Salubris Oct - Dec 2012 by National Cancer Centre Singapore

Issue No. 23 • MICA (P) 061/10/2010

AN NCCS QUARTERLY PUBLICATION October – December 2012

...HELPING R E A DER S TO ACHIEV E GOOD HE A LT H

PUBLIC VERSION

Salubris is a Latin word which means healthy, in good condition (body) and wholesome.

INTRODUCTION TO PALLIATIVE CARE

REFLECTIONS OF 2012 WITH STORIES OF LOVE AND HOPE

SALUBRIS OCTOBER – DECEMBER 2012

DERMATOLOGICAL EFFECTS OF CHEMOTHERAPY

NAIL DISORDERS Nail cells divide rapidly and thus, become very sensitive to the side effects of chemotherapy drugs. Several nail changes that are associated with chemotherapy include banding, discolouration, onchylosis, paronychial inflammation and subungual splinter haemorrhages.

BY AFIDAH BINTE ABDUL MANAF Principal Pharmacist Department of Oncology Pharmacy, NCCS

Chemotherapy drugs given intravenously or orally can cause a number of changes to the skin, mucous membranes, hair and nails. Thus, when dermatologic lesions arise in patients being treated for cancer, they need to be properly assessed to exclude the possibility of more serious causes such as infection, metastatic tumour involvement, paraneoplastic phenomenon, exacerbation of a previously existing condition, graft-versus-host disease or a nutritional disorder. This article will mainly discuss the common dermatological effects specifically caused by chemotherapy.

ACRAL ERYTHEMA (HAND-FOOT SYNDROME) This effect is most common in patients receiving fluorouracil via continuous infusion, capecitabine or liposomal doxorubicin. Symptoms usually develop two to 12 days after drug administration. It may start with a tingling or burning sensation on the palms and soles of feet, followed by an intense, symmetrical erythema and swelling several days later. Patients may experience discomfort and pain, with development of vesicles and bullae in the next two days. Blistering is common over pressure areas, followed by desquamation (peeling), hyperkeratosis (thickening) and re-epithelialisation (healing). Patients are advised to apply emollient, a soothing cream at the start of therapy followed by exfoliating agents such as urea containing products for hyperkeratotic calluses. Regional cooling strategies such as cold compress may relieve pain. Patients may also need systemic analgesics for pain management. They should avoid hot water and sunlight as a warm environment can worsen the condition.

ACNEIFORM RASHES This effect is the most common in patients receiving epidermal growth factor receptor (EGFR) inhibitor such as Gefitinib, Erlotinib, Cetuximab and Lapatinib. The onset of rashes can occur seven to 10 days after the start of treatment and they usually arise on the T-zone of the face (forehead, chin, and nose) but can also occur on the upper chest and back. Some patients may even have extensive rashes that cover their entire body. The intensity and severity of the rashes may fluctuate and improve over time despite the continued treatment of these agents. Patients undergoing EGFR inhibitor therapy are advised to moisturise the dry areas of the body twice a day with thick alcohol-free emollient and use a sunscreen of SPF 15 or greater. The method of treatment of rashes depends on its extensiveness. A mild, asymptomatic rash may not require treatment while rashes that cause itch may require topical antibiotic in combination with oral antihistamines for pruritis.

Banding is the formation of pale white lines or grooves across the nail plates and is usually asymptomatic.

Patients undergoing EGFR inhibitor therapy are advised to moisturise the dry areas of the body twice a day with thick alcohol-free emollient and use a sunscreen of SPF 15 or greater.

Patients with moderate rash with itch and signs of confluence may need to be started on oral antibiotics. When rashes become severe with pain and ulceration, the discontinuation of EGFR inhibitor is strongly recommended, with concurrent high dose of antihistamines and antibiotics. Severe reactions where the skin becomes exfoliative with ulcerative dermatitis are extremely rare. Patients need to be treated in the burns unit if such incidences occur and should not be re-challenged with the EGFR inhibitor.

IMMUNE-MEDIATED HYPERSENSITIVITY REACTIONS All chemotherapeutic agents have the potential to initiate an infusion reaction. There are different types of skin rashes that can accompany infusion reactions of chemotherapy drugs either in the setting of an anaphylactic reaction or a mild “standard infusion reaction”. Although they are generally infrequent, these reactions occur more frequently with chemotherapy drugs such as paclitaxel, docetaxel, carboplatin and oxaliplatin.

The method of treatment of rashes depends on its extensiveness. A mild, asymptomatic rash may not require treatment while rashes that cause itch may require topical antibiotic in combination with oral antihistamines for pruritis.

Most reactions involve type I hypersensitivity and are presented with urticaria, pruritis, angioedema and flushing. Severe anaphylactic reactions can occur and cause hypotension, shock and occasional death. Pre-medications prior to the administration of the above chemotherapy drugs are usually given to prevent such incidences.

PIGMENTARY CHANGES This effect, involving the skin, nails and mucous membranes, is common in patients receiving cytotoxic agents such as alkylating agents and antitumour antibiotics. The pigmentary changes usually resolve with drug discontinuation. One way to minimise the risk of hyperpigmentation is to avoid sun exposure and make appropriate sun barrier preparations. Fluorouracil is one of the most commonly used drugs in cancer patients and it can be given via intravenous infusion, continuous infusion or orally. Some of its common side effects are the darkening of nail beds, inducement of the mucosal pigmentation of the tongue and conjunctiva.

