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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

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A Publication of NUH GP Liaison Centre (GPLC)

Advisor Editors Editorial MemberA/ProfGohLeeGan AmarantaLim YvonneLin KarinLim

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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


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


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.


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.


EarlyPhaseClinicalTrials–

The NCIS Developmental Therapeutics Unit

Insights


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


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.


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


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


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


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


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


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.


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.


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.


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


Treatment Room

Treating Our 100th Patient And Beyond

Stereotactic Ablative Radiotherapy (SABR) Programme –


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


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


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.



Landscape



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


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


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.


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.


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.


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


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


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].


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

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