Low-dose thoracic CT screening of chronic and former smokers aged over 50 would help to detect early lung cancers and save lives, according to Singapore lung cancer expert Dr Toh Chee Keong. The leading oncologist says he would like to see a subsidised program for early detection – much like the mammogram screening program for breast cancer.  Dr Toh will be speaking at a ‘Love Lunch’ event being managed by the 365 Cancer Prevention Society on September 10, providing an overview of lung cancers and discussing new treatment options. Here’s some of what he will be discussing.

“Most people know about lung cancer being related to cigarette smoking, but the reality is that there are now a large number of non-smokers now being diagnosed with lung cancer in Singapore. We don’t really know why – it may be passive smoking, a link to environmental pollution, or even another factor we have yet to identify.

Most of the time, lung cancer patients present when their disease is already at a late stage – stage three or four – when the cure rate is much lower. It would be much better if their cancers were detected early, because there is opportunity for cure with surgery before the disease has spread.

One of the difficulties is that lung cancer is usually asymptomatic in its early stages. If there are any symptoms it might be bone pain, back pain, or breathlessness. Some patients develop headaches because of brain metastases when the cancer has already spread, or they may begin coughing blood if their cancer is close to the airways.

The earlier lung cancer is diagnosed, the better the outcome.  Several studies have now demonstrated that low-dose thoracic CT screening can detect early lung cancers.

Low dose thoracic CT screening is done yearly. Usually, if the lung cancer is detected in the first few years, we follow up on any lung nodules to determine if they are cancerous. If the nodules don’t grow over two to three years, they are unlikely to be cancer.

There are some downsides to this low-dose thoracic CT screening, so patients should discuss this with their doctors before going down this path.

Sometimes this kind of screening detects other things, which can necessitate further investigation and cause unnecessary anxiety– such as thyroid nodules, or the lung nodules may turn out not to be cancer – a false-positive result.

The good news for patients diagnosed with advanced lung cancer is that we have new treatment options, thanks to technological advances and molecular testing. If we find mutations in a tumour, then patients may be suitable for targeted therapy, which means the treatment is targeted specifically to their type of cancer.

These therapy options have been shown to improve outcomes.  While this kind of treatment is not curative, it may be able to better control a cancer and help patients to live longer. We are learning more all the time and there is always hope.”

*September 2022

Rare cancers in Singapore are not so rare, according to medical oncologist Dr Jason Chan, who specialises in treating patients with less common oncologic variations.

He says up to 7000 Singapore cancer patients are diagnosed every year with one of about 200 rare cancer variations – which means there are fewer treatment options and scarce information.

Dr Chan will be speaking at a 365 Cancer Prevention Society event on September 3, with the headline topic “Fighting rare and young adult cancers in Singapore”. He gave us an insight into what he wants patients to know.

“Some people have a skewed perception when it comes to rare cancers that they are one in a million, or that they may happen once every few years. But the truth is, when we combine the number of people diagnosed with rare cancers in Singapore, the incidence unfortunately is not that uncommon.

Rare cancers tend to affect young adults, usually in their twenties and thirties. This is a time when they are graduating from school, or perhaps starting a family. You can imagine how it affects their lives – everything is changed very suddenly.

Half of the rare diagnoses we are seeing are soft tissue cancers called sarcomas, rare blood cancers called lymphomas, gastrointestinal stromal tumours and even uncommon melanomas.

We are actually starting to see more cases of a very unique type of melanoma happening in Asians where it is appearing in their hands and feet – areas that have not been sun-exposed.

We don’t know why these melanomas are occurring, and we have been studying this for a few years. It could be genetic or environmental reasons at play, but we need more research.

Many of our rare cancer patients in Singapore are being diagnosed at a later stage, and we need to help these patients access therapies that might be beneficial. There is a lot less clinical data for rare cancers and there are fewer treatment options for patients. Sometimes there are no treatment options at all.

This all means that rare cancers are more difficult to manage for the non-specialist physician. Patients can feel very isolated and five-year survival outcomes for rare cancers are typically poorer than they are for patients diagnosed with other more common cancers.

From my perspective, every rare cancer patient has to be managed in a personalised manner. It should be a joint effort with the patient, the medical team and the family.

Named patient access programs are extremely important, where pharmaceutical companies enable early access to emerging therapies that may be yet to pass through all the regulatory hoops, but there is a great need to give these therapies a go in the absence of any other treatment options. We must think of creative ways to get patients access to drugs.

What do I love about my job? Somebody has to do it! It is challenging and rewarding at same time. We have seen some cases which are really one of a kind in country, or even the world. We definitely have to use our detective skills!

