantation(HPCT)SupportGroup
• LymphomaSupportGroup• MultipleMyeloma(MM)Support
Group• MyelodysplasticSyndrome
(MDS)SupportGroup• NPConeHeartSupportGroup• SarcomaSupportGroup
Patients,survivorsandcaregiversengageincommunaldrummingduringNCISCelebratesLife-anannualyearendpartyforalloursupportgroups.
ChefsfromtheLesAmisGroupconductlivecookingdemonstrationsofdishesspeciallycreatedforcancerpatientsandsurvivors.
ProfessionalsconductingademonstrationduringourLookGoodFeelBetterprogramme.
MembersoftheGynaecologicOncologyPatientsTEALSupportGroupduringanexcursiontotheRiverSafari.
28 médico JUL - SEP 2016
Specialist in Focus
ProfessorChng Wee Joo
SpecialistinFocus:
12
3
your specialty interests are in multiple myeloma and lymphoma. Why these two areas in particular, and did you have any role models in your earlier days as a clinician scientist? Ihavealwaysbeenmoreinterestedinmalignanthaematologycomparedtobenignhaematology.Ofthemalignanthaematology,myelomaandlymphomaprovidethemoreinterestingchallengesduetotheheterogeneouswaysinwhichpatientspresent,thediagnosticchallengesandtheexcitingresearchanddrugdevelopmentsinthesediseases.Inmyearlierdays,IlookeduptoDrGohBoonCher,ourcurrentHeadintheDepartmentofHaematology-OncologyatNCIS,whowasblazingthetrailswithfirstinhumanstudiesincancerdoneinSingapore.Ihavealsobeeninspiredbymanyscientistswhohavemadeseminaldiscoveriestomedicine.
There has been a gradual increase in cancer cases in Singapore since 2010. What do you think are the challenges in encouraging people to go for regular cancer screening programmes, and how can we overcome them?ThisistheeasiestthingtodotohaveamajorimpactyetitisthemostchallengingassomehowSingaporeansdonotgoforscreening.Weareplanningtoinitiateafewprogrammes,workingcloselytogetherwithprimarycarephysicians,embarkingoneducationalprogrammesandpublicitycampaignswiththeHealthPromotionBoardandtheSingaporeCancerSociety,aswellasworkingwiththehumanresourcedepartmentsofcompaniestoactivelypromotescreening.Wealsoworkwithbehaviouralscientiststoseehowwecanalterbehaviourofthepopulationwhenitcomestoscreening.Ithastobeamulti-prongedapproach.
How can our local general practitioners (GPs) work together with the NCIS in the fight to bring down cancer cases?Wecandefinitelyworktogethertoidentifyhigh-riskpatientsthatshouldgoforscreening.GPscanalsobeourpartnersinmanagingpatientswhohavealreadyhadtheirtumourseradicatedsothatthesepatientscanbemonitoredmainlyinthecommunity.Iamveryhopefulthattherecanbeclosepartnershipstoensurethatpatientshavecareinthemostappropriatesetting.
National University Cancer Institute, Singapore (NCIS) 29
Specialist in Focus
46
5What is the one significant event in your research that has enriched your life?Ithinkthemostenrichingthingiswhenwhatwediscoverinourresearchleadstoanimpactinourpatient’slife.Veryoftenthisismostapparentandgratifyinginclinicaltrialswhichweareconductingthathaveledtoimprovedpatientoutcomeswithprolongedsurvival.
After a long day, how do you relax and unwind?Iliketospendtimewiththefamily(mywifeandthreekids),wewatchmoviesordosports(badminton,bowling)orplayboardgamestogether.Onmyown,Iliketolistentomusic(IamamusicbuffwithinterestsinabroadrangeofmusicfromclassicaltojazztorocksoIlistentowhatmymooddictates)andIread(lesstimeforlongnovelsnowadayssoIamreadingalotmorecomicsandgraphicnovels).Ihavebeencollectingcomics(notjustsuperherocomicsbutalsoothers)sincemysecondaryschooldays.
