Issue No. 16 • MICA (P) 061/10/2010
AN NCCS BI-MONTHLY PUBLICATION May / June 2011
...HELPING R E A DERS TO ACHIEV E GOOD HE A LTH Salubris is a Latin word which means healthy, in good condition (body) and wholesome.
PHARMACY: MORE THAN MEETS THE EYE
PAGE A2
In Other Words
SALUBRIS
May / June 2011
PHARMACY: MORE THAN MEETS THE EYE
Caroline was only in Primary Four when she became a regular patient at the National Cancer Centre Singapore (NCCS). She was a brave and clever child. She impressed the hospital pharmacist so much that she was allowed to print the label that was to be attached to her own medication. This elated Caroline very much, and when asked what she wanted to do when she grows up, she declared, “I want to be a pharmacist!” Sadly, Caroline never got to fulfill her ambition. Despite having received a bone marrow transplant, the spirited child, who was suffering from leukaemia, suffered a relapse and passed away.
T
he courage and determination of patients like Caroline continue to motivate Ms Lita Chew, Head of Oncology Pharmacy at NCCS. “They are very good teachers,” she said, thankful to her patients who are ever supportive and appreciative of her work. They are also the reason for her sustained dedication to the job.
It has been 20 years since Lita became a pharmacist. It was by accident that she chose pharmacy as a career. Her faculty offered her a place, but at that time, she was not even sure about the definition of a pharmacist. Soon enough, she found herself falling in love with working in the lab and compounding chemicals that help to save lives. “It is baking science. Just like cooking,” said Lita. Two years into her work, there was an opening in the oncology ward for an oncology pharmacist. That was how Lita decided to specialise in the discipline, subsequently leading her to building acquaintance with cancer patients.
She’s a familiar face to many patients who are undergoing chemotherapy – bespectacled and fair, with long hair pulled back in a ponytail. She frequently dons a long floral print dress. Lita and her team of pharmacists would often speak with patients before their chemotherapy session, asking them questions like “How did you do in the last treatment?” and “Did you develop any adverse reaction when you were administered the drug previously?” When nurses notice signs of adverse drug reactions, the pharmacists will be the ones who have to put things back in order. Gone are the days when pharmacists simply sit behind the counter to dispense drugs and instruct patients on their prescription. Now, the role of pharmacists has taken a big leap. They must ensure that patients are provided the correct medication and take their medication correctly, a responsibility that previously belonged solely to doctors. Today’s pharmacist takes on a more independent role. At the same time, they help to relieve the doctors’ heavy workload. Their work is not unlike an Advanced Practitioner Nurse.
On what she hopes to bring to the profession, she said: “I hope to be the catalytic lighthouse that improves pharmacy services for patients, helping pharmacy staff to grow and develop satisfying careers, and applying our unique drug knowledge in every available opportunity across the continuum of care. Ms Lita Chew Head of Oncology Pharmacy, NCCS
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In Other Words
SALUBRIS
May / June 2011
Today’s pharmacist takes on a more independent role. At the same time, they help to relieve the doctors’ heavy workload. Their work is not unlike an Advanced Practitioner Nurse.
Lita’s team of 15 pharmacists plays a variety of roles in the patients’ care process. Some walk the wards with doctors, review prescriptions given by doctors to ensure accuracy and completeness, check the laboratory results to make sure that prescribed dosages are safe and all adverse reactions are properly recorded. They also prepare the medications before the patients arrive for their chemotherapy sessions. In addition, pharmacists at NCCS are also tasked with teaching and research roles. Lita’s areas of interests for research include medication safety, drug toxicity and symptom management, monitoring adverse drug reactions, pharmacoeconomics and outcome research. She is also teaching at the National University of Singapore, helping to groom a new generation of pharmacists.
With the ever-changing pharmaceutical scene and with new research discoveries announced daily, pharmacy has become a job with great challenges and responsibilities. Naturally, this translates into immense pressure. However, the rewards far surpass the satisfaction that comes from merely concocting medicine in the lab.
In fact, with her new appointment as Chief Pharmacist of MOH, Lita will be doing more.
“As a CP at MOH, my main roles are to oversee the development of pharmacy and the pharmacy profession in Singapore and advise MOH on pharmaceutical professional matters. I would also support the nation’s healthcare goals through effective regulation and registration of pharmacists, promote training and continual professional development, and ensure high professional standards.” On what her new appointment meant for her, she felt it was an opportunity to continue the good work of her predecessors. “Pharmacists would not be where they are today without our past leaders and the legacy they left behind. I have been blessed during my career to work with numerous excellent colleagues from whom I have learnt from more than I have given back to. I am most honoured to be trusted with this leadership role.” On what she hopes to bring to the profession, she said: “I hope to be the catalytic lighthouse that improves pharmacy services for patients, helping pharmacy staff to grow and develop satisfying careers, and applying our unique drug knowledge in every available opportunity across the continuum of care. I see myself as the ‘constant gardener’, attending to the pharmacy services garden... planting the appropriate seeds in rich soil and a nurturing environment, so that they will bloom and thrive.”
She has a piece of advice for her students, who are pharmacists in the making. Regardless of whichever vocation they choose, or whether they take their career path to the public hospital or private sectors, “always keep patients in mind”.
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In Focus
SALUBRIS
May / June 2011
TRACING THE ROAD MAP FROM MEDICAL CLINICAL TRIALS TO THE BEDSIDE
SALUBRIS looks at the Department of Medical Oncology’s Early Clinical Research Unit. There used to be a time when patients frowned upon the offer to be on a clinical trial. This posed a major obstacle to clinician-researchers who needed to test novel drugs on cancer patients before they could be used on a bigger group. Fortunately, this concern is slowly diminishing as patients are better educated and they have a better understanding of clinical research and what the trials can do for them. Dr Choo Su-Pin, Director of ECRU and Senior Consultant from the Department of Medical Oncology says: “While we cannot guarantee that novel therapies will bring benefit, we are encouraged when we see patients who have run out of standard treatment options benefit from a phase 1 trial that is available. It is heartening to see the novel treatment control their cancer growth.”
