Issue No. 18 • MICA (P) 061/10/2010
AN NCCS BI-MONTHLY PUBLICATION September / October 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.
A PROFESSIONAL AND PERSONAL PERSPECTIVE ON QUALITY OF LIFE
PAGE A2
In Focus
SALUBRIS
September / October 2011
QUALITY OF LIFE – A PERSONAL AND PROFESSIONAL PERSPECTIVE
Once, a patient’s relatives complained to me: “The other doctor is so heartless – I told him I did not want to give up on my mother yet and he told me, but she has no quality of life… how would he know? He is not my mother.”
Hence the importance of patient peersupport groups in many chronic disease conditions: meeting someone else (amputee, arthritis, alcoholism, etc) with similar experiences (or with worse disability but coping well) puts your own expectations in context. All these factors make it difficult to measure quality of life: people have different personalities and expectations at the beginning of their illness, people may be at different phases of their illness when their quality of life is measured, and their expectations may change over time (the “response shift”).
W
My mother used to support people who facilitated euthanasia, like the late “Dr Death”. As soon as it became available in Singapore, she signed an advanced medical directive. When friends or relatives passed away, she consoled herself: “they are happier now and no longer suffering”.
That said, there are patients with severe disease who report a reasonable quality of life. One explanation is that quality of life is the discrepancy between our expectations of life and our experience of it. Patients who have low expectations or who have become accustomed to their reduced level of function may regard their quality of life as good. On the other end of the spectrum, patients with good function and high expectations may rate a minor disability as a severe reduction in quality of life (the “disability paradox”).
Last year she was diagnosed with a progressive terminal illness. She began to talk about euthanasia for herself and how she wanted to end things while “the going was good and she was still able to get going”.
e often use “quality of life” to explain medical decision-making, especially at the end of life. The more medical technology progresses, the more we realise that it is not just the length, but the quality of survival, that matters.
PAGE A3
In Focus
SALUBRIS
September / October 2011
She weakened slowly over the months. She talked less about euthanasia, at least with regard to her own situation. Her attitude, however, appeared unchanged – in many of her hospitalisation episodes, she would point to someone else in the same ward and say out loud: “she shouldn’t be kept alive – she’s suffering”. (Much to our horror and embarrassment, she often said this within earshot of the family of whoever she was pointing to.)
We noticed that her spirits improved considerably when she started to attend a hospice daycare centre. One day she told me she felt a bit like a fraud – all the other patients appeared to be much weaker than she was. I realised that one of the reasons she enjoyed the sessions (in addition to the company, the care and the activities) was that being with other ill patients who took their disease and their prognosis in stride made her own suffering pale in comparison. Given how subjective quality of life is, why do doctors still look for the “perfect” measuring tool, especially in chronic disease and end-of-life situations? In clinical practice, quality of life tools can help identify and prioritise complex problems the patient is facing. It can help communication when the patient has multiple symptoms, screen for hidden problems, and assist in shared clinical decision making.
More commonly, it helps monitor response to treatment. In cancer, for example, where some of the treatments have side effects that affect patients’ function, but can prolong the number of days, quality of life measures are used. As a research tool, quality of life measures can compare two different treatments for the same disease or symptom where outcome measures are not clear. A simplified example would be: comparing one treatment which prolongs life by 2 months but has severe side effects, with another treatment that prolongs life by 1 month with minor side effects. What happens when the patient cannot communicate their wishes? In such situations, we often expect their partners or close family to act as their proxies – people who know what the patient would want in a similar situation and who would act in their best interests. How much is the agreement between the patient and their partner, or between the patient and their healthcare worker? – Studies have shown fairly good agreements (almost half were identical or close ratings, and less than 20% showed profound discrepancies). But is that enough? Unfortunately, as in the story mentioned in the beginning of the article, not everyone accepts this assumption. We can ask as many people as we can what they would wish in the same situation, but they are not that person. Even if you are that person, things may change over time. My mother’s disease continued to progress. A few times, she was admitted to the intensive care unit. Each time, she would initially refuse intubation, and we would talk her into accepting it. She recovered well each time – somehow proving that we (her “proxies”) had been right to “persuade” her into accepting life-support measures.