Onchylosis is the separation of the nail plate from the nail bed and can occur with chemotherapy drugs such as anthracyclines, taxanes and fluorouracil. Managing this effect includes the application of anti-microbial solutions, maintenance of short nails and avoidance of contact with irritants. Paronychial inflammation happens when the nails and skin surrounding them progressed from redness to swelling to inflammation to pus formation around the affected nails. This can be very painful and affects the quality of life. Some ways to manage this effect are to avoid friction and pressure on the nail folds by wearing loose-fitting shoes, apply topical antiseptic creams to prevent infections and apply topical steroids to prevent initial lesions from becoming more severe in conjunction with antiseptic creams. Lastly, subungual splinter haemorrhages resemble wood splinters under the nails that are straight black lines which will move forward as the nail grows. They are usually harmless and occur in patients receiving Sorafenib or Sunitinib.

RADIATION RECALL Radiation recall is an inflammatory reaction that sometimes occurs when an individual receives chemotherapy following radiation therapy for cancer. The symptoms can occur just a few days after radiation therapy is completed, or years later. It is uncertain how often this reaction happens, but one study estimated that it occurs in nine percent of people who go through both radiation therapy and chemotherapy for cancer.

The symptoms of radiation recall are due to inflammation in a region that was previously treated with radiation. The most common type of reaction is a skin rash involving redness, swelling, and/or blistering of the skin. The rash is often painful and has the appearance of severe sunburn. Other regions that may be affected include the mouth (radiation recall mucositis), larynx, esophagus, stomach, small intestine, lungs (radiation recall pneumonitis), muscles (radiation recall myositis), and the brain. Though radiation recall is most commonly reported with chemotherapy drugs, other medications such as antibiotics and herbal supplements have been linked with a radiation recall reaction. The chemotherapy drugs most commonly associated with radiation recall include: doxorubicin, docetaxel, paclitaxel, gemcitabine and capecitabine. The treatment for a radiation recall reaction is primarily supportive care – managing symptoms until the problem resolves on its own. Eliminating the source of the reaction (for example, discontinuing the chemotherapy drug felt to be responsible) is often the first step. Medications such as corticosteroids and anti-inflammatory preparations may be used in some cases to decrease the inflammation. For radiation recall dermatitis, wearing loose-fitting clothing made of nonirritable fabrics might make you feel more comfortable. Using a cool compress has helped some people manage the discomfort, but it is important to check with your doctor regarding his/her recommendations. While the rash is healing, it is important to avoid worsening the rash, such as being excessively exposed to the sun and sunburns. Unfortunately, it is impossible to predict if someone will react to a particular chemotherapy drug or other medications after radiation therapy. Even if someone has had a radiation recall reaction before, it may or may not occur a second time. Radiation recall does seem to be less common when the time interval between radiation therapy and chemotherapy is longer, but considerations other than radiation recall are often more important in decisions regarding the timing of treatments.

SALUBRIS OCTOBER – DECEMBER 2012

化疗对皮肤产生的影响

甲损害甲细胞分裂快速，因此对化疗药

AFIDAH BINTE ABDUL MANAF

物的副作用非常敏感。与化疗相关

肿瘤学化疗首席药剂师肿瘤学化疗药剂部门新加坡国立癌症中心

的甲变化包括条纹、变色、脱甲、甲沟炎及甲下线状出血。受化疗药物影响的甲板，可能出现

静脉注射或口服化疗药物，都会使皮肤、粘膜、毛发和指甲产生一些变化。因此，当癌症病患出现皮肤问题时，他们必须接受适当的检查，以排除其他更严重的因素，如感染、转移癌、肿瘤伴随症候群、病情恶化、移植物抗宿主病或营养失调。本文将主要讨论化疗所引起的常见皮肤问题。

淡淡的白线或布满凹洞，一般没有任何症状。脱甲即甲板和甲床分离，引发此症状的化疗药物包括葱环类药、紫杉

接受表皮生长因子受体治疗的病患，应每天两次以无酒精的润肤剂涂抹身体干燥部位，以及使用防晒度15 （SPF 15）或更高的防晒霜。

皮疹的治疗方式取决于受影响部位的面积。轻微、无症状的皮疹可能无须治疗，而引起瘙痒的皮疹则可能在涂抹外用抗生素之余，也必须服用治疗瘙痒的口服抗组胺药。

醇及氟尿嘧啶。护理这类症状的方法包括使用抗微生物药剂、将指甲剪短及避免接触刺激物。当甲及周围皮肤从发红、肿胀至发炎，脓液在受影响指甲周围形成，就是所谓的甲沟炎。病患会感到非常疼痛，影响生活素质。其中一些

肢端红斑（手足综合症）肢端红斑最常见于通过持续静脉滴注输入氟尿嘧啶，进行卡培他滨或阿霉素脂质体治疗的病患，症状一般在用药两至12天后出现。一开始，病患可能会感觉手掌和脚跟有刺痛或灼热感。数天后，病患会出现明暗度强的对称性红斑及肿胀。病患可能会感觉不适和疼痛，并在接下来两天内出现大大小小的疱。受压皮肤起泡是很常见的，接着是脱屑（皮层剥落）、角化过度（皮层增厚）及表皮细胞再生（复原）。病患应在开始接受治疗时，涂抹镇静皮肤的润肤剂，然后使用针对过度角化老茧的含尿素去角质产品。冷敷等局部降温法，也可减轻疼痛。病患也可能须要服用全身镇痛药，以控制疼痛。他们也应避免接触热水和阳光，因为温热的环境会导致病情恶化。