P
hase 1 trials are the early stage of testing in human subjects. Normally, 20 to 100 patient volunteers will be selected. This phase includes trials designed to assess the safety, tolerability, and body-drug interaction. Trials at this phase normally include administering different doses of a drug to patients. Such trials are usually safe as the tested range of doses will usually be a fraction of the dose that causes harm in animal testing. Furthermore, the trials can only take place after requirements have been fulfilled for laboratory safety, and approval from relevant health authority or ethics committee is attained. These together with the small pool of patients enrolled enhance surveillance and further safeguards trial participants’ interest and safety. Phase 2 trials are the next step which enrolls a larger cohort of patients to further assess safety and efficacy of the novel treatment. While the recruitment of trial participants remains a challenge, it is also an administrative nightmare to manage the high volume of projects undertaken. In 2009, the National Cancer Centre Singapore conducted 127 trials, of which 86.6 per cent or 110 of the trials were conducted by the Department of Medical Oncology. To enhance the development and support for such studies, ECRU – a unit that focuses on investigator-initiated trials and early phase (phase 1/2) clinical trials – was established on 16 October 2009. The unit aims to provide a core team of investigators and clinical research coordinators for DMO-led trials and to consolidate links with various clinical and laboratory collaborators, as well as pharmaceutical companies from which these investigational new drugs (IND) are sourced. It also works to source for these IND and funds needed to support these projects undertaken by the department. This is done in the hope of benefiting more patients. With ECRU, it means a more focused effort towards meaningful research. As Dr Choo puts it, “The unit focuses on translational research. That means we are actively bringing what we have discovered in the laboratory to the patient in clinic. This is a niche that a small country like Singapore can develop. In these phase 1/2 trials, only a small number of patients are required to demonstrate ‘proof-of-concept’ that a drug works. We also have the advantage of being within easy reach of our scientific collaborators for these trials so that we can try to understand how drugs work better.”
QUESTIONS YOU MAY HAVE:
Q A
How do doctors find time to do research?
Q A Q A
Will research work hinder doctors’ clinical service?
With a supportive department and cancer centre, we are able to carve out time from our busy schedules to do research. The truth is, if you are interested in research, and your colleagues are supportive, you will find time for it, even if it is outside office hours.
No. Clinical service or clinical research always places patients as a priority. How can doctors’ research work benefit cancer patients?
If we keep doing good quality research, we will gain a better understanding of cancer and this will eventually translate into benefits for cancer patients.
Q A
Should I participate in a clinical trial? Why?
Q A
How can I participate in clinical trials?
Yes. It may not benefit you directly, but it will lead to better understanding of cancer and benefit patients in the future. If you derive benefit, you could be among the first few who do so.
You can contact your oncologist or call the NCCS hotline, tel: 6225 5655.
Early phase clinical trials initiated by ECRU also adds to the academic development of the Outram Campus, says Dr Choo. “For investigator-initiated trials, the ideas and rationale for the studies come from the investigator, usually a clinician or scientist, and are usually driven by a quest for scientific logic and advancement. This is important for Singapore’s drive to become a biomedical hub.” Should such early phase studies show a clear signal for safety and efficacy, the studies can then be expanded into multi-centre trials regionally. As of January 2011, ECRU oversees 24 research studies and has another 10 upcoming studies.
SLEEP DISTURBANCES IN CANCER
PAGE B1
Tender Care
SALUBRIS
May / June 2011
Sleep disturbance is a common symptom among cancer patients (Engstrom et al, 1999). This is not surprising, given the anxiety and fear triggered by the diagnosis of cancer and the physical impact of cancer treatment. Sleep disturbances in cancer patients may take the form of either insomnia (inability to initiate or maintain sleep) or hypersomnia (inability to maintain wakefulness when desired).
I
nsomnia is not defined by a specific duration of sleep that one gets as individuals vary widely in their sleep needs and habits. Insomnia is classified based on the duration of the problem. In general:
• symptoms lasting less than one week are classified as transient insomnia; • symptoms between one and three weeks are classified as short-term or acute insomnia, and; • those longer than three weeks are classified as chronic insomnia. Insomnia experienced by cancer patients may be a manifestation of an emotional reaction to cancer diagnosis or fear of treatment and related side effects. Sleep disturbance generally abates as patient gradually learns to accept their condition. Although most of us have experienced insomnia and the impact of sleep deprivation on physical well being and work performance at some point in time, few of us are aware of the behavioural and medical options available to treat insomnia. Insomnia can be primary or secondary and can take the form of sleep onset difficulty, sleep maintenance difficulty, early morning awakening or all three. Insomnia in cancer patient often falls under the domain of secondary insomnia which may be treatment related. This form of insomnia is often treated pharmacologically which, inevitably has its side effect of further disrupting the sleep pattern as well.
COMMON CONTRIBUTORY FACTORS IN SLEEP DISTURBANCES INCLUDE THE FOLLOWING: • • • • • • •
Decrease in physical activity, with increase in the amount of time spent in bed and napping Profound daytime fatigue and a preference for sedentary activities Physical illness (hypoxia, urinary frequency, fever, pruritus, endocrine disorders) Pain/ Fears of pain on awakening Anxiety Medication/ drugs (prolonged use and withdrawal) Disturbing hospital and/ or home environment Continued on page B2.
PAGE B2
Tender Care
SALUBRIS
May / June 2011
SLEEP DISTURBANCES IN CANCER
Continued from page B1.
WAYS TO OVERCOME SLEEP DISTURBANCES • Stay in bed only for the hours intended for sleep. Most people have a tendency to remain in bed to try to get some sleep when they are not sleeping. The opposite is true as being in bed and not sleeping can lead to lighter sleep and an increase in number of awakenings.
• Exercise on a consistent basis. Exercise helps promote quality sleep. It is recommended to exercise 4-7 hours before sleep as intense exercise raises body temperature for approximately 6 hours after exercise. For those who cannot exercise, a 20 minutes hot bath 2 hours before bedtime produces the same effect.
• Establish a bedtime and wake time and maintain it. The wake time is particularly important in establishing a sleep-wake rhythm. If there are awakenings during the night or difficulty getting to sleep, you should still get up at your chosen wake time.
• Individualise the sleep environment. The perfect sleep environment should be individualised. Some prefer dark, quiet and cool rooms while some sleep best in dimly lit rooms with music or steady noises like that from a fan which masks other noises in the environment. Set the environment that best suits your sleeping habits.