As an example, we had a patient diagnosed with a rare nose cancer about five years ago.

It turned out that his younger brother had a similar cancer in the same location, and he had died. This was very unusual and was unheard of worldwide.

We did some investigative work together with their family and identified a genetic cause that has not been described before.

Essentially, we were able to provide some answers.

What we are doing in Singapore is bringing together like-minded people, scientists, researchers and medical practitioners who are interested in rare cancers and we are forming a national consortium to have a louder voice to advocate for these patients. This is a great step forward but there is much to be done.”

*August 2022

While 1 in 13 Singaporean women will be diagnosed with breast cancer in their lifetime – the highest incidence in South-East Asia – senior oncologist Dr Lynette Ngo wants her patients to know that five-year survival rates “are better than they have ever been”, even for those with advanced cancers.

“I have patients now with stage four cancers who were given six months to live, and they are now living eight or nine years,” Dr Ngo says.

“These impressive results are partly due to the availability of HER2-targeted therapies in recent decades and the response has been amazing.”

Dr Ngo will be speaking about the breast cancer treatment landscape at a 365 Cancer Prevention Society event on August 20 which is co-sponsored by Specialised Therapeutics. Here are some of her insights.

“What do I want women to know? I want them to know that there are a lot of advances in breast cancer and a lot of new medications. Survival outcomes are improving, even when women are diagnosed at the advanced stage.

Breast cancer is not just one disease and there are many sub-types. In Singapore we are lucky because we have access to most of the latest treatment options for breast cancer. The biggest problem women face is funding. But for patients who have insurance coverage, access to new therapies is not typically an issue.

Why is the incidence of breast cancer so high in Singapore? I would say that lifestyle and diet is playing a part. Many families in Singapore have adopted typical Western dietary habits and lifestyle choices. The diets of some women now include excessive amounts of red meat and animal fat, alongside a reduced intake of fruits and vegetables. This has led to an increasing average body weight of women in Singapore.

In addition, many women are working full time and do not have time for exercise. As well as a high fat diet, there can be quite a high alcohol intake as well.

Women are frequently having children at a later age, or having fewer children – or none at all. Some of them are choosing not to breastfeed. All of these factors have an impact.

I am advising my patients to modify their lifestyles and we try to help them implement diet and exercise programs for them when they have finished active chemotherapy. We follow the national guidelines, advising at least 150 to 300 minutes of moderate intensity aerobic activity every week, as well as strength training and functional balance at least three times a week. The American Cancer Society also recommends an alternative of 75 to 150 minutes of vigorous intensive physical activity per week.

Taking control of their diet and exercise is one thing women can do to try and reduce their risk of recurrence, and this is a very common fear among patients. It can also be quite debilitating. Some women want to come and see their doctor a lot more frequently and others want more frequent scans for reassurance. Taking some control back in their lifestyle is one way to manage their fear of relapse.

I originally worked in palliative care before I was drawn to working in oncology, specialising in breast and gynaecological cancers. It gives me great satisfaction to see patients smiling after everything they have been through and seeing them with their families and doing what they love.

I love helping women, seeing them defy the statistics, keep working and continue contributing to society. I really do love my job.”

*July 2022.

He was one of Singapore’s first medical oncologists and now in his late seventies, Dr Tan Yew Oo is one of the oldest practising oncologists, seeing cancer patients daily and striving to make a difference. Born in Malaysia, the father of two and now grandfather has enjoyed an enduring career that has taken him around the world, working in the United States and Canada, enabling him to witness the arrival of new therapies like molecular targeted agents and immunotherapies that have changed the treatment landscape and helped many patients with some cancers to live longer, with better quality of life.

Dr Tan loves his work and continues to inspire the next generation of oncologists to deliver best practice, evidence-based care.  His career has been marked with some wonderful highs – like the time a young mum given no chance to live defied all the odds. But there have also been some devastating lows because, he says simply, oncology and mortality are the ultimate levellers “and the day we are born, we are destined to die”. In the low times he turns to his faith – he is a practising Catholic – and encourages patients and their families to seek solace in any kind of spirituality. At this stage, Dr Tan has no plans to immediately retire, and predicts the next leap forward in oncology will come from new targeted immune-mediation agents being discovered for difficult to treat cancers and potentially, from the use of mRNA technology (made famous in the manufacture of COVID vaccines) to treat cancers.

In 2011, a young cancer patient Mary (not her real name) arrived in Dr Tan’s Singapore office.

He recalls their first consultation well. She was a mother with young children, who was living with advanced lung cancer. She was desperate to live longer, but it was clear to Dr Tan that time was fast running out.