痤疮状疹

患有会瘙痒的中度皮疹并出现汇合

大多数反应包括第一型过敏性反

迹象的病患，可能必须开始口服抗

应，症状包括荨麻疹、瘙痒、血管

痤疮状疹最常见于进行吉非替

生素。如果皮疹恶化，伴随疼痛和

性水肿及红潮。病患也可能出现严

溃疡，就应停止表皮生长因子受体

重的过敏性反应，导致低血压和休

治疗，并服用高剂量的抗组胺剂和

克，甚至死亡。在使用上述化疗药

抗生素。脱屑、溃疡性皮肤炎的严

物之前，先服用一些预防性的药物，

重反应极为罕见。若出现这样的情

可避免发生这些状况。

尼、埃罗替尼、西妥昔单抗及拉帕替尼等表皮生长因子受体治疗的病患。症状在治疗开始七至

10 天后出现，一般影响脸部T区（额头、下巴和鼻子），但也可能影响上胸及背部皮肤。有些病患甚至全身都会出现皮疹。虽

况，病患必须在烧伤部接受治疗，而

然持续接受这些药物治疗，但皮疹的严重程度会渐渐有所变化和改善。接受表皮生长因子受体治疗的病患，应每天两次以无酒精的润肤剂涂抹身体干燥部位，以及使用防晒度15（SPF 15）或更高的防晒霜。皮疹的治疗方式取决于受影响部位的面积。轻微、无症状的皮疹可能无须治疗，而引起瘙痒的皮疹则可能在涂抹外用抗生素之余，也必须服用治疗瘙痒的口服抗组胺药。

免疫造成的过敏反应所有化疗药物都可能引发输液反应。无论是过敏性反应，或轻微的 “标准输液反应”，化疗药物所引起的输液反应，可能伴随不同类型的皮疹。虽然不常见，但这些反应比较容易由紫杉醇、多西紫杉醇、卡铂和奥沙利铂等化疗药物引发。

宽大的鞋子，涂抹外用消炎药膏预防感染，并同时涂抹外用类固醇以避免病情恶化。最后，甲下线状出血的情况，就好像甲板下有木屑，而这些黑色直线会随着甲板的生长而往前移动。它

且不应再尝试进行表皮生长因子受体治疗。

护理方法包括避免磨擦和施压，穿

通常是无害的，常见于接受索拉非

色素变化涉及皮肤、指甲和粘膜的色素变化，常见于进行烷化剂和抗肿瘤抗生素等细胞抑制剂治疗的病患。一般上，停止服用药物后，色素变化问题也将跟着消失。减少色素沉着风险的方法之一，就是尽量避免阳光曝晒，并采取适当的防晒措施。静脉滴注、连续输注或口服氟尿嘧啶，是癌症病患最常使用的药物之一。此药物的常见副作用包括甲床颜色变暗、舌头和结膜色素沉着。

尼或舒尼替尼治疗的病患。

辐射回应是由于接受放射治疗的部位发炎而引起的。最常见的是伴随发红、肿胀、以及/或起泡的皮疹。这类皮疹往往会让病患感觉疼痛，看起来像被严重晒伤。其他可能受影响的部位包括嘴巴（辐射回应粘膜炎）、喉咙、食道、胃、小肠、肺（辐射回应肺炎）、肌肉（辐射回应肌炎）及大脑。虽然辐射回应经常与化疗药物有关，但抗生素和草药保健品等药物也可能引发辐射回应。最常跟辐射回应有关的化疗药物包括阿霉素、多西紫杉醇、紫杉醇、吉西他滨及卡培他滨。辐射回应的疗法主要是支持性护理— —控制症状直到问题自行解决。第一个步骤往往是消除引起反应的来源（例如停止使用可能引起反应的化疗药物）。为了减少发炎，有些病患可服用皮质类固醇及抗炎制剂等药物。辐射回应皮肤炎患者，应穿非刺激性布料制成的宽松衣物，让自己比较舒服。冷敷也有助于纾缓不适，重要的是必须先咨询医生的意见。在皮疹康复期间，以免症状恶化，不要过度曝晒和晒伤。遗憾的是，没有人可以预测病患是否会在放射治疗后，对某种化疗药物或其他药物产生反应。即使一些病患曾出现辐射回应症状，但该症状未必会复发。当放射治疗和化

辐射回应辐射回应现象是一种发炎反应，偶尔会发生在接受癌症放射治疗后的化疗病患身上。症状可能在放射治疗的数天后出现，也可能在几年后才出现。虽然无法确定这类反应的发生频率，但有一项研究估计，9% 接受放射治疗和化疗的病患会受影响。

疗之间的间隔时间较长，辐射回应似乎就不太普遍。不过，在决定治疗时机时，其他因素往往比辐射回应来得更为重要。

SALUBRIS OCTOBER – DECEMBER 2012

SO, WHAT IS SELF-ESTEEM? According to psychologist Dr Wendy Schain (n.d.), she describes self-esteem as being made up of four components:

NET WORTH OF PHYSICAL SELF – the appearance and functional ability of your physical body

SOCIAL SELF – your relationships and the emotional support that you can receive from others

TOTAL SUM OF ACHIEVING SELF – the achievements that you have accomplished in different areas of your life

SPIRITUAL SELF – the strength that you draw from your spiritual and moral beliefs Cancer treatment takes time and can be costly. It may adversely impact your physical functioning, relationships with others, your work, studies and even your spiritual faith.

IMPACT OF CANCER AND TREATMENT ON SELF-IMAGE AND SELF-ESTEEM BY TRAVIS LOH KOK WAH Senior Medical Social Worker Department of Psychosocial Oncology, NCCS

Coping with cancer can be challenging for many cancer patients. There may be many struggles and concerns that a cancer patient faces in his/her cancer journey. One of these concerns can be the impact of the illness on self-image and self-esteem.

elf or body image refers to how one perceives his/her own appearance, even though it may not be the way other people see him/her. Looking good is important and how one looks can affect how one feels about him/herself. Therefore, the overall physical appearance can be said to influence self-esteem.