• Do not worry about getting sleep. The more you try to sleep in fear that you will not be able to, the less likely sleep will be achieved. Worrying, anger and frustration inhibit sleep. Sleep is achieved when your body is relaxed and your mind is either not active or thinking about some mundane, unexciting subject.
• Stimulus control technique (SCT) The SCT has been shown to be one of the most effective behavioural treatments for insomnia (Fogel, 2003). This technique requires patience and tremendous amount of discipline. Initial stage on embarking is tedious and takes about 3 to 6 weeks to master.
• Set the alarm clock and keep it out of sight. Remove all clocks from the bedroom.
There are five basic tenets:
• Deal with worries that may inhibit sleep before bedtime and not at bedtime. Bedtime is known to be the first time of the day one can step aside from one’s daily routine and schedule to focus on some other concerns or tasks that need attention. One way is to set aside 30 minutes before sleep time to think about the concerns or jot it down to remind yourself when you wake up the next morning. • Avoid stimulants like caffeine. Coffee, colas, mountain dew, tea and chocolates contains caffeine. Reducing or eliminating caffeine intake after late afternoon helps reduce its effect on sleep. • Avoid Central Nervous System (CNS) depressants. CNS depressants such as alcohol may induce sleep but can be disruptive to sleep quality at times.
Go to bed only when sleepy and intending to sleep; Use the bed only for sleeping, not watching television, reading or eating; If unable to fall asleep quickly, get out of bed and move to another room, staying there until sleepy and only then returning to the bed to fall asleep; Set an alarm and get up at the same time everyday regardless of the amount of nighttime sleep; and Do not nap. • Pain Management For the best pain relief, pain medication should be taken on a regular basis. If pain is the main cause inhibiting sleep, it may be necessary to consult the doctor to assess the need for dosage adjustment for the prescribed analgesics.
• Pharmacologic Approaches With the potential adverse effects of pharmacologic interventions in mind, behavioural interventions to treat sleep problems should be attempted before deciding on pharmacologic approaches. Nevertheless, factors inhibiting sleep must be taken into consideration in order to predict if pharmacological or non-pharmacological techniques should be attempted. Evidence suggests that quality of life is closely intertwined with adequate sleep (Baldwin et al, 2010). Prolonged stress or poor adaptation to diagnosis and treatment could lead to chronic insomnia. Sleep Deprivation over prolonged periods could lead to reduced ability to work, socialise or to experience pleasure in daytime functioning. Sleep disturbances could influence the outcomes of therapeutic and supportive care measures as well. Patients with sleep disturbances may experience irritability and inability to concentrate which may affect compliance with treatment protocols and relationships with significant others. Thus it is important to recognise and treat sleep problems of cancer patients early to enhance coping and functioning and to minimise sequelae stemming from long-term treatment.
REFERENCES J. Fogel (2003). Advance Practice Nursing eJournal. 3(4)©2003 Medscape L. Baillargeon, M. Demers & R. Ladouceur (1998). Stimulus-control: nonpharmacologic treatment for Insomnia. Canadian Family Physician. 44 (1)73-79. C.H. Yarbro, M.H. Frogge & M. Goodman (1999). Cancer Symptom Management.(2nd Ed). Boston:Jones and Bartlett Publishers C.A. Engstrom, R.A. Strohl , L. Rose et al (1999) Sleep alterations in cancer patients. Cancer Nursing 22(2): 143-8. C.M. Baldwin, A.M. Ervin, M. Z. Mays, J. Robbins, S. Shafazand, J. Walsleben & T. Weaver (2010). Sleep Disturbances, Quality of Life, and Ethnicity: The Sleep Heart Health Study. Journal of Clinical Sleep Medicine, 6(2)176-183.
By Jenna Teo
Senior Nurse Manager Cancer Education & Information Service NCCS
TOMOTHERAPY: EVOLUTION OF A REVOLUTION IN RADIATION ONCOLOGY
TomoTherapy®, literally “slice treatment,” is one of the most exciting developments in radiation oncology in recent years. As TomoTherapy makes its NCCS debut in 2010, we look at why this new equipment has been touted as the next revolution in the field of radiation oncology.
WHAT IS TOMOTHERAPY? The equipment used for TomoTherapy looks similar to a CT scanner (Figure 1 & 2). The difference is that the machine produces a thin slice of fan-shaped megavoltage X-rays used for treatment, rather than the kilovoltage X-rays used in diagnostic CT scans. Patients lie on a couch that moves into the gantry ring opening at the same time as the gantry rotates. As a result, the radiation beam makes a spiral (or helical) pattern around the patient.
Linear accelerator (Linac) inside gantry produces a thin slice of fan shaped radiation beam
FIGURE 1
Gantry Patient moves into the gantry ring progressively during treatment
FIGURE 2
PAGE B3
Tender Care
SALUBRIS
May / June 2011
By Dr Soong Yoke Lim
Consultant Radiation Oncologist
Francis Ngoi Chong Ling
Principal Radiation Therapist
Hanifah Bte Syed Ahmad
Senior Radiation Therapist
Department of Radiation Oncology NCCS
As the radiation beam makes a spiral (or helical) pattern around the patient, TomoTherapy is able to better conform to complex tumour shapes. TomoTherapy not only allows inverse planning and Intensity Modulated Radiation Therapy (IMRT) to be utilised, but treatments can be delivered continuously, from all angles around the patient. In addition, the device divides a single beam into many smaller, narrow “beamlets.” This significantly increases flexibility in the treatment plans and enables high doses to be confined to the tumour (Figure 3 & 4).
The design of the TomoTherapy device also makes it possible to acquire CT images. Radiation oncologists use the images acquired from the patient just before treatment and compare it with the reference CT used in planning. In this way, tiny corrections of the patient’s position can be made to ensure that radiation will be directed with accuracy. These images can also potentially be used to analyse the changes in size, shape and location of tumours to decide if modifications are required at any point during the treatment course.
PICTURES OF TOMOTHERAPY HI-ART® SYSTEM Continued on page B4.
TOMOTHERAPY: EVOLUTION OF A REVOLUTION IN RADIATION ONCOLOGY
PAGE B4
Tender Care
SALUBRIS
May / June 2011
Continued from page B3.