What are the three most important things to you in your life?(1)Myfamily,(2)mypatients,(3)mycolleagues,staffandstudents
Professor Chng Wee JooistheDirectoroftheNationalUniversityCancerInstitute,Singapore(NCIS).HeisalsotheDeputyDirectorandaSeniorPrincipalInvestigatorattheCancerScienceInstitute(CSI),Singapore,NationalUniversityofSingapore(NUS).ProfessorChngisalsoaProfessorofMedicineattheYongLooLinSchoolofMedicine,NUS.HeistheChairmanoftheCSIGraduateStudiesCommittee,andisthePresidentoftheSingaporeSocietyofHaematology.HehasaPhDfromtheNUSandfellowshipsfromtheRoyalCollegeofPhysicians,Edinburgh;AcademyofMedicine,Singapore;andtheRoyalCollegeofPathologists,UK.HealsohasaspecialistAccreditationinHaematology,Singapore.Hisresearchinterestsfocusaroundmultiplemyeloma,andthebiologyandtherapeuticsofhaematologicmalignancies.Heisamemberofmanyinternationalprofessionalcommittees,suchastheAmericanSocietyofHaematologyScientificCommitteeonPlasmaCellNeoplasia.
ProfessorChngisinthepeerreviewcommitteeofjournalssuchasBlood,Leukaemia,CancerResearch,andNatureGenetics.HeisalsoinvolvedinanumberofGrantReviewCommittees,ConferenceOrganisingCommittees,AdvisoryBoardsandSteeringCommitteesofglobalclinicaltrials.Hehasauthoredmorethan150publicationsinmanyreputedjournals,suchasTheNewEnglandJournalofMedicine.ProfChnghasalsoauthoredseveralbookchapters,activelyparticipatedinclinicaltrialsandhasdeliveredtalksonmultiplemyelomainnumerousnationalandinternationalconferences.HehaswonmultipleawardsforhisresearchbothlocallyandinternationallyincludingtheNationalMedicalResearchCouncilClinicianScientistAward.
Captions
1. ProfChngonaholidaywithhisfamilyinPhuket.
2. ProfChngconsultingwithapatient.
3. Walkingamonggiants- ProfChngwiththeBeatles,
hisfavoriteband.MusicofallgenresisoneofProfChng’sfavouritepastimes.
1
2
3
30 médico JUL - SEP 2016
Happenings @ NUH
UPCOMING EVENTS
Eventinformationlistediscorrectattimeofprint.Whileeveryattemptwillbemadetoensurethatalleventswilltakeplaceasscheduled,theorganisersreservetherightstomakeappropriatechangesshouldtheneedarises.Pleaserefertooureventscalendaratwww.nuh.com.sg/nuh_gplcformoreupdatesandinformation.
+9 JUL 2016 Gastroenterology and Hepatology Updates for GPsUniversityMedicineClusterNUHSTowerBlockAuditorium,2pm–4pm
TheDivisionofGastroenterology&Hepatologyprovidesacomprehensivearrayofdiagnosticandtherapeutictreatmentfordigestiveandliverdiseases.Itsstrengthslieinseveralkeyservices,notablyinviralhepatitis,livercancer,functionalboweldiseasesandtherapeuticendoscopy.Thededicatedfacilityisequippedwiththetechnologyandknow-howtoprovideaccuratediagnosisaswellasmanagementplansforbothcommonandcomplicatedgastrointestinal,liverandbiliaryconditions.Thedivisionalsoprideitselfasatertiaryreferralcentreforcomplexclinicalcasesandaneducationhubforpatients,nurses,medicalstudentsanddoctorsintheprinciplesandpracticeofdigestiveandliverdiseases.
13 AUG 2016 Urology Updates for GPsUniversitySurgicalClusterNUHSTowerBlockAuditorium,2pm–4pm
TheNUHDepartmentofUrologyisawell-knownproviderofoneofthemostadvancedurologicalservicesintheregion.Itfocusesonthedeliveryofspecialisedmedicalandsurgicalcareinallmajoraspectsofadulturology.Thisleadingedgeiscomplimentedbypioneeringresearchinthefieldofurologicalcancers(bladder,kidneyandprostate),kidneytransplants,treatmentofbenignprostatichyperplasia,managementofurinarystoneconditionsandmalesexualdysfunction.Theirstrongresearchprogrammeisbackedbystate-of-the-artequipment,whichallowspatientswithcomplexconditionstobetreatedwithadvancedtechnologiessuchasminimally-invasiveroboticsurgery,transurethralneedleablativeproceduresandflexibleureteroscopy.
30 JUL 2016 Orthopaedics Updates for GPsUniversityOrthopaedics,HandandReconstructiveMicrosurgeryClusterNUHSTowerBlockAuditorium,2pm–4pm
TheUniversityOrthopaedics,Hand&ReconstructiveMicrosurgeryCluster(UOHC)isattheforefrontofadvancedsurgicaltechniquesandithasthelargestnumberofSingaporeanpatientswhohaveundergonethoracoscopic“keyhole”scoliosissurgery,hipsurfacereplacement,advancedcartilagerepairusingautologouscartilageimplantationormesenchymalstemcells,andartificialspinaldiscreplacement.