Physical changes caused by cancer and its treatment are unique to each patient/survivor. They can prevent you from studying, working or doing the things that you used to enjoy prior to cancer. Such changes include:

• Temporary side effects of treatment such as hair loss, skin/nail changes, weight loss, numbness in limbs etc. Permanent physical changes include permanent stoma and amputation. • Scars and disfigurement caused by surgeries. • Other body losses such as incontinence, loss of femininity or masculinity, and loss of eyesight and hearing. Physical changes due to cancer or treatment can be very distressing as they can reduce one’s selfconfidence. This may cause a significant impact on the self-esteem and eventually the strength and will to overcome the challenges of cancer and its treatment.

Even if the physical changes are hidden and not noticeable by others, it can also have an impact on the self. Body image is about how one feels about his/her body and not how it actually looks to others. Hence, even if there are no physical changes, one may still feel as though he/she is being seen differently and that he/she is unable to relate to others. The feelings of uncertainty and insecurity may then affect one’s body image. With poor body image and low self-esteem, it can impact one’s intimacy with his/her partner. For example, women who have undergone a mastectomy may find it difficult to be intimate with her partner due to mental, physical and emotional barriers. She may feel ashamed, self-conscious and anxious about her body. Intimacy is not just about sex; it is also about the physical (touching, holding and hugging), mental (ability to care for the other person) and emotional (sharing of feelings such as fears and hopes) connection that one shares with his/ her partner. The ability to connect and feel supported can have an impact on a patient’s quality of life. The following are some possible signs of a poor body image and low self-esteem affecting a patient’s quality of life:

• Not wanting to leave the house because of the fear of people seeing him/her • Avoiding intimacy or sex with his/her partner • Feeling ashamed for having cancer • Not being able to accept him/ herself after the cancer diagnosis

Some coping strategies that patients can adopt to build a more positive body image and self-esteem: 1. Regaining confidence in your appearance • Wear clothes that you like and which can make you feel good about yourself • Camouflage the body changes by using make-up, wigs, prostheses or clothing • Enroll in the “Look Good Feel Better” programme 2. Broadening of perspective. If you focus only on your physical appearance and losses, you may overlook the other strengths, interests and talents in your life. For instance, a cancer patient may pick up a new hobby such as painting as a way of expressing what he/she is experiencing and feeling. Also, while it may be physically challenging for a patient to engage in strenuous exercises, he/she may still enjoy light exercises such as morning walks. The focus is now shifted to building up on what you enjoy and can do. 3. Allowing yourself the space and time to get used to the physical changes and how you feel about yourself. Go slow and do things at a comfortable pace. Over time, your body image will improve as you adjust mentally and emotionally to life after cancer. 4. Sharing of any sexual concerns that you may have with your partner. Taking the first step to talk about intimacy issues may be difficult. However, it is also likely that your partner is as concerned as you are over these issues. Open communication helps to build the couple’s relationship and in turn, enhance the emotional support between each other. 5. Building up your support network by talking to other patients and survivors who share similar struggles with body image and self-esteem. Join a support group where you can share your experiences, learn new coping methods and talk about your feelings in a safe environment. 6. Strengthening your spiritual life. Spirituality may or may not be tied to a particular religion. According to Sherfield (n.d.), spirituality is about the inward exploration of the self to gain inner peace and understanding. It involves the appreciation of self, the environment and the role one plays in the “big picture of life”. A strong sense of spirituality may bring about a greater sense of inner peace, purpose and belonging which will ultimately strengthen one’s self-esteem. 7. Seeking professional counselling for yourself and your loved ones. You may wish to speak to a medical social worker in the hospital.

At the end of the day, when cancer patients are able to better manage and deal with body image and self-esteem concerns, they gain greater confidence and are empowered to be in control of their lives.

REFERENCES:

Emotional impact of cancer and its treatment. [n.d.]. Retrieved from the Australian Cancer Survivorship Centre Website: http://www.petermac.org/cancersurvivorship/ Emotionalimpactofcanceranditstreatment

Rebuilding self-esteem. [n.d.]. Retrieved from the American Cancer Society Website: http://www.cancer.org/Treatment/TreatmentsandSideEffects/PhysicalSideEffects/Sexual SideEffectsinWomen/ SexualityfortheWoman/sexuality-for-women-with-cancer-self-esteem

Self-esteem and cancer treatment. [n.d.]. Retrieved from thefactsabout.co.uk Website: http://www.thefactsabout.co.uk/content.asp?menuid=45&submenuid=180&pageid=180&menuname= Self%2Desteem+and+cancer+treatment&menu=sub

Sherfield, R. M. [n.d.]. Why spirituality matters. Retrieved from the netplaces Website: http://www.netplaces.com/self-esteem/spirituality/why-spirituality-matters.htm

SALUBRIS OCTOBER – DECEMBER 2012

那么，何谓自尊心？心理学家谢恩博士 (Dr Wendy Schain) 指出，自尊心包含以下四个部分：

1 2 3 4

身体净值— —外表和身体功能社交— —感情关系以及所能得到的情感支援成就总值— —在各种领域所取得的成就精神生活— —从精神和道德信仰中获得的力量

癌症治疗需要耗费时间和金钱。它可能会对病人的身体功能、和别人的关系、工作、学业，甚至宗教信仰带来负面的影响。

癌症及其治疗对病人自我形象与自尊心的影响罗国华高级医疗社工心理社会肿瘤学部门新加坡国立癌症中心

对许多癌症病人来说，面对癌症是一项极其艰巨的挑战。在抗癌的过程中，癌症病人得面对很多困难和担忧，包括疾病对病人自我形象与自尊心的影响。自我形象指的是个人对自己外表的看法，这不一定是其他人对他/ 她的印象。一个人的外表好看与否是很重要的，它会影响个人对自己的看法。因此，整体形象会影响一个人的自尊。