Another feature of TomoTherapy is that it allows for a treatment verification method called “dose reconstruction” that allows radiation oncologists to view the calculated treatment dose on the daily images. Hence they are able to determine if future treatments should be modified to correct for discrepancies in completed treatments in a process called “adaptive radiation therapy.”
FIGURE 3
FIGURE 4
Right: Total marrow irradiation. Higher doses given to marrow (red) while sparing organs especially lungs and kidneys.
TomoTherapy used for treatment of mesothelioma. High dose areas are in red.
TREATMENT PROCEDURE
CONCLUSION
Each TomoTherapy delivery usually takes about 15-30 minutes, depending on the complexity of the treatment. The first part of the procedure is patient positioning on an immobilisation device to prevent patient’s movement during treatment. Then, CT images are acquired on the machine to visualise the treatment area. The next step is image registration whereby the newly acquired CT images are electronically compared with the reference CT images. Small changes in patient positioning may be corrected at this point.
Helical TomoTherapy is a novel concept in radiation therapy that combines IMRT treatment, inverse treatment planning and 3D imaging in one integrated machine. Two major strong points of TomoTherapy are the tumour-directed dose delivery capability, and the concept of on-board imaging system which allows the verification of patient positioning prior to each treatment delivery. A radiation oncologist can tell if TomoTherapy is right for a patient’s particular situation. Each patient is different and a radiation oncologist who is familiar with the patient can evaluate all of the different treatment options, including treatment on a TomoTherapy Hi-Art® system.
One of the main advantages of TomoTherapy is that verification of CT images are acquired before each treatment. With daily CT imaging, the correctness of positioning can be verified for each treatment. This is particularly useful when treating a tumour site that can be influenced by day to day anatomical changes. For example, rectum or bladder distension can change the position of prostate gland tumours. Another feature of TomoTherapy is that it allows for a treatment verification method called “dose reconstruction” that enables radiation oncologists to view the calculated treatment dose on the daily images. Hence they are able to determine if future treatments should be modified to correct for discrepancies in completed treatments in a process called “adaptive radiation therapy.” This allows us to modify the treatment plan and doses when there is a change in the patient’s anatomy due to weight loss or tumour shrinkage. This is particularly useful when treating head and neck tumours. For the past 18 months, TomoTherapy at the NCCS has been used to treat head and neck, brain, lung, prostate and paediatric cancers. It is also used to treat challenging and difficult situations encountered in recurrence cases where patients already had radiation treatment to the same area. The following is the flowchart of the treatment procedure:
CT IMAGE ACQUISITION
IMAGE VERIFICATION
COUCH POSITIONAL ADJUSTMENT
TREATMENT DELIVERY
Prior to TomoTherapy, a patient will be briefed on the pre-treatment preparations, treatment sessions, management of treatment side effects and nutritional intake. With the newly introduced ring gantry-based TomoTherapy Hi-Art® system, NCCS provides yet another elegant integrated CT imaging with conformal radiation therapy to deliver sophisticated radiation treatments with speed and precision while reducing radiation exposure to surrounding healthy tissue.
癌症病人的睡眠障碍
PAGE B5
温柔呵护 SALUBRIS
May / June 2011
睡眠障碍是癌症患者常见 的症状 (Engstrometal, 1999)。病人在须经历癌症诊 断所导致的焦虑及恐慌，加上 治疗所产生的生理影响后，会 出现睡眠障碍是不足为奇的。 癌症病人的睡眠障碍可体现 于失眠症（无法入睡或维持睡 眠状态）或嗜睡症（无法在必 要时保持清醒）。
克服睡眠障碍的方法