Happenings @ NUH
National University Cancer Institute, Singapore (NCIS) 31
POSTEVENTS HIGHLIGHTS+
16 APR 2016NUHS GP Engagement Event
GPsareimportantpartnersinourcommunity,andwewouldliketodomoretogetherwithyou,saidAdjunctAssociateProfessorJoeSim,DeputyChiefExecutive(ClinicalEnterprise),NationalUniversityHealthSystem(NUHS)andChiefExecutiveOfficer,NationalUniversityHospital(NUH),toabout150GPsattendingtheNUHSGPEngagementEventonSaturday,16April2016.
InhisremarkstoourGPpartners,AdjunctA/ProfSimsaidthatwewouldneedafundamentalshiftinourapproachtoageingandhealthinordertoprovidesustainablecareforourrapidlyageingpopulation.
AdjunctA/ProfSimsharedthatonekeythrustwouldbetotransformcaredeliveryfromthecurrentmodelthatwasbuiltaroundthehospitaltoonethatiscommunity-based.Withthisshift,moreresourceswouldbechannelledtoprimarycare,andGPscouldexpectanincreaseinpatientload.
TosupportourGPpartners,NUHSwoulddevelopprimarycarenetworks(PCNs)thatwouldreinforcecarepartnershipwithourGPpartners,andtheirpatientswouldhaveaccesstonursing,alliedhealthandspecialistcare,aswellassocialandcommunityintervention.Byimprovingcaredelivery,thePCNinitiativewouldalsomoveusclosertoourvisionof“OneFamily,OneFamilyDoctor”.AdjunctA/ProfSimannouncedthatourfirstPCNwouldbeestablishedinBukitPanjang,andwewouldextendthisinitiativetootherareassubsequently.
Our‘OpenAccess’initiativewouldalsoallowGPstodirectlyrefertheirpatientsforoesophago-gastroduodenoscopy(OGD)andcolonoscopy,whichwouldallowtheirpatientstobypasstheneedtofirstseeaspecialistattheSOC.
Anotherareaforcollaborationwouldbetoimprovecancerpreventionandcareinthecommunity.TheNationalUniversityCancerInstitute,Singapore
(NCIS)wouldaccreditGPpartnerstoestablishCancerPreventionCareClinicsinthecommunity.
AdjunctA/ProfSimaddedthatanotherimportantshiftweneedtomakewouldbetomovebeyonddeliveringhealthcaretomaintaininggoodhealth,andhighlightedtheimportanceofearlyscreeningandintervention.Tothisend,heencouragedGPstojoinourScreenforLife@WestinitiativeandCommunityHealthScreeningeffort.
Theevent,whichwasalsosupportedbytwonationalcentresofNUHS,namelyNationalUniversityCancerInstitute,SingaporeandNationalUniversityHeartCentre,Singapore,wasjointlyorganisedbyNUHInternationalandtheNUHSRegionalHealthSystemPlanningOfficetothankourGPpartnersfortakingcareofourpatientsinthecommunity.
GPswhoareinterestedinanyoftheprogrammesmentionedcancontactMsKristineLinat6772 [email protected].
32 médico JUL - SEP 2016
GPLCNUH GP Liaison CentreAt the NUH, we recognise the pivotal role general practitioners (GPs) and family physicians play in providing and ensuring that the general public healthcare is of the highest quality and standard. As such, we believe that through closer partnerships, we can deliver more personalised, comprehensive, and efficient medical care for our mutual patients. The GPLC aims to build rapport and facilitate collaboration among GPs, family physicians and our specialists. As a central coordinating point, we provide assistance in areas such as patient referrals, continuing medical education (CME) training, and general enquiries about our hospital’s services.
Through building these important platforms of shared care and communication, we hope that our patients will be the greatest beneficiaries.
NUH CME EventsAt the NUH, we strive to advance health by integrating excellent clinical care, research and education. As part of our mission, we are committed to provide regular CME events for GPs and family physicians. These events aim to provide the latest and relevant clinical updates practical for your patient care.
Organised jointly by the GPLC and the various clinical departments within NUH, our specialists will present different topics in their own areas of specialties in these monthly symposiums.
For more information on our CME events, you can go to www.nuhcme.com.sg or scan the following QR code.
If we could be of any assistance to you, please feel free to contact our office fromMon - Fri : 0900-1200hrs, 1400-1800hrs
GP Appointment Hotline Tel: +65 6772 2000 Fax: +65 6777 8065
GP Liaison CentreTel: +65 6772 2535 / 5079