每个癌症病人/幸存者，所面对的癌症及其治疗所引起的身体变化各不相同。这些变化可能会让他们无法继续学习、工作或做自己在患癌之前喜欢的事情。一些变化包括：

• 暂时性的副作用，如脱发、皮肤/指甲出现变化、体重下降、手脚麻木等。永久性的身体变化包括永久性的造口和截肢

即使身体上的变化不明显及不容易被察觉，它也可能给病人带来一定的影响。形象是一个人对自己身体的感受，而不是它在别人眼中的样子。因此，即使没有任何身体变化，他们还是会觉得别人向自己投下异样的眼光，而无法跟别人沟通。这种不确定和局促不安的感觉，可能进一步影响病人的自我形象。不良的自我形象及缺乏自尊心会影响病人与伴侣之间的亲密关系。例如，接受乳房切除手术的女性可能因身体、精神和情感上的障碍而难以跟伴侣亲密。她可能觉得羞愧、不自在，以及对身体感到忧虑。其实，亲密不只是指性行为，还包括了肢体接触（触摸、牵手、拥抱）、心理（关怀别人），以及病人跟伴侣的情感联系（分享心情如忧虑和期盼）。能够跟别人沟通和感到被支持，有助于提高病人的生活素质。以下是一些因不良的自我形象及缺乏自尊心而影响生活素质的迹象：

• 怕别人看到自己而不愿意出门 • 避免跟伴侣有亲密接触或发生性关系

病人可通过以下方法建立一个更美好的形象，以及提高自尊心： 1. 恢复对外表的信心

• 穿自己喜欢及让自己漂亮的衣服

• 利用化妆品、假发、假体或服饰掩饰身体上的变化

• 参加“亮丽外表，美好人生”活动

2 . 开阔视野。如果病人只注重自己的外表和不幸，那他可能忽略了自己

的其他优势、兴趣和才华。例如，癌症病人可以培养新嗜好如画画，来表达自己的体验和心情。此外，虽然病人可能无法进行剧烈运动，但他/她仍然可以享受轻松的运动，如早晨漫步。病人现在应该把注意力转向自己喜欢并可以做到的活动。

3 . 给自己更多时间和空间去习惯一些身体变化，以及对自己的感觉。放慢脚步，以自己舒适的步伐做事情。当病人在心理和情感上都适应自己患癌后的生活时，自我形象就会渐渐提升。

4. 病人应该跟伴侣分享自己对性生活的任何顾虑。主动谈论亲

密话题也许很困难，但伴侣很可能也对这方面的问题有相同的顾虑。坦诚沟通有助于增进夫妻之间的感情，加强彼此给对方的情感支持。

5 . 跟其他同样面对自我形象和自尊心问题的病人及幸存者聊

天，建立自己的支援网络。参加互助小组，分享自己的经验，学习别人的应对方法，以及在一个安全的环境里诉说自己的心情故事。

6 . 加强自己在精神层面的追求。精神上的追求不一定是指病人必须

拥有宗教信仰。根据谢菲尔德的说法，精神上的追求指的是自我对内在平静与了解的一种探索。它包含了对自我和环境的评价，以及自己在生命的整个过程中所扮演的角色。加强自己在精神层面的追求，可以带来更大的内心平静、意志力和归属感，从而增强自尊心。

7. 为自己和亲人寻求专业咨询。病人可以联系医院里的医疗社工。

• 因患癌而感到无地自容

当癌症病人能够更好地处理和面对自我形象与自尊心问题时，他们就会更有自信、更能掌控自己的生活。

• 手术造成的疤痕和缺陷

• 被诊断出患癌后，无法接受自己

• 身体的其他影响，如失禁、失去女性或男性特质，以及失明和失聪

REFERENCES:

Sherfield, R. M. [n.d.]. Why spirituality matters. Retrieved from the netplaces Website: http://www.netplaces.com/self-esteem/spirituality/why-spirituality-matters.htm

癌症或治疗所造成的身体变化会降低病人的自信心，让他们感到难过。这可能会对病人的自尊心带来很大的影响，最终导致他们丧失克服癌症与治疗的勇气和意志力。

SALUBRIS OCTOBER – DECEMBER 2012

NCCS LEADS ANTI-LIVER CANCER ADVOCACY WITH WALKATHON

SERVICE EXCELLENCE: NCCS STAFF LEARNS TO BETTER UNDERSTAND CANCER PATIENTS

The sunny morning of August 25 saw a sea of yellow slowly gathering along the Alexandra Park Connector. These early birds were up for a good cause – to take part in this year’s Liver Cancer Awareness Month Campaign jointly organised by NCCS and SGH. CHARISSA ENG reports.

Difficult, demanding or unreasonable patients – it is all in the mind, literally, said Asst Prof Lee Boon Ooi at the lunch-time talk on cancer patients’ psychology. CHARISSA ENG reports. Dr Chia Shi-Lu flagging off the walkathon.

n a move to walk the talk and get the public started on ‘Healthy Living for a Healthy Liver’, the organising committee for the 5th Liver Cancer Awareness Month Campaign (LiCAM) decided to do something different this year. Instead of the usual public forums and exhibitions, a walkathon was held to drive home the message on healthy living and the prevention of liver cancer. This proved to be a formula that worked. A month before the registration deadline, all slots were fully taken up. More than 300 people, including cancer survivors and well-wishers, signed up for the walkathon to show support for the cause. The emerging trend of Non-Alcoholic SteatoHepatitis (NASH), or more commonly known as “fatty liver”, as a causative factor of liver cancer has raised eyebrows among the doctors. NASH is a condition where fats are accumulated in the liver even though the person drinks little or no alcohol. It is linked to obesity, diabetes mellitus and the metabolic syndrome with studies indicating that NASH is increasingly an attributive causative factor for liver cancer. Dr Chan Chung Yip, Chairman of LiCAM 2012, said, “Fatty liver has common links to a sedentary lifestyle with a high fat diet. With the long term ill effects of fats causing inflammation and scarring in the liver, it leads to cirrhosis and eventually cancer. By putting in some effort to exercise and cut down on unhealthy food, individuals are doing their health a favour and reducing their risk of liver cancer.” Dr Chan is also a Consultant at the Department of General Surgery at SGH.