刺激控制法是治疗失眠症的最佳行为方法
• 只在该睡觉的时间躺在床上 大多数的人在不睡觉时，仍会躺在床 上，尝试入睡。然而，在不适当的时间 躺在床上，将导致更浅层的睡眠状态， 以及更常在半夜苏醒。 • 设定并维持就寝及起床时间 设定起床时间是建立睡眠觉醒节律 的关键。即使在半夜觉醒或睡不着， 您也该在设定的时间起床。 • 别担心无法入眠 您越担心自己睡不着，越有可能无法 睡好。担心、气愤及沮丧等情绪都有 可能抑制睡眠。当您的身体放松、头 脑不活跃，或在想着单调的事，睡意 自然而然就会来。 • 调好闹钟，让它远离视线
每个人的睡眠需求和习惯都不一样，因此失眠症 的定义并非以睡眠时间的长短而定，而是以问题 存在的时间长短而分类。一般上： • 症状不超过一周称为暂时性失眠 • 症状介于一至三周称为短期或急性失眠 • 症状持续超过三周称为长期失眠 癌症病患所面对的失眠症也许是对癌症诊断或恐 惧癌症治疗的情绪反应, 又或是与治疗的副作用 有关及其副作用的情绪反应。当病人逐渐接受自 己的病况，睡眠障碍也会随着消失。虽然大部分 的人都曾在不同阶段被失眠症困扰，也体会过缺 乏睡眠对身体及工作表现的影响，然而，只有一小 部分的人对失眠症的行为及医药疗法有所认知。 失眠症可分为原发性失眠或次发性失眠。它可体 现于难以入眠、无法维持睡眠或极早苏醒，甚至三 者合一。癌症病人所面对的失眠症往往是次发性 失眠，这或许是因治疗而引起。这类失眠症一般 靠药物治疗，但也因而难免产生副作用，并进一步 捣乱睡眠规律。
常见的睡眠障碍导因包括： • 体力活动的减少，加上睡觉或睡午觉的时 间增加 • 在白天感到极度疲倦，和偏好静态活动 • 身体的疾病（缺氧、频尿、发烧、瘙痒、内 分泌失调） • 疼痛／害怕苏醒时感到的疼痛 • 焦虑 • 药物治疗／药品（长期使用以及戒断症状） • 医院或住家环境令人不安
• 刺激控制法
将所有的时钟拿出睡房。 • 在临睡前解决可能妨碍睡眠的烦恼 事别在临睡时处理 就寝时间往往是人们能抛开日常工 作，把集中力放在其他需要关注的事 项上的时候。其中一个方法是在睡觉 前拨出半小时想想挂心的事情，或把 事项写下，以便在隔天早上睡醒时提 醒自己。 • 避开咖啡因等兴奋剂 咖啡、可乐、茶和巧克力都含有咖啡 因。近傍晚时分,就应减少或避免饮 用咖啡因，将能减轻它对睡眠所产生 的影响。 • 避开中枢神经系统抑制剂 中枢神经系统抑制剂如酒精, 虽能促 使睡眠，但有时也会干预睡眠品质。 • 定期运动 运动能增进睡眠的品质。一般建议在 睡前4至7小时做运动，激烈的运动将 让体温提高约6小时。若无法运动，在 睡前两小时泡20分钟的热水澡也能 产生同样的效用。 • 营造个人化的睡眠环境 一个完美的睡眠环境应是贴身打造的。 有些人喜欢黑暗、安静、凉爽的房间， 有些则在灯光暗淡、播放着音乐，或 由电风扇等电器所发出的稳定性噪音 以遮掩其他声响的房间里睡得最舒 适。依照自己的睡眠习惯营造最适合 自己的睡眠环境。
(Fogel, 2003)。然而，它需要耐性和自律。 治疗初期非常艰巨，需要三至六周才能掌 握控制法。 刺激控制法的五个原理： 在疲倦或想睡时才上床 除了睡觉，别在床上看电视、阅读或吃 东西 若无法马上入睡，起床到另一个房间， 呆在那儿直到睡意来袭时才上床睡觉 调好闹钟，无论前一晚的睡眠多少，每 天务必定时起床 别小睡 • 疼痛管理 要达到最佳效益，就必须定时服用止痛药。 若疼痛是妨碍睡眠的主要导因，或许得向 医生询问，调整止痛药的剂量。 • 药物法 服用药物可能产生副作用，因此建议先 尝试行为干预法解决睡眠问题。与此同时， 也得考量失眠的导因，以断定是否该使用 药物或非药物法来应对。 证据显示，生活素质与足够的睡眠息息相关 (Baldwin et al, 2010)。长期的压力或无 法调适心情接受诊断结果及治疗可导致长期 性失眠。长期缺乏睡眠可削减工作及社交能 力，或让人无法在日常生活中取得乐趣。 睡眠障碍也可能影响治疗结果和辅助性措 施。患有睡眠障碍的病人可能会感到烦躁、 无法集中精神。这将导致他们不能遵循治疗 程序，影响他们与家人朋友的感情。因此， 及早识别及诊治癌症病患的睡眠问题将能协 助他们更好地应付日常生活，减少同长期治 疗相关的后遗症。
参考资料 J. Fogel (2003). <<高级临床专科护士电子期刊>>. 3(4) ©2003 Medscape L.Baillargeon, M.Demers & R. Ladouceur 拉都索 (1998).<<刺激控制：失眠症的非药物治疗>>.Canadian Family Physician.44(1)73-79. C.H.Yarbo, M.H.Frogge & M.Goodman (1999).<<癌 症症状管理>>.(第二版). Boston: Jones and Bartlett Publishers. C.A.Engstrom, R.A. Strohl, Rose et al (1999). <<癌症 病患的睡眠改变>>. Cancer Nursing 22(2):143-8. C.M.Baldwin, A.M.Ervin, M.Z.Mays, J.Robbins, S.Shafazand, J.Walsleben & T.Weaver (2010). <<睡眠障碍、生活素质及种族：睡眠心脏健康调查>>.
Journal of Clinical Sleep Medicine, 6(2)176-183.
张月玲 高级护士经理 癌症教育与资讯服务 新加坡国立癌症中心
螺旋断层放射治疗系统： 放射肿瘤科的革新演变
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温柔呵护 SALUBRIS
May / June 2011
螺旋断层放射治疗，也称为“切片治 疗”(Slice Treatment)。它于2010年在 新加坡国立癌症中心启用，是近年来放 射肿瘤科最振奋人心的发展。让我们来 进一步了解这个新仪器为何被誉为放 射肿瘤科领域的另一革新。
放射肿瘤科顾问 宋毓霖医生 首席放射科治疗师 魏忠灵 高级放射科治疗师
Hanifah Bte Syed Ahmad 著 新加坡国立癌症中心放射肿瘤科
何谓螺旋断层放疗？ 螺旋断层放疗所使用的仪器看似和电脑断层扫描器相同（图一和二）。它们不同 的地方在于此仪器产生薄片的扇形兆伏级 X光线来进行治疗，而并非诊断性电脑 断层扫描所使用的千伏级 X 射线。病患躺在治疗床上，随着机头的旋转而进入机 头环入口。因此，辐射束便会在病人身上映出螺旋图案。 机头 机头里的直线加速 器 (Linac) 产生薄 片的扇形辐射束
图（一）
在治疗过程， 病人逐渐进入 机头环内
图（二）
螺旋断层放疗Hi-Art 系统照片
当辐射束在病人身体映出螺旋状图案， 螺旋断层放疗能彩更有针对性地按照 复杂的肿瘤形状进行治疗。螺旋断层 放疗不仅允许逆向计划和调强放射治 疗的使用，治疗也可从病人身体的各 个角度同步进行。此外，仪器也将辐射 束分割成许多狭窄的小波束。这大大 提升了治疗计划的伸缩性，并将高剂 量局限在肿瘤上（图三和四）。
螺旋断层放疗仪的设计 也能摄取电脑断层扫描 图像。放射肿瘤科医生使 用病患在接受治疗前的图 像，与治疗计划中取得的 电脑断层扫描图像作比较。 这样一来就能调整病患 的位置上做出薇小的调整， 以确保辐射更准确。这些 图像也可能用来分析肿瘤 大小的变化、形状以及位 置，从而决定是否得在疗 程中作出任何修改。
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螺旋断层放疗的另一特征是能 让放射肿瘤科医生进行一种 称为“剂量重建”的治疗认证 法。这能使放射肿瘤科医生从 每日的图像中看到计算的治疗 剂量。因此，医生就能断定接 下来的治疗是否该调整，以修 改已完成疗程中的差误。此过 程称为“自适应放疗”。
图（三）：
图（四）：
（右）全身性骨髓照射。高剂量集中在 骨髓上（红色），其他器官，尤其是肺 部和肾脏则幸免。
螺旋断层放疗用来治疗间皮瘤。红色 代表高剂量区。
治疗程序
结论
螺旋断层放疗的时间是根据治疗的复杂性而定，每次约15至30 分钟。首先，治疗师 将病患定位在固定器上，避免病患在治疗中移动。接着，仪器摄取电脑断层扫描图 像，将治疗部分形象化。下一步是图像配准，把刚取得的电脑断层扫描图像与考性 的电脑断层扫描图像做比较。这时也许会对病患的位置作出小调整。
螺旋断层放疗是放射疗法中结合 调强放射治疗、逆向放射治疗计 划、三维成像为一仪器的新概念。 它的两大强项分别在于具备肿瘤导 向剂量递送能力，以及应用机载影 像系统，在每次治疗前能够查证病 患的位置。放射肿瘤科医生也能断 定螺旋断层放疗是否适用于病患 的病情。每名病患情况不一，而熟 悉病患的放射肿瘤科医生便能评 估个别治疗选项，包括使用螺旋断 层放疗Hi-Art 系统进行治疗。