I left for a brief period of training in Australia when her disease looked stable. She was suffering from a bad bout of oral thrush infection when I left, and our farewell dinner was quite disappointing – her favourite curry dish “only tasted of pain” and she stared at the food on the table mumbling “what a waste…”. When peach season arrived in Australia, I lamented to myself that I could not bring the peaches back home for my mum, who loves peaches. Midway through my training, I received a phonecall. My mother was in intensive care again. I booked my flight back. On the way out of the house, I grabbed a bag of peaches from the kitchen. I stayed in Singapore long enough to see my mother out of intensive care and extubated. She devoured the peaches. I took her out on home leave while in hospital, back to her favourite restaurant. Her oral thrush infection had been treated and she wolfed down her food. Her memory is fading, and she now needs to be in a wheelchair when she goes out. She used to be imperiously impatient and pride herself in being the fastest to do anything – one of her favourite phrases was “time and tide and Irene wait for no man, woman or child”. Now, whenever we tell her it is time to do something – go out with us, take a shower, change her clothes… she would refuse to let us help her (not even with the simplest task of getting dressed), scold us for not giving her time to think, then stop and stare around her, looking for something she would never find. I don’t know what she would have thought of herself last year, had she seen herself now. Yet, she has stopped talking about ending her life, and seems to be enjoying it.
By Dr Wong Ting Hway
Associate Consultant, Department of General Surgery, SGH
PAGE A4
In Other Words
SALUBRIS
September / October 2011
STEPPING UP ON SERVICE – THE NCCS WAY
hat initially started as an attempt to understand the importance of service quality for a clinician has now been spun off into a whole corporate culture shift in NCCS.
Hours of deliberation followed thereafter. Finally the common purpose was written up: “We offer our patients hope by providing the best care, by having the best people and by doing the best research”.
An innocuous three-day seminar on “Disney’s Key to Excellence” saw among its participants our Senior Consultant, Dr Terence Tan, from the Department of Radiation Oncology at NCCS. Together with two other colleagues, they learnt about the Disney Approach to Business Excellence and Service Excellence. It was not only very interesting and engaging, but it inspired him to ask: why not at NCCS?
Next came the task of getting the staff to embrace the new quality standard in this order: Safety, Courtesy, Show and Efficiency. Knowledge and practice of safety is important for staff although they may not be directly involved in caring of patients. Safety must always come first, without any compromise.
“This was a programme which has been very well thought out, is established and known to produce good and consistent results. We came away feeling that it may be just what we needed to help bring service quality in NCCS to a new and higher level,” he said. He immediately got down to work, crafting NCCS’s common purpose. It was a big hurdle as there was no universal agreement on what the common purpose ought to be. A retreat was held for the senior management. It didn’t end there.
PAGE B1
Looking Forward
SALUBRIS
September / October 2011
Gynaecological Cancers broadly refers to cancers of the cervix, uterus and ovaries; less commonly also includes cancers of the vulva, vagina and fallopian tube. This article will focus on the three commonest gynaecological cancers, namely cancers of the uterus, ovaries and cervix, which are the 4th, 5th, and 6th commonest female cancers in Singapore.
Disney comes to NCCS as the centre takes a great leap forward to improve its delivery to patients by adopting their service culture. VERONICA LEE reports.
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GYNAECOLOGICAL CANCERS: TREATMENT AND SCREENING I
“Everyone who attended the programme could see how well it worked for Disney. Applying it to our various work scenarios, we could see that it applied equally well. Indeed, using appropriate examples in the subsequent phases of Disney implementation in NCCS, it was obvious that all staff understood and appreciated the applicability of the new service quality standard,” explained Dr Tan. The staffs responded enthusiastically. Attendance at a service quality event was overwhelming. It demonstrated a commitment to embrace a new culture – to provide better service to patients.
“This is very heartening as it indicates our staff’s desire to learn more about how they can improve the way they can provide care to their patients,” added Dr Tan. Driven by the heartening response, what lies ahead is to take advantage of the current interest and momentum to ensure that the service standards and expected behaviours are universally adopted and practiced. “NCCS Cares”, a programme to continuously train and remind staff about the importance of putting the standards into practice, was rolled out with the launch of the NCCS Cares logo. It depicts a heart with two arms in a warm embrace, symbolising the spirit of caring. All NCCS patients can expect to receive “HOPE” with the “Best Experience”. NCCS is proud to be the first healthcare institution in the Singhealth cluster to implement such a programme. Dr Tan said that support from staff in supervisory roles is crucial. “We are counting on all HODs, managers, supervisors and all others in positions of influence to not only model the desired behaviours themselves, but also to motivate all others to exhibit the behaviours that will give patients the best experience.”
CANCER OF THE CERVIX This is currently the 6th commonest female cancer in Singapore, with an incidence rate of 11.5 per 100, 000 per year. In KK Gynaecological Cancer Centre, we see an average of 140 to 150 new cases per year. The peak age groups affected are women in the 40s and 50s.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. In recent years, the underlying cause of cervical cancer has been uncovered. It is attributed to a sexually transmitted virus called the Human Papilloma Virus (HPV). This virus is said to account for 99.7% of all cervical cancers. There are two subgroups of HPV virus: low risk subtypes e.g. HPV type 6 and 11 and high risk subtypes e.g. HPV type 16 and 18. HPV virus is very prevalent in the community. Most sexually active women will have been exposed to this virus. Majority of the virus infection resolves spontaneously. It is only the persistence of the infection by the high risk subtypes that may result in cervical cancers years later. Hence, cervical cancer is a very rare outcome of a very common infection. People who are immunocompromised e.g. HIV patients, renal transplant patients, patients with autoimmune diseases on immunosuppression therapy, are more likely to have persistent infection.