Asst Prof C. Kunalan leading a warm-up session before the walk.

On hand to flag off the walkathon was the Guestof-Honour, Dr Chia Shi-Lu, who is also the MP for Tanjong Pagar GRC. The 300 walkers began their walk along the Alexandra Park Connector. Some of them decided to challenge themselves and jogged to the end point. Others chose to walk at a comfortable pace while enjoying the beautiful scenery along the path.

o Asst Prof Lee from the Department of Psychological Studies at the National Institute of Education (NIE), there is no such thing as a difficult patient. If at all, there are only “patients in need”, and their unpleasant behaviour can always be explained by psychology.

After the 1.5 km walk, the participants congregated at the Youth Olympics Games (YOG) Gallery at Kay Siang Road. YOG Gallery’s Assistant Prof Canagasabai Kunalan, an ex-Olympian, shared his story about leading an active lifestyle. Participants were then treated to a singing performance by the Colorectal Cancer Support Group followed by a YOG Gallery guided tour and various sports activities to encourage them to have good lifestyle habits. In addition to the fun, informational posters were put up to educate the participants on liver cancer prevention.

In his one-hour engaging discourse on patient psychology, Asst Prof Lee explained why understanding patients’ feelings and how they may behave in a certain manner is very important. To label patients as “difficult” or “demanding” is highly counterproductive. This random labelling of patients may well be unnecessary and untrue of their personality. If at all, it only embeds in our minds a bias towards them.

When asked on his advice on how to maintain the health of the liver, Dr Chan said, “Have good lifestyle habits, such as regular moderate exercise and a balanced diet. Just like the old adage, prevention is definitely better than cure.”

This talk was organised by the Service Quality Management team as part of NCCS’ service excellence programme for staff.

Earlier in July, a scientific forum and post-graduate course on hepatocellular carcinoma (HCC) was held for over 40 doctors from the public and private sector to share their knowledge and experiences on HCC as part of LiCAM 2012. The organisers are grateful to the Singapore Sports Council (YOG) for supporting the campaign and to Bayer Healthcare who is the main sponsor.

Asst Prof Lee said, “Cancer patients face emotional distress due to many reasons. They may feel a loss of control in life, either a physical or psychological loss. They may also feel like they lost a sense of freedom and connectivity. Life becomes very uncertain for cancer patients, causing some of them to feel fearful.”

There is a thin line of difference between fatigue due to cancer and fatigue due to depression. As such, the reasons for fatigue are always difficult to identify. If we are able to better understand what cancer patients are feeling, we will be able to provide better service and care for them.

To try and regain control, some patients may at times display a behaviour that constitutes as resisting, hostile, irritable, angry or depressed. Thus, it is very important to provide a positive approach to patient care – effective communication by understanding patients helps in the long run to make patients feel better.

Cancer patients may also face other problems in their lives that are caused by cancer. For example, there may be a fear of dying/death, fear of relapse, inability to tolerate cancer symptoms, unemployment, financial difficulty, changes in lifestyle and many others, causing patients to feel a strong sense of emotional distress.

For example, cancer patients may suffer from fatigue, which can either be cancer related or due to other reasons. For cancer related fatigue, patients feel an unusual and persistent sense of tiredness due to the cancer and its treatment that interferes with the usual body functions. However, fatigue can also set in due to physiological factors. There is a thin line of difference between fatigue due to cancer and fatigue due to depression. As such, the reasons for fatigue are always difficult to identify. If we are able to better understand what cancer patients are feeling, we will be able to provide better service and care for them.

To relate better to patients and their families, Asst Prof Lee has this advice, “Do not treat patients as a disease but as a person. Do not focus on the symptoms but on the person who has feelings and emotions. Always listen and do not pretend to understand. Always be sincere, compassionate and sensitive.” For staff who attended the talk, especially those on frontline duty, they now feel more confident in interacting with patients and are better equipped to deliver the service excellence expected of them.

SALUBRIS OCTOBER – DECEMBER 2012

NCCS BREAST CANCER AWARENESS CAMPAIGN: LET’S GO FLY KITE!

SALUBRIS OCTOBER – DECEMBER 2012

How would you like to sit on a soft grass patch with your loved ones while you enjoy delicious snacks? The wind is gentle on your skin and you are looking up at a myriad of colours in the sky.

NCCS REACHES OUT TO THE PEOPLE IN ANTI-CANCER ADVOCACY

OUTREACH – PUBLIC FORUMS & CANCERWISE WORKSHOPS

Event

Date, Time, Venue

Registration

CancerWise Workshop – Role of Chemotherapy in Lymphoma

20 October 2012 Saturday

Admission Fee: $5

Session will be conducted in English.

To register, please call: 6225 5655

TOPICS:

1pm – Registration 1.30pm to 4pm – Workshop

or register online: www.nccs.com.sg (click events)

Function Room Level 4 National Cancer Centre Singapore 11 Hospital Drive Singapore 169610

Strictly NO admission for children below 12 years old.

10 November 2012 Saturday

Admission Fee: $5

Session will be conducted in English.