螺旋断层放疗的最大好处之一在于每次治疗之前都会取得电脑断层扫描图像查证。 每日的电脑断层扫描图像能确认病患每次接受治疗的位置。这对治疗某些肿瘤是 有极大帮助的,因为人体日常的变化。例如，直肠或膀胱膨胀可改变前列腺肿瘤的 位置。 螺旋断层放疗的另一特征是能让放射肿瘤科医生进行一种称为“剂量重建”的治疗 查证法。这能使放射肿瘤科医生从每日的图像中看到计算的治疗剂量。因此，医生 就能断定接下来的治疗是否该调整，以修改在疗程中的差异。此过程称为“适形放 疗”。当病患的身体因消瘦或肿瘤缩小产生变化时，医生便能够修改治疗计划及剂 量。这在治疗头颈部肿瘤时特别管用。 过去18个月，国立癌症中心已使用螺旋断层放疗来治疗头、颈部、脑部、肺部、前列 腺以及儿童癌症。它也用来治疗具挑战性并棘手的个案，如已在同个部位接受过放 射性治疗的癌症复发病患身上。以下是治疗程序流程:
索取电脑断 层扫描图像
图像认证
调整治疗 床位置
给予治疗
在接受螺旋断层放疗前，医生会向 病患讲解治疗前的准备、疗程数 量、如何应付治疗副作用，以及营 养的摄取。有了新推出的环机头螺 旋断层放疗Hi-Art 系统，国立癌症 中心将提供另一个结合电脑断层 成像和适形放射治疗，给予快速、 精准的尖端放射性疗程，同时减少 周围健康组织所接触的辐射。
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Outreach
SALUBRIS
May / June 2011
UPCOMING PUBLIC EDUCATION ACTIVITIES / PROGRAMMES
Event Name
Date, Time, Venue
Registration Details
CancerWise Workshop – Reducing Cancer Risk For Women
21 May 2011, Saturday
Admission fee: $5
Session will be in English.
To register, please call: 6225 5655 or online: www.nccs.com.sg (click events).
TOPICS: THE FEMALE REPRODUCTIVE SYSTEM a. Anatomy & Functions b. Common Gynaecological Problems c. Contraceptive Pills & Hormone Replacements Therapy – Are there health risks? d. Other Myths & Misconceptions
1pm – Registration 1.30pm to 4pm – Workshop Function Room, Level 4 National Cancer Centre Singapore 11 Hospital Drive, Singapore 169610
CANCERS OF THE FEMALE REPRODUCTIVE SYSTEM: CERVIX, OVARY AND UTERUS e. f. g. h. i.
Risk Factors, Signs & Symptoms Early Detection & Prevention What is PAP smear? Screening & Treatment procedures Questions & Answers
Bilingual Public Forum – Cancer and Depression TOPICS: a. Chicken and Egg: How depression related to cancer? b. Issues related to depression in cancer patients c. How to help cancer patients manage depression? d. Questions & Answers
28 May 2011, Saturday
Free Admission
MANDARIN SESSION Time: 9.30am to 11am (Registration starts at 9am to 9.30am)
Strictly no admission for children below 12 years old. Registration is a MUST as seats are limited and available on a first-come-first serve basis.
ENGLISH SESSION Time: 1.30pm to 3pm (Registration starts at 1pm to 1.30pm) The URA Centre Function Hall (Level 5) 45 Maxwell Road Singapore 069118
REGISTRATION IS BY PHONE ONLY. Please call: 6225 5655 / 6236 9432 / 6236 9447 (from Monday to Friday, 9am to 5pm)
CancerWise Workshop – Pain Management
9 July 2011, Saturday
Admission fee: $5
Session will be in English.
TOPICS:
1pm – Registration 1.30pm to 4pm – Workshop
To register, please call: 6225 5655 or online: www.nccs.com.sg (click events).
a. What is a pain? b. How does pain occur? c. Why does cancer cause pain? d. Pain Assessment e. Management of pain f. Other options for Pain management g. Medication & side effects h. Questions & Answers
Function Room, Level 4 National Cancer Centre Singapore 11 Hospital Drive, Singapore 169610
RECOGNITION FOR PASSION, DEDICATION OF NCCS STAFF
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People
SALUBRIS
May / June 2011
Six officers win SingHealth Awards. MARK KO reports. It takes more than just qualifications and hard work if you want to pursue a career in a healthcare institution. Certainly dedication and a passion to serve are qualities that the employees should have if they are to cope with the demands of their work in a healthcare environment. These quality traits come across in all the six recipients of this year’s Group Chief Executive Officer (GCEO) Excellence Award and SingHealth Excellence Award – which are annual awards given to employees from various institutions under the SingHealth group. The GCEO Excellence Award is awarded to individuals who had displayed great passion and talent with dedication to their institution, and is the highest tribute bestowed upon staff by SingHealth. Recipients of the award are Dr Ho Gay Hui (Outstanding Clinician Award), Mr Amir Ahmad s/o Dabir Ahmad (Outstanding Administrative Staff Award), Ms Yusnita Binte Omar (Outstanding Allied Health Professional Award), Ms Parvathy d/o Peria Karuppan (Outstanding Ancillary Staff Award) and Ms Lee Kim Hua (Outstanding Nurse Award).