Already, some of the region’s specialists had advised that the only option remaining for Mary was hospice care, to keep her comfortable. She had been advised to “prepare for the end”.

But Dr Tan did not want to give up. Every patient, he says, has their own story and he believes specialists must take a holistic approach, and consider all parts of a family network when treating patients. Mary was a mother and a breadwinner on whom her family relied.

So, as targeted therapies were beginning to emerge on the oncology treatment landscape, he ordered another biopsy, to try and determine if there was a ‘molecular driver’ igniting her cancer.

Doctors discovered this lady had an ALK (anaplastic lymphoma kinase) gene rearrangement, a genetic mutation in the DNA of lung cells that occurs when two genes fuse and the cancerous lung cells can replicate rapidly and spread to other parts of the body.

Dr Tan kept musing about this case, determined to find another treatment if it existed.

“If you find a molecular driver you can extend a patient’s life, a lot.”

He remembered studying a presentation at the annual American Society of Clinical Oncology conference, or ASCO, a convention attended by the world’s cancer specialists every year.

Data had been shared about a targeted drug called crizotinib that targeted ALK mutated lung cancer and was showing some success. He thought it was “worth a shot” for this lady and so decided to approach the drug company who marketed the therapy to see if they would consider supplying it on compassionate grounds, as there was nothing else left.

He recalls now, “And she had a fantastic response. It was amazing. She went into remission and has remained there for more than ten years. She remains on therapy but is very well and actively working. I warned her it might work for a couple of years and then the cancer would become resistant. It has not. When I first saw her, her children were still young. Now her daughters are married, and her husband has had a stroke and passed away. She was taking care of her elderly mother; now her mother has died. She has outlived them all. I use her as an example as to why we should never give up hope and why we must never stop trying to help patients.”

Dr Tan and Mary at a presentation in 2017

But Dr Tan concedes that for every success in oncology, there are many other patients who pass away despite the very best efforts, treatment and care.

“People often ask me, ‘Don’t you get depressed?’ But I believe that every patient who presents with advanced disease is a challenge, and everyone is unique in trying to overcome that challenge. Many times, you are able to prolong life and ameliorate suffering.”

And he knows that every family can be touched by cancer – even his own. Despite his vast experience, he admits even he feels helpless when it is close to home.

A 38-year-old nephew has been recently diagnosed with a rare lymphoma known as NK/T-cell lymphoma and requires treatment with “very intense chemotherapy and radiation” but has limited financial resources.

“I am trying to find ways to treat him where he is in Malaysia, or to find out how to bring him to Singapore in an affordable way. He is a bachelor, self-employed with a girlfriend and not from a rich family. He has a limited insurance plan. These are the things he is grappling with, and which many families grapple with. I am doing what I can and having a pathologist re-investigate his diagnosis so we can make sure we get the compass right to point in the right direction. I have made contact with a haematology colleague in my nephew’s hometown who is willing to follow the chemotherapy regime used successfully in Singapore. He has now started on this program. But when anyone is impacted by any kind of cancer, it is very hard and no family is immune.”

The gratitude Dr Tan inspires is acknowledged by patients who keep in touch at times like Christmas and Chinese New Year. Some patients have become personal friends and he has been invited to family weddings and anniversary celebrations. His own reward is seeing them continue successful, healthy lives where they can spend more time with their families.

At this stage, he has no immediate plans to retire. “I am an ancient old man who is trying to stay active mentally and physically,” he laughs. “I enjoy my work so much that I want to continue what I am doing. But I am now in my late seventies. It took me ten years of working in Singapore at the beginning of my career to have medical oncology recognised as a sub-specialty of internal medicine. At the time there were fewer than 10 anti-cancer agents and now there are hundreds. There has been an explosion in the number of cytotoxic drugs, anti-cancer hormonal agents, molecular targeted therapies, antibody drug conjugates and immune checkpoint inhibitors. There is still a long way to go to improve the outcomes of difficult to treat cancers like pancreatic, gall bladder and colorectal cancer, as well as sarcoma and brain tumours. “I have seen a lot already, but I hope to see the advent of new therapies such as CAR T-cell therapy or even gene therapies that will improve survival outcomes for these cancers.

“I am not ready to go and leave the exciting future just yet.”

*March 2022.
Besides patient care, Dr Tan has served many public healthcare bodies and institutions, including the MediShield Life Council (MSLC), the Anticancer Therapy Committee looking at cost containment, the SingHealth Cluster, MOH National Cancer Care Committee and the Proton Advisory Committee. He was awarded The Public Service Medal by the President of Singapore in 2020.