Other risk factors that predispose women with persistent infection with high risk subtypes include: women with multiple sexual partners, smokers and early age at first intercourse.
Persistent infection with high risk HPV virus does not lead to cervical cancers overnight. The cells of the cervix initially undergo some changes first. These changes occur months to years before cancer develop and are known as precancer changes of the cervix, aka Cervical Intraepithelia Neoplasia (CIN). At this stage, there are no symptoms and signs. Precancer changes of the cervix can only be detected on routine Pap smears. It is only when precancer changes are undetected and untreated that cervical cancer eventually develops. Continued on page B2.
PAGE B2
Looking Forward
SALUBRIS
September / October 2011
GYNAECOLOGICAL CANCERS: TREATMENT AND SCREENING I
COPING WITH UTERINE (WOMB) CANCER
PAGE B3
Tender Care
SALUBRIS
September / October 2011
Continued from page B1.
The uterus, or womb, is an important female reproductive organ. The uterus is the pelvic organ that holds the baby during pregnancy. Cancer of the womb (or uterine cancer) usually occurs after menopause and it is now the 4th most common cancer among women in Singapore. There are about 300 cases diagnosed annually according to the Singapore Cancer Registry 2005-2009.
THE COMMON SYMPTOMS OF CERVICAL CANCERS ARE: • Bleeding after intercourse • Bleeding in between menses • Blood stained or foul smelling vaginal discharge • Bleeding after menopause • Pain is often a late sign of cervical cancer Cervical cancer presents as a growth on the cervix and a biopsy will be taken by the doctor to confirm the presence of cancerous cells. Once the cancer is confirmed, the patient will be referred to a gynaecologic oncologist for further management, which entails further investigations to determine the extent/spread of the cancer. This often entails imaging studies e.g. CT scan, MRI and a procedure called examination under anaesthesia. The stage of the cancer will determine the type of treatment. The cancer is referred to as early if it remains confined to the region of the cervix. It is referred to as advanced if it has spread beyond the confines of the cervix to the surrounding organs or distant organs.
A
For early cancers, the choice of treatment is between surgery and radiotherapy. The choice will largely be dependent on factors e.g. age, surgical feasibility etc, which the oncologist will advice accordingly depending on the individual patient. For advanced disease, the treatment will be radiation concurrent with chemotherapy or chemotherapy.
FIVE-YEAR OUTLOOK (SURVIVAL) IS DEPENDENT ON STAGE:
• Stage 1
80-90%
• Stage 2
50-70%
• Stage 3
20-40%
• Stage 4
10-20%
s this is a cancer that affects mainly women after menopause (75% of cases), the most common presenting symptom is postmenopausal bleeding (vaginal bleeding after menopause). However, in women who are still menstruating, it may present with heavy irregular periods or intermenstrual bleeding. There are several known risk factors for this cancer including: increasing age, late menopause, obesity, family history of breast or womb cancer, personal history of breast cancer, polycystic ovary syndrome and estrogen only hormone therapy.
The good news is that cervical cancer can be prevented. Concurrently, one can prevent cervical cancer by HPV vaccination (primary prevention) and Pap smear (secondary prevention). There are 2 vaccines available now: Cervarix and Gardasil. The latter covers subtypes 16 and 18 i.e. the high risk subtypes that account for 70% of cervical cancers, the latter besides covering subtypes 16 and 18 also covers low risk subtypes 6 and 11 that causes genital warts. The vaccines are indicated for girls aged 9 to 26. Cervarix is available at all polyclinics and is medisave deductible. Pap smear screening is recommended for all sexually active women aged 25 to 65 at least once every three years. The Pap smear test is a screening test for cervical cancer. It aims to detect precancer changes on the cervix which can easily be treated so that cancer development can be prevented. It is a simple and affordable test available at all polyclinics, GPs and Gynaecology Clinics.
Treatment for womb cancer varies depending on overall health and how advanced the cancer is. Fortunately, most cancers of the womb occur at an early stage and surgery alone is curative. However, some patients will require further treatment after surgery if there is evidence of the cancer spreading. This includes radiotherapy, chemotherapy or hormonal therapy.
By Dr Chia Yin Nin
MBBS(S’pore), MRCOG(UK), FAMS(S’pore), DGO(RANZCOG), GDipHCML(SMU) Certified Gynaecologic Oncologist Head & Consultant , Gynaecological Cancer Unit, KK Women’s and Children’s Hospital Adjunct Assistant Professor, Duke’s Medical School, Singapore Visiting Consultant, National Cancer Centre Singapore
Uterine cancer can be particularly difficult to cope with, physically and emotionally.