T
he SingHealth Excellence Award is presented to employees in recognition of their outstanding and exemplary performance and contributions, both at cluster and institution level. Dr Lim Soon Thye, Deputy Head, Department of Medical Oncology was conferred the Young Leader Award under this category. Recipients were nominated by their colleagues in SingHealth, backed up by the support of the recipient’s Head of Department. The nominations were substantiated with evidence, specific examples, accompanied by citations on the nominated employees, and submitted to the human resource departments of the respective individuals. MR AMIR AHMAD, who has always gone about his administrative duties unassumingly, said: “I was shocked and surprised when I first got to know that I will be receiving that award.” When asked on what kept him at NCCS, Amir, a cheerful man who will be serving his 10th year of service in June gave a big smile and replied, “NCCS have nice people whom I worked with. I enjoy my work a lot and most importantly, passion is what motivates me everyday.” Amir works in the operations department. Besides his daily paperwork, he also oversees the booking of facilities such as meeting rooms and auditorium in NCCS. His duties include managing of incoming and outgoing mails, managing the carpark and providing assistance to his fellow colleagues in the department. Often, when Amir is not too tied down with his work, he would lend a helping hand to anyone in need of advice on work related matters and provide adequate support for requests from other departments. For MS YUSNITA, the award is an additional push to work even harder. She is a Principal Radiation Therapist in the Department of Radiation Oncology, and she plans and administers radiation treatment for patients.
Constantly serving with a smile, Yusnita has also established good working relationships with her colleagues at NCCS. “I was speechless and never expected to receive any awards,” she said. “Winning the award serves as a recognition and motivation for me to work harder. At the end of the day, it feels good to have put a smile on the faces of people whom I have served and knowing that I have played a part in their life,” she added. MS PARVATHY, the Team Leader of the Call Centre, has been with NCCS for 12 years. She oversees the daily operations in the call centre. There are times when she has to answer difficult callers but that did not deter her from providing good service. Prior to receiving this award, in 2009, Ms Parvathy was the recipient of the Excellence Service Award. “I always put myself in the callers’ shoes to understand how they feel. I will listen attentively to what they say and try my best to help them,” she explained. “I will always go the extra mile to help the patients.” Continued on page A6.
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People
SALUBRIS
May / June 2011
RECOGNITION FOR PASSION, DEDICATION OF NCCS STAFF
Continued from page A5.
The Outstanding Nurse Award recipient, MS LEE KIM HUA when responding to a written interview said: “I felt honoured, immensely proud and privileged to receive this award.” Ms Lee is currently doing a Master's degree programme in the United States. “This award symbolises the true value of care and compassion in my job as a nurse beyond my personal success,” she wrote. Ms Lee works in the Ambulatory Treatment Unit (ATU) as a Nurse Clinician. One of her priorities is to ensure that appropriate care is rendered to the patients receiving chemotherapy at ATU. Ms Lee also mentors the junior staff, observing their learning progress and their ability to coach others. She worked closely with the nurse manager, Sister Mag Tan to identify service and clinical gaps to improve procedures for the patients. “Kim Hua is an excellent staff who puts her heart and soul into achieving her goals and institution’s goals. We work hand in hand to develop a culture where ATU staff can apply their six sense to treat patients,” said Sister Mag. Ms Lee has been a nurse for about 11 years. What has helped her to thrive is the sense of achievement she derives. “Being able to accomplish my job well by overcoming obstacles along the way has been most satisfying and fulfilling. Although the basic knowledge and research were central, the experiences that I learned from the interaction with patients were equally critical and rewarding,” she said. To qualify for the GCEO Excellence award, individuals have to achieve professional excellence by contributing significantly towards elevating the quality of healthcare delivery and for the benefit of the Singapore community. It also includes possessing values such as professionalism, exceptional commitment and passion towards patient care and outstanding behaviour and team spirit in achieving SingHealth / Institution’s goals. DR HO GAY HUI’s care and concern for patients had won her many accolades. She has been receiving various recognition for her dedication and commitment to NCCS since 2003, where she was conferred with the Courage Medal in recognition of her commitment and courage during the SARS outbreak. This year, besides receiving the SingHealth Excellence Award, Dr Ho’s commendable efforts also saw her being conferred with the Healthcare Humanity Award presented by The Courage Fund. This award is given out to distinguished healthcare workers who are inspirational models that go the extra mile to offer care and comfort to the sick and the infirmed annually. DR LIM SOON THYE, Deputy Head in the Department of Medical Oncology received The Young Leader Award in recognition of his contribution to NCCS and for demonstrating skills in strategic thinking and bringing innovative ideas. He has also been an inspiration to his colleagues to achieve higher standards.
Throughout his 10 years of service, he has been active when in education, research, administration and mentoring his charges. He has been proactively pushing various new initiatives since his days as a training director in the department. He also extended a regular teaching platform to help senior colleagues organise teaching materials to produce structured training programmes. At the same time, he has also been initiating numerous research projects. During his four-year tenure as the President of Singapore Society of Oncology (SSO), he spun off a series of international collaborations and put SSO into the international arena. He also helped to strengthen the finances of SSO. “Dr Lim is always willing to learn new things and take up new challenges,” said Dr Kevin Tay, Associate Consultant, Department of Medical Oncology, who has been a colleague of Dr Lim for the past year. “It is good to know that you can count on someone to get things done right and well. He is a good mentor to our medical students and junior staff who have joined the department. He leads by example, and is always available and willing to help any of the juniors if any problem arises.” Dr Lim has led many of his mentees to win awards locally and internationally and also recognition for their published papers in peer journals. His efforts have helped the department to become one of the most prolific clinical departments in SingHealth. On weekends, he sets aside some time in the evenings to promote the ‘Teach Me’ programme, to help the underprivileged children to find tutors. The ‘Teach Me’ project is a tuition programme aimed at helping children of needy cancer patients to improve their academic performance.
WELL DONE TO ALL OUR RECIPIENTS. YOU HAVE DONE NCCS PROUD.
SHARING PLATES… SHARING LIVES, SHARING HOPE
Hippocrates, the father of western medicine once said ”Let your medicine be your food and your food be your medicine.” It simply means, eating right will keep your body healthy and in good condition. Cancer patients find it even more important to eat right. Cancer treatments such as surgery, radiation therapy, and chemotherapy are designed to stop the spread of cancer by killing the cancerous cells. Unfortunately, in the process of radiation therapy and chemotherapy, many of the body's healthy cells are also damaged or destroyed.