To register, please call: 6225 5655

1pm – Registration 2 to 4.30pm – Workshop

or register online: www.nccs.com.sg (click events)

Auditorium, Level 4 National Cancer Centre Singapore 11 Hospital Drive Singapore 169610

Strictly NO admission for children below 12 years old.

OCTOBER 2012

Since March, the National Cancer Centre Singapore (NCCS) has been actively spreading the anti-cancer advocacy to share cancer information with the various communities through talks and roadshows.

• What is chemotherapy? • Common chemotherapy regime in lymphoma

his relaxing scene will be turned into reality this November, as we celebrate this year’s Breast Cancer Awareness Month (BCAM), brought to you by the National Cancer Centre Singapore (NCCS).

MAKE A DATE WITH US TODAY AND FLY WITH NCCS!

We cordially invite all patients, caregivers, well-wishers and anyone who wish to support the breast cancer awareness movement to join us in an afternoon of kite-flying and picnic at the Marina Barrage.

EVENT DETAILS

Participants will fly a specially-designed pink ribbon kite and be enthralled by the captivating view of a spectacular kite display while enjoying a picnic. The Layangman and his layang kakis will form a giant ribbon in the sky which transforms into a heart. Cancer need not be depressing. If breast cancer patients seek treatment early, they can live life to the fullest, enjoying pleasurable activities with their loved ones. Many cancer patients continue to be successful and even become high fliers. This is the message that we hope to spread through this meaningful activity.

Date:

3 November 2012 Saturday

hrough the small group public talks at company offices and non-government organisations, as well as the use of informational graphics and posters as exhibits, the NCCS team has scoured many areas from the heartlands in the east to the central and to the west. The team has met residents in Geylang Serai, Siglap, to Braddell Heights and Taman Jurong.

Time: 4pm – 7pm Cost:

$15 for adults, $10 for children

(Includes a specially designed event T-shirt, a pink ribbon kite and refreshments)

Registration is required. For registration, call in to the Cancer Helpline at 6225 5655 from 26 September to 12 October.

This outreach programme includes participation in wellness activities organised by the grassroots and other groups, including students. The key messages are leading healthy lifestyles, going for regular screenings and that cancer need not be an end journey. The feedback has been positive so far, with many people asking questions about the symptoms, the disease and the treatment protocol. NCCS is also taking the opportunity to explain to them about its research work and how this has contributed to improved knowledge, better diagnosis and treatment for the patients.

To date, the team from Corporate Communications, working in collaboration with the Cancer Education Information Service, and at times with the support of the doctors, has held eight public talks and four roadshows. “According to research, the cancer incidences are likely to continue hiking. So by educating the public on ways to reduce their cancer risk, it can help to lower these incidences,” said Ms Zaiha binte Salim, senior staff nurse who actively participates in the outreach programmes. The public can find out more about the events and activities on NCCS’ Facebook page – www.facebook.com/ NationalCancerCentreSingapore – where the team updates information on their activities. Should you wish to invite the roadshows/ talks to your office or organisation, please email corporate@nccs.com.sg.

BY MARK KO

• Common side effects of chemotherapy • Recent advances in treating lymphoma

NOVEMBER 2012 CancerWise Workshop – Lung Cancer TOPICS: • What is lung cancer? • Risks, Signs & Symptoms • Prevention • Diagnostic tests to detect lung cancer • Treatments available • New development in lung cancer • Targeted therapy

SALUBRIS OCTOBER – DECEMBER 2012

SMILING HER WAY TO THE HEARTS OF PATIENTS

LIVING WELL BEYOND BREAST CANCER – BREAST CANCER SURVIVORSHIP FORUM 2012

It was some 13 years ago when Ms Rossnani Abdullah had to make a decision that was to impact on her career. She had to either stay with the Singapore General Hospital’s (SGH) Oncology Centre or leave and join the newly set up National Cancer Centre Singapore (NCCS). She shares with MARK KO why she took the leap of faith to join NCCS and has since never looked back.

ossnani enjoys helping and interacting with people. She may have been at her job for more than a decade, yet she still exudes the enthusiasm of a newcomer when she carries out her duties as a Patient Relations Officer. Indeed, it is not altogether surprising when she was named the Gold Award Recipient of the Singapore Health Quality Service Award this year. Her current role is a total change from her previous career as a draftswoman where she was desk-bound and saddled with architectural drawings. The opportunity came for her to realise her dream when she took on a job with the SGH Haemotology and Radiotherapy Clinic in 1989 as a patient assistant. Back then, she assisted the patients with their registration, explained to them the treatment processes and provided financial counselling. Then came a reorganisation within SGH and she began work at the Oncology Centre at SGH as a senior patient assistant within the Haemotology and Medical Oncology Clinic in 1994. Another switch came when NCCS was set up and many of the patients were moved to the new centre.

“I chose to join NCCS because of my passion to help the cancer patients and also the bond that I have built with them,” said Rossnani, 54. Initially, her duties as a senior patient care officer at NCCS included conducting patient registration at the counter and helping doctors in the consultation rooms when they tend to patients. Her work was thus more administrative in nature.

BY WINSTON TAY Executive Department of Surgical Oncology, NCCS VIPs and guests having a light-hearted moment.

Living beyond cancer refers to life after cancer treatment while survivorship is about living and having the best quality of life possible.