Uterine cancer can be particularly difficult to cope with, physically and emotionally. If you have cancer, you may often feel tired. It is important to learn ways to manage symptoms of cancer and the side effects from cancer treatment, and to maintain good nutrition and overall well-being. Continued on page B4.
PAGE B4
Tender Care
SALUBRIS
September / October 2011
COPING WITH UTERINE (WOMB) CANCER
妇科癌症：治疗与筛检 1
PAGE B5
往前看 SALUBRIS
September / October 2011
Continued from page B3.
BE ACTIVE IF YOU CAN Most people feel, eat and sleep better when they exercise. Choose an exercise or sport that you enjoy. Even walking for a short time each day or a short ride on a bike / exercise bike can significantly boost your energy.
DO FEWER THINGS Do the activities that are most important to you first. There will be times when you feel high in energy, but there will be low periods as well. Ask family and friends for help. They can make meals, drive you to the doctor, or help in other ways. Know your limits and avoid filling your day with too many activities.
PLAN A WORK SCHEDULE THAT IS RIGHT FOR YOU Some people feel well enough to work, while others need to slow down. Take medical leave if needed and consider asking your boss if you can work part-time or from home.
PLAN TIME TO REST You will need more rest during treatment especially following radiation therapy. Sleep at least eight hours each night and take short naps during the day (not more than an hour at a time). Studies have shown that relaxation techniques are essential to help reduce treatment-related side effects and improve emotional adjustment for patients undergoing non-surgical cancer treatment (Lubert et al, 2001). Engage in activities that help you to relax. Listening to music, watching your favourite TV show or reading helps to achieve relaxation.
MANAGING SIDE EFFECTS OF CHEMOTHERAPY Chemotherapy side effects can be unpleasant. Knowing the side effects in advance can help you cope better during treatment.
It is important to remember that most of the side effects of chemotherapy are short-term and will gradually disappear once the treatment is completed. Before you start your treatment, your doctor will discuss with you about the side effects of the treatment that you are having.
MANAGING SIDE EFFECTS OF RADIATION THERAPY Treatment such as radiation therapy to the pelvis can lead to dryness, itch or burning sensation in the vagina, causing discomfort during sexual intercourse. There are gels or creams that help to alleviate these effects. Scarring from the treatment can narrow the vagina. A device called a dilator can help stretch the narrowed vagina. Side effects such as bowel changes, bladder and skin irritation may occur as well. Before you receive radiation treatment, you will be seen by a Radiation Oncologist (a doctor specialised in this type of treatment) who will assess your condition and explain to you about the treatment and its side effects. Talk to your doctor or nurse to get personalised advice tailored to your needs.
SEXUALITY Many women have a sense of loss following a hysterectomy, feeling less feminine as a result. If you have not yet reached menopause, you have to come to terms with losing fertility. Side effects of radiation therapy, such as fatigue or pain can lower your sexual desire. If this applies to you, you are not alone. At times, losing interest in sex stops you from making an effort to enjoy all physical contact with your partner. If you feel nervous about starting your sex life again, give yourself time and more importantly, talk things over with your partner. Together you may work out what is best for you both. For most people, things improve with time. Keep in mind that you can always initiate a discussion with your doctor or nurse on matters concerning sexual relationship. If you prefer, you can request to be referred to professionals or specialists for support. There are also support groups composed of other women in similar life situations who meet regularly and share their experiences.
MANAGE PAIN
REFERENCES
Having cancer does not mean that you will have pain. But if you do, you can manage most of your pain with medicine and other treatments. Cancer pain can range from mild to very severe. Some days it may be worse than others. It can be caused by the cancer itself, the treatment, or both. You may also have pain that has nothing to do with your cancer. Headaches and muscle strains are common for some people. Work with your doctors, nurses, and others to find the best way to control your pain, and check with your doctor before taking over-the-counter medications.