PAGE A7
Community
SALUBRIS
May / June 2011
Sharing Plates is a charming booking with a compilation of 40 mouthwatering recipes and heartwarming stories from those who have been touched by cancer. It is a reminder of their great culinary skills and the rich lives they lead. This cookbook is truly from the cancer community to the Singapore community – a true labour of love for everyone involved. Each recipe is tried and tested by award winning Chef Pang Nyuk Yoon using ingredients which are locally available and their nutritional values vetted by NCCS Principal Pharmacist, Ms Chang Yok Ying and UK registered dietician, Mr Phua Tien Beng. Each recipe featured is unique and have been modified to suit the altered tastes and appetites as a result of cancer and its treatments. Any patient undergoing cancer treatment will find this book to be an essential asset.
Six final-year students from the Nanyang Technological University’s Wee Kim Wee School of Communications and Information (WKWSCI) embarked on a campaign to raise more awareness about eating well during cancer. This project is a collaborative effort between the Nanyang Technological University (NTU) and the National Cancer Centre Singapore (NCCS). From left to right: Rhys Lim, Goh Jien,Rachel Koh, Joan Kuang, Ng Jiamin and Kuek Jinhua.
P
roper nutrients assist the body in rebuilding damaged cells. Eating the right foods and avoiding the wrong ones may be difficult to adjust to at times, but it is certainly possible. The side effects of the cancer treatment can often interfere with the act of eating itself. Cancer patients can develop eating problems such as loss of appetite, nausea, vomiting, diarrhoea, constipation, mouth blisters or dry throat and mouth, changes in taste, and fatigue. Anyone affected by cancer knows that patients lose their strength and appetite while fighting the disease. In order to improve their nutrition and recover, they still have to eat. But what? The objective of this project is to introduce to cancer patients and their caregivers simple and palatable dishes they can prepare and share with their families during their treatment phase. This book project aims to educate those affected by cancer that eating at the time of their illness can be an enjoyable experience and need not be bland and tasteless.
Since its soft launch on 5 March at one of NCCS’ Public Forum, close to 2,000 books have been sold. It has also received media publicity namely in the Straits Times, Prime Time Morning, LianHe Zaobao, 938 LIVE , FM 100.3 and many more. Sharing Plates also has an unspoken mission which is to increase people’s confidence in the kitchen. All too often recipe books have hundreds of recipes with only a handful that you can actually use. Sharing Plates is not full of hard to read recipes with ingredients that you cannot find anywhere. The dishes are easy to make and great to eat. It is hoped that patients and cancer survivors in the community and their families will enjoy using this cookbook and be a testimony that eating or cooking need not be bland and boring for those who are going through their fight through cancer. This is a good, healthy cookbook that can be used by anyone to prepare healthy everyday meals. Sharing Plates is currently only available at the National Cancer Centre Singapore at $15. To purchase a copy, please contact 6236 9440 or email donate@nccs.com.sg. For online orders, please visit NCCS website www.nccs.com.sg and complete the online booking form.
By Flora Yong
Manager, Community Partnerships Division of Community Outreach & Philanthropy, NCCS
BEING G.R.E.A.T. @ NCCS
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Community
SALUBRIS
May / June 2011
As the familiar adage goes “Charity Begins at Home”, that phrase formed the basis of the “G.R.E.A.T. @ NCCS” campaign which was launched within NCCS to create awareness and to encourage NCCS staff to participate in the Employee Give-Back Programme (EGBP). The EGBP allows NCCS staff to make a small monthly contribution via their payroll to support cancer research and various initiatives to improve patient care and experience.
P
rof Soo Khee Chee, Director of NCCS said during his address at NCCS’ Annual Staff Appreciation Week, “We cannot expect the community to do what we are not prepared to do ourselves.” It makes perfect sense. If we are not prepared to support our own home organisation, why should members of the public pay any attention and donate to our research efforts and patient care causes. One of the objectives of the “G.R.E.A.T. @ NCCS” campaign is to create awareness about the spirit of giving & promoting a culture of kindness within the walls of NCCS.
G.R.E.A.T. stands for: G IRO donation in support of NCCS R esearch in cancer E ducation for patients, caregivers and healthcare workers A ssistance in welfare to patients and families T raining for patients, caregivers and volunteers It is important for NCCS donors and supporters to witness that NCCS staff believe and support their own organisation’s causes, vision and mission. Motivation and encouragement fuels actions. It is hoped that the “G.R.E.A.T. @ NCCS” campaign will be able to move and motivate each staff to action. Casting the G.R.E.A.T. net further, we hope to be able to touch the hearts of the Singapore community so that they too can be G.R.E.A.T. supporters of NCCS. Editorial Advisors
Contributing Editor
Medical Editor
Dr Kon Oi Lian Prof Soo Khee Chee
Dr Wong Nan Soon
Dr Richard Yeo
Members, Editorial Board
Members, Medical Editorial Board
Mr Mark Ko Ms Sharon Leow Dr Shiva Sarraf-Yazdi Ms Flora Yong
Ms Lita Chew Dr Mohd Farid Dr Melissa Teo Dr Teo Tze Hern Dr Deborah Watkinson
Executive Editors Ms Veronica Lee Mr Sunny Wee
One in four people will die of cancer. The importance of finding a cure and urgency in meeting the impending needs of cancer patients are significant. Last year, NCCS had 128,000 patient visits. NCCS is not just a cancer institution. It is the community’s cancer hospital, providing services from basic research to diagnosis, to treatment and to palliative care. NCCS needs the support of its staff and the community to carry on doing the important work it does in research, in treatment, in education and in providing care.
Please support us and you too can be G.R.E.A.T. To donate to cancer research, please visit http://www.nccs.com.sg/DivCOP/03.htm
By Joe Chia
Executive, Community Partnerships Division of Community Outreach & Philanthropy, NCCS
SALUBRIS
is produced with you in mind. If there are other topics related to cancer that you would like to read about or if you would like to provide some feedback on the articles covered, please email to salubris@nccs.com.sg.
NATIONAL CANCER CENTRE SINGAPORE Reg No 199801562Z
11 Hospital Drive Singapore 169610 Tel: (65) 6436 8000 Fax: (65) 6225 6283 www.nccs.com.sg