The opportunity came after 12 years of dedication when a change was effected in the clinics in October 2011. Rossnani was re-designated as a Patient Relations Officer and her duties require her to interact with patients, which was what she always wanted. She explained that some patients may be confused with the registration processes and forms. She would gladly walk them through the procedures and make their clinic experience more pleasant. Her work day includes keeping a vigilant look-out for patients who may be in need of help, offering a blanket to wheelchair-bound patients to keep warm, calling for medical assistance if a patient shows signs of discomfort, and perhaps getting a mobile bed for patients if they feel very unwell while waiting to see the doctor. Rossnani is enjoying every single moment of her interactions with the patients she meets. She has that magical charm and a friendly demeanour that exudes warmth and gentleness that won her the award. To her, helping others comes from the heart and she cherishes the many beautiful moments she has spent with the patients. “It is sad to hear the passing of some patients. But I try to focus on the positive, and the opportunity to serve them makes me happy. Their family members will drop by at times to express their appreciation and that is my source of fuel to push on further and help the other patients,” said Rossnani. With 2012 coming to a close soon, she has these thoughts for the New Year: “I hope that I will see less cancer-burdened patients and that everyone stays positive in life. The only way to make others happy is to make ourselves happy.”

ith this in mind, the National Cancer Centre Singapore (NCCS) organised a forum on June 30 to address the common concerns faced by breast cancer survivors. Some of these concerns include the fear of cancer recurrence and the late effects of treatment, a survey done for the Breast Cancer Survivorship Programme @ NCCS found.

This survivorship programme was initiated to provide holistic and quality care for breast cancer survivors who have remained relapse-free for at least five years. To do this, Advanced Practice Nurses (APNs) will partner doctors to provide counselling on healthy lifestyle and screening for colorectal and cervical cancer, in addition to the annual surveillance for cancer recurrence and treatment-related side effects. At the forum, a token of appreciation was presented to Ms Wong Luan Wah, Director of the School of Health Sciences (Nursing), Nanyang Polytechnic Singapore. Nanyang Polytechnic is NCCS’ partner for the survivorship programme. Ms Tan Beng Le and Ms Clair Khoo, both Advanced Practiced Nurses, were honoured for their contributions towards the programme.

A/Prof Koong Heng Nung, Head of Surgical Oncology, NCCS, presenting a token of appreciation to Ms Wong Luan Wah, Director, School of Health Sciences (Nursing), Nanyang Polytechnic.

The workshops organised for the survivors covered topics such as nutrition and lifestyle practices after breast cancer, myths and facts of Traditional Chinese Medicine in breast cancer, how to cope with the fear of cancer recurrence, and prevention and management of arm lymphedema. The participants were then treated to a magic performance by Dr Sin Yong (a.k.a Syros) before they headed for a sumptuous lunch. A total of 302 breast cancer survivors had participated in the programme from April 2008 to March 2012. Participants enjoying the workshop.

SALUBRIS OCTOBER – DECEMBER 2012

KRANK FOR HOPE RAISES MONEY FOR COMMUNITY CANCER FUND A heave and a ho, and a resident doctor with the National Cancer Centre Singapore (NCCS) spent two weeks in early August sacrificing his lunch-hour for a good cause.

isitors to NCCS would have seen him working on the strange-looking machine, not quite the same as a bicycle. It is known as a Krankcycle and works by moving the handlebars in a circular motion with your arms. Krank-cycling is said to be a good workout to tone up the muscles in the arms and shoulders, and is especially helpful for breast cancer patients who have had a mastectomy. Krank for Hope is an initiative to raise funds for the Community Cancer Fund (CCF) which is run by NCCS. Dr William Tan from NCCS Department of Medical Oncology was working on the Krankcycle for one hour each day to support CCF. Despite being paralysed from the waist down due to polio at age two, he worked his way to become a medical doctor and a neuroscientist. Dr Tan empathised with cancer sufferers, having been diagnosed with end-stage leukaemia in 2009, and mooted the idea of giving up his lunchtime to work out on the Krankcycle to raise funds for patients.

Dr William Tan kranking at the launch of Krank for Hope.

Dr Toh Han Chong, giving an opening speech before the launch of Krank for Hope.

Several NCCS staff also took turns on the machine and they were supported by their colleagues, patients and visitors. Dr Toh Han Chong, Head for NCCS Department of Medical Oncology, officiated the opening of Krank for Hope. He said, “This is a meaningful activity that brings multiple benefits. Besides contributing to charity, arm-workout helps to tone up muscles and is a good form of exercise. While the novelty interests and encourages our staff to exercise during their break, this most importantly illustrates that one can live positively and actively even as you fight cancer.” At the end of the two-week project, the staff and Dr Tan cranked up almost $7,000 from donors, thanks to the support of the patients, public and staff.

THE CCF IS SET UP TO PROVIDE: • Programmes providing financial assistance for needy patients and improvements to enhance patient care • Education and training of medical, nursing and paramedical professionals for better patient care and cancer prevention • Development of cancer related publications for oncology professionals, patients and the public

If you wish to support CCF, you can donate via: • Online portal www.sggives.org/comcf or • Send a cheque addressed to “Community Cancer Fund” and mail to COMMUNITY CANCER FUND c/o Division of Community Outreach and Philanthropy, National Cancer Centre Singapore 11 Hospital Drive, Singapore 169610

If you have further enquiries, please contact NCCS Community Partnerships via Tel: (65) 6236 9440 or email donate@nccs.com.sg.

Editorial Advisors

Members, Editorial Board

Members, Medical Editorial Board

Prof Kon Oi Lian Prof Soo Khee Chee Dr Tan Hiang Khoon

Mr Mark Ko Ms Sharon Leow Dr Shiva Sarraf-Yazdi Ms Jenna Teo

Medical Editor

Executive Editors

Ms Lita Chew Dr Mohd Farid Dr Melissa Teo Dr Teo Tze Hern Dr Deborah Watkinson

Dr Richard Yeo

Ms Charissa Eng Ms Veronica Lee Mr Sunny Wee

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