C.H. Yarbro, M.H. Frogge & M. Goodman (1999).Cancer Symptom Management. (2nd Ed). Boston: Jones and Bartlett Publishers Luebbert, K., Dahmeb, B & Hasenbring, M. (2001). The effectiveness of relaxation training in reducing treatment-related symptoms and improving emotional adjustment in acute non-surgical cancer treatment: A meta-analytical review. Psycho-Oncology.10: 490-502. www.gyncancer.com/uterus.html www.cancer.gov/cancertopics/coping/ physicaleffects#Fatigue
By Jenna Teo
Senior Nurse Manager, CEIS
妇科癌症一般指的是子宫颈癌、子宫 癌和卵巢癌；较少见的还包括外阴癌、 阴道癌和输卵管癌。本文将着重介绍 三大常见妇科癌症—子宫癌、卵巢癌 和子宫颈癌，它们分别是新加坡女性 第四、第五和第七大常见癌症。
子宫颈癌 目前，子宫颈癌是新加坡第七大常见妇科癌症。每年的发病率是每10万人中，就有 11.5人患病。在竹脚妇科癌症中心，每年平均有140至150 起新病例。女性发病高 峰年龄段是在40岁至50岁。 近年来，研究人员已找出罹患子宫颈癌的根本原因。它是由一种称为“人类乳头状瘤 病毒” （简称HPV）的性传播病毒所引起的。在所有子宫颈癌病例中，有99.7%是 由这种病毒所引起的。HPV 病毒可分成两大类：低危亚型如第6型和第11型HPV 病毒，以及高危亚型，如第16型和第18型HPV病毒。HPV 病毒感染在社区非常普 遍。大多数性生活活跃的女性 已感染这种病毒。在多数情况 下，病毒感染会自发清除。只 有持续感染高危亚型病毒，才 会在几年后患上子宫颈癌。换 言之，子宫颈癌其实是由一种 常见病毒感染而引起的罕见后 (卵巢) 果。免疫系统削弱者如爱之病 (输卵管) 患者、肾脏移植病人，以及接 (子宫) 受免疫抑制疗法的自身免疫性 (肿瘤) 疾病患者，都比较有可能出现 (子宫颈) 持续感染。其他导致持续感染 (阴道) 高危亚型病毒的女性较容易 患病的风险因素包括：有多个 性伴侣、吸烟，以及年龄很小 就发生第一次性交。
持续感染高危亚型HPV 病毒，并不会使子宫颈癌 在一夕之间形成。子宫颈 细胞会先经历一些变化。 这些变化经过几个月甚至 几年的时间，才会形成癌 症，这种情况叫做“子宫颈 癌前病变”或“宫颈上皮 内瘤样病变” （Cervical
Intraepithelia Neoplasia，简称CIN）。 这个阶段并没有任何症状 或征兆。子宫颈癌前病变 只能通过例常的子宫颈抹 片检查检测出来。只有当癌 前病变未被检测和治疗时， 子宫颈癌才会形成。
妇科癌症：治疗与筛检 1
PAGE B6
往前看
应对子宫癌
PAGE B7
温柔呵护
SALUBRIS
SALUBRIS
September / October 2011
September / October 2011
(正面图) (正常)
子宫是女性的重要生殖器官。妇女怀孕时，子宫是孕育胎儿的盆 腔器官。子宫癌一般发生在更年期后，目前是新加坡妇女第四大 最常见癌症。根据新加坡癌症注册局 2005 年至 2009 年间的数 据，每年有大约300起确诊病例。
(癌细胞)
(癌症)
(子宫颈)
由于这种癌症主要影响更年期后的妇女（占75% 的病例），因此 最常见的症状是停经后出血（即更年期后阴道出血）。那些还没 停经的妇女，则会出现月经量过多且经期不规律，或是月经间期 出血的症状。这种癌症的一些已知风险因素包括：年龄增长、更 年期较迟、肥胖、家族成员曾患有乳癌或子宫癌、自己曾患有乳 癌、多囊卵巢综合症，以及接受雌激素治疗。
(阴道壁)
(低度)
(高度)
子宫癌的治疗，须视病患的健康情 况和病情发展而定。幸好，多数的 子宫癌发生在初期，只需动手术即 可治愈。不过，如果癌细胞有扩散 的迹象，病患就必须在手术后接受 进一步的治疗，包括放射治疗、化 疗或荷尔蒙疗法。 子宫癌使人在生理和心理上都特别 难以应付。癌症患者经常会觉得疲 惫。你必须学习如何应对癌症症状 和癌症治疗的副作用，以及维持均 衡饮食和整体健康。
(盆腔检查时，通过扩张器观看的子宫颈 )
子宫颈癌的常见症状 包括： • 性交后出血 • 月经间期出血 • 阴道分泌物有血迹或异味 • 停经后出血 • 疼痛通常是子宫颈癌的后期 征兆 子宫颈癌以肿瘤的形式生长在子宫颈， 医生会对肿瘤进行活组织抽样检查， 以确认癌细胞的存在。一旦确认病人 患上癌症，病人将被转介给一名妇科 肿瘤医生作进一步检验，以确认癌症 的范围/扩散程度。这往往包括一些影 像侦查，如电脑断层扫描（CT scan） 、磁共振成像扫描（MRI），以及一种 在麻醉下进行的检验。 治疗的类型将取决于癌症的阶段。如 果癌细胞只局限在子宫颈部位，癌症 仍处于初期；如果癌细胞已扩散到子 宫颈外邻近或较远的器官，癌症就处 于晚期。初期癌症病患可选择动手术 或进行放射治疗。
这主要是根据年龄、手术可行性等因素而定，妇科肿瘤医生将根据个别病患的情况 给予建议。至于晚期癌症病患的治疗方法，则采用放射治疗加化疗，或是化疗。
“5年存活率” 是根据癌症的阶段而定：
子宫癌使人在生理和心理上 都特别难以应付。
• 第1阶段
80-90%
• 第2阶段
50-70%
尽可能保持活跃生活
应付化疗的副作用
• 第3阶段
20-40%
• 第4阶段
10-20%
多数人在运动后，心情、食欲和睡眠都会比较 好。选择一项你喜欢的运动或体育项目。即 使每天只是短暂步行，或是骑脚车/运动脚车， 也能大大提高你的体力。
化疗的副作用可能会引起不适。事先了解化疗的 副作用，可帮助你更好地应付疗程。须知的重点 是：化疗的副作用大多数是暂时性的，疗程一旦 结束，副作用也会跟着逐渐消失。在你开始接受 化疗前，医生将跟你解释有关疗程的副作用。
值得庆幸的是，子宫颈癌是可以预防的。人们可以同时通过HPV 疫苗注射（第一 级预防）与子宫颈抹片检查（第二级预防）来预防子宫颈癌。目前，市面上有两种疫 苗：卉研康（Cervarix）和加德西（Gardasil）。后者可预防第16型和第18型亚型 病毒，即导致70%子宫颈癌病例的高危亚型病毒；后者除了可预防第16型和第18 型亚型病毒外，也可预防导致生殖器疣的第6型和第11型低危亚型病毒。这些疫苗 适合年龄介于9岁至 26岁的女性注射。其中，卉研康在所有综合诊疗所都有提供， 而且可动用保健储蓄支付费用。所有年龄介于25岁至65岁、性生活活跃的女性，每 三年应进行至少一次子宫颈抹片检查。子宫颈抹片检查是检验子宫颈癌的方法。它 志在于检验出易于治疗的子宫颈癌前病变，以避免癌症的生长。这是一项简单且负 担得起的检查，在所有综合诊疗所、家庭诊所和妇科诊所都有提供。
不要操劳过度 先处理那些你认为最重要的事情。有时候，你 会觉得精力充沛；有时，你又会觉得精神不振。 你可以向家人和朋友寻求协助。他们可以帮你 准备膳食、载送你去看医生，或是通过其他方 式协助你。凡事量力而为，不要在一天内进行 太多活动。
安排适合你的工作计划 有些人觉得自己的身体状况足以应付工作， 有些人则须放慢脚步。需要的话，你可以请 病假，以及考虑向雇主要求转为兼职或在 家办公。
以上文章由谢燕妮医生提供
安排时间休息
MBBS（新加坡），MRCOG（英国），FAMS（新加坡）， DGO（皇家澳大利亚和新西兰学院妇产科）， GDipHCML（新加坡管理大学） 妇科肿瘤注册医生 竹脚妇幼医院妇科癌症部门主任兼顾问 新加坡杜克—国大医学研究院兼职助理教授 新加坡国立癌症中心客座顾问
治疗期间，你需要多休息，尤其是接受放射治 疗后。每晚要睡至少8个小时，白天则可以小 睡片刻（每次不超过1小时）。研究显示，放松 技巧不但有助减轻跟治疗相关的副作用，也能 让那些接受非手术治疗的癌症病患调整情绪 (Lubert et al, 2001)。多进行一些能够帮助 你放松心情的活动。无论是听音乐、观看喜爱 的电视节目或阅读 ，都有助于松懈身心。
应付放射治疗的副作用 一些治疗，例如在骨盆部位进行放射治疗，可能 导致阴道干燥、痕痒或有灼痛感，使你在性交时 感到不适。涂抹凝胶或药膏，可缓解这些副作 用。此外，治疗后留下的疤痕，可能会使阴道狭 小。使用一种叫做“扩张肌”的装置，有助撑大 狭小的阴道。你也可能会出现其他副作用，例如 排便习惯改变、膀胱和皮肤的不适。在你接受放 射治疗前，一名放射肿瘤科医生将评估你的病 情，并解释有关治疗的程序及其副作用。你可向 医生或护士咨询。他们将根据你的需要，提供适 合你的个人建议。
应付疼痛 癌症患者并不一定会感到疼痛。不过，如果你有 疼痛的话，你可通过药物和其他治疗来缓解大 部分的疼痛。癌症引起的疼痛可以是轻微的，也 可以非常严重；有时会比平常来得更痛。疼痛可 能由癌症或治疗引起，或两者皆有。你也可能会 有与癌症无关的疼痛。有些人会经常头痛和肌 肉酸痛。请向你的医生、护士和其他人咨询控制 疼痛的最佳方法，并且在服用非处方药之前，向 你的医生查问清楚。
性欲 许多妇女在进行子宫切除术后感到失落，觉得 自己缺少了女性特质。如果你还没有进入更年期， 你就必须接受无法生育的事实。放射治疗的副 作用，例如疲劳或疼痛，也可能会降低你的性欲。 如果你有上述情况，你绝对不是独立个案。 有时候，失去性欲会使你无法享受跟伴侣之间的 亲密接触。如果你对重新展开性生活感到惶恐 不安，就给自己多一些时间。更重要的是，跟伴 侣一起讨论，共同找出对彼此最好的解决方法。 对多数人而言，情况会随着时间的流逝而好转。 切记，你随时都可以主动向医生或护士咨询关 于性关系的问题。如果你愿意，也可以要求转介 到专家或专科医生，向他们求助。本地也有一些 由其他面对同样经历的妇女所组成的互助小组， 她们会定期见面，分享经验。
参考资料 C.H. Yarbro、M.H. Frogge 和 M. Goodman （1999年），《癌症症状管理》（第二版）， Boston: Jones and Bartlett Publishers Luebbert, K.、Dahmeb, B和 Hasenbring, M.（2001年），回顾分析：放松疗法在纾缓 跟治疗有关症状和改善急性非手术癌症治 疗的情绪方面的有效性， 《心理肿瘤学》， 10: 490-502。 www.gyncancer.com/uterus.html www.cancer.gov/cancertopics/coping/ physicaleffects#Fatigue
张業苓 高级护理经理 癌症教育与资讯服务
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Outreach
SALUBRIS
September / October 2011
UPCOMING PUBLIC EDUCATION ACTIVITIES / PROGRAMMES
Event Name
Date, Time, Venue
Registration Details
Breast Cancer Awareness Month English Public Forum –
15 October 2011, Saturday
Admission fee: $5
9.30am to 1.30pm
To register, please call: 6225 5655 or register online: www.nccs.com.sg (click events).
KEEP ABREAST FOR HEALTH
Auditorium, Level 4 National Cancer Centre Singapore
CancerWise Workshop – Coping with Cancer
22 October 2011, Saturday
Admission fee: $5
Session will be conducted in English.
TOPICS: a. Understanding your reactions and feelings towards the cancer b. Coping and adjustment to life after cancer treatment (Part 1) c. Coping and adjustment to life after cancer treatment (Part 2) d. Coping strategies
1pm – Registration 1.30pm to 4pm – Workshop
To register, please call: 6225 5655 or register online: www.nccs.com.sg (click events).
TOPICS: a. Cancer Pain: Myths and Reality b. What is Palliative Care and how can it help? c. Palliative Care services in Singapore
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People
SALUBRIS
September / October 2011
NCCS TEAM LENDS EXPERTISE IN CURRICULUM DEVELOPMENT The challenge for a group of NCCS doctors and scientist was daunting. On their shoulders rest the responsibility to draw up the curriculum and conduct the training for the pioneering group of clinician scientists. Undaunted, they gave their best shot, juggling between their clinics at NCCS and the Duke-NUS Medical School. Their efforts paid off when the first batch of 24 medical students graduated in July this year amid much fanfare.
TOPICS: a. Early Detection & Screening b. Common Breast Problems & Diagnosis c. Treatment Options
Public Forum on Pain & Palliative Care
LAYING THE TRACKS FOR DUKE-NUS’ FUTURE CLINICIAN SCIENTISTS
T
he work of the pioneers from NCCS did not go unnoticed. They were among those named in the Faculty Awards 2011, namely, Prof Kon Oi Lian and Prof Koong Heng Nung for the Pioneer Award and Outstanding Educator Award; and A/Prof Patrick Tan and A/Prof Ha Tam Cam for the Pioneer Award. Indeed the challenges of drawing up a good curriculum were multiple-pronged as Prof Kon reflected on her task. She had worked with A/Prof Patrick Tan in developing the course on “Molecules and Cells”. They had to take into account the student’s expectations, some of whom had thought that the programme was a replication of the one in Duke University in the US.
Function Room, Level 4 National Cancer Centre Singapore
Then there was the added challenge to set up a local faculty staff with the relevant knowledge and willingness to be content experts in specialised topics.
19 November 2011, Saturday
Admission fee: $5
Session will be conducted in both English & Chinese
To register, please call: 6225 5655 or register online: www.nccs.com.sg (click events).
For A/Prof Tan, the tight timeline was his challenge. Fresh from attending a course on Team-Based Learning at Wright State University, he found himself having to put to good use his newly acquired skills. An added difficulty was the need to make it tightly aligned to the module at Duke University and to get the approval of the local faculty.
9.00am to 3pm The URA Centre Function Hall (Level 5) Maxwell Road Singapore 069118
”We were keenly aware that many key Duke-NUS stakeholders would be observing the performance of the students in the course. We needed toensure that the course was executed smoothly and without hiccups.” A/Prof Patrick Tan
A/PROF PATRICK TAN Continued on page A6.
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People
SALUBRIS
September / October 2011
LAYING THE TRACKS FOR DUKE-NUS’ FUTURE CLINICIAN SCIENTISTS
PAGE A7
People
SALUBRIS
September / October 2011
Continued from page B3.
The local faculty developed a curriculum that supplemented the video lectures and programme provided by Duke University. For the students, they benefited from learning from a one-of-a-kind programme where they could acquire knowledge from the best of two worlds – a leading medical college and a leading medical institution.
What needs to be addressed now is how the curriculum can continue to be engaging for the next batch of students. Both professors already have some new learning strategies in mind. Their priority is to put together materials that maximise the students’ learning.
“The Duke-NUS students are working hard to master two courses, albeit complementary, simultaneously. They became highly motivated and driven for success.”
“The students can learn how to prioritise their preparation for class sessions with clearer direction from the faculty. It may help that they understand the rational framework for each topic before the inundation of facts and factoids. Reading materials can also be more appropriately selected and realistically scaled to the preparation time that students have.”
Prof Kon Oi Lian
Prof Koong Heng Nung
The Team-Based Learning approach was strongly advocated throughout the course developed by Prof Kon and A/Prof Tan. It requires the students to be divided into teams of six to eight students. They take their assignments as a team and grades were assigned on individual and team performance.
A/Prof Tan believes that the new curriculum should also be about helping the students focus on what is really important and to make them feel the pulse of research. “One important work-in-progress we have lies in getting the faculty members to list the key learning objectives of each team-based learning session and striking a balance between pet topics of faculty members and key general concepts. We should also get students to be excited about research, and let them witness how discoveries, translated from bench to bedside, can radically transform and improve clinical practice. If we can achieve this, then I am sure we have succeeded.”
To ensure the programme’s effectiveness, the faculty had to produce preparatory and class room materials that were well designed and of high standards. To supplement and complement the US and Singapore content, it introduced short test questions and proof of application.
According to Prof Kon, the approach not only benefitted the students but also the faculty. “It relieved the faculty from doing all the work during lectures, placing the responsibility of learning squarely on the students and offering great potential for developing deep learning. Students were able to acquire collegial skills of working in teams and to develop firm friendships.”
Another innovation is the availability of all lectures on hard-drives before the commencement of the course. This way the students can prepare for their classes ahead of time and spend class time working on their assignments. Added Prof Kon, “We all learned a good deal of what it took to make learning interesting, stimulating and enduring.”
PROF KON OI LIAN
Despite the high demands on the students, they graduated with flying colours. Prof Kon said that the curriculum has been helpful in getting the students to achieve success. “My impression is that although the students continually find the curriculum and learning methods rather challenging, they do enjoy learning in teams, acquiring confidence to explain their answers and pursuing areas of doubt to clear resolution.”
The commitment shown by our clinicians and scientists in their quest for a better curriculum has also made an impression on the current batch of students such as Mr Christopher Ross Schlieve of Class 2013. Motivated by Prof Koong, who was conferred the Pioneer and Outstanding Educator Awards. Mr Schlieve decided to enroll into the surgical clerkship elective and has not looked back since. He said ”Prof Koong is constantly thinking of new and unique ways to engage us as learners. He has devised a multitude of learning tools that has maximised our learning within the clerkship.” His colleague, Ms Fatima Usmani could not agree more. “Prof Koong’s commitment to our learning made itself evident repeatedly during our surgical clerkship as he taught me and my colleagues to extract valuable conceptual lessons from seemingly mundane clinical experience. By glancing at our answers, addressing our approaches and giving us constructive feedback, he effectively created an environment in which we were able to question, reflect, learn from one another, and address our own weaknesses.”
PROF KOONG HENG NUNG
To date, 16 NCCS staff members are holding teaching positions at the medical school. NCCS Director Prof Soo Khee Chee leads the team as the DukeNUS Vice Dean of Clinical and Faculty Affairs. In shouldering this added responsibility they are paving the way for NCCS to attain its goal of becoming a global leading cancer centre in patient care and research, as well as education. By Veronica Lee
BE IT THROUGH CORPORATE OR INDIVIDUAL GIVING, IT CAN BE YOUR WAY OF LIFE
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Community
SALUBRIS
September / October 2011
CANCER CARE FOR THE NEEDY
CANCER RESEARCH FOR BETTER CARE & HOPE FOR CURE
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 Jenna Teo
Ms Lita Chew Dr Mohd Farid Dr Melissa Teo Dr Teo Tze Hern Dr Deborah Watkinson
Executive Editors 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.
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