Singapore Cancer Research Articles

Cost-effectiveness of pertuzumab and trastuzumab biosimilar combination therapy as initial treatment for HER2-positive metastatic breast cancer in Singapore

ABSTRACT Background This study evaluates the cost-effectiveness of pertuzumab with trastuzumab biosimilar and docetaxel as initial treatment for HER2-positive metastatic breast cancer (MBC) in Singapore. Methods A partitioned survival model with three health states was developed to evaluate the cost-effectiveness of trastuzumab biosimilar and docetaxel with or without pertuzumab from a healthcare system perspective over a 15-year time horizon for patients with HER2-positive MBC. Key clinical inputs were derived from the CLEOPATRA trial. Health state utilities were derived from the literature and direct medical costs were obtained from local public healthcare institutions. Results The base-case resulted in an incremental cost-effectiveness ratio (ICER) of SGD366,658 (USD272,244) per quality-adjusted life-year (QALY) gained. One-way sensitivity analyses showed that the ICER was sensitive to utilities in the progression-free state, price of pertuzumab and time horizon. When the price for trastuzumab reference biologic (branded) was applied, the ICER was even higher (SGD426,996 [USD317,045]/QALY). Conclusion Although trastuzumab biosimilar reduced the cost of the pertuzumab combination regimen, the ICER remained high and was not cost effective in Singapore’s context. As pertuzumab contributed 80% of the overall combination treatment cost, price reductions for pertuzumab will be required to improve the cost-effectiveness of combination treatment to an acceptable level.

Reference values for the short forms of the Singapore Caregiver Quality of Life Scale

PurposeThe 15- and 10-item short forms of the Singapore Caregiver Quality of Life Scale (SCQOLS-15 and SCQOLS-10) were recently developed as a quick assessment of caregiver quality of life. Reference values describing the distribution of the total and domain scores are available for the full-length version, but they are not yet available for the short forms. This study aimed to estimate the reference values for the short forms.MethodsData from a cross-sectional survey of 612 family caregivers of patients with advanced cancer in Singapore were fitted in quantile regression models. Percentiles were estimated by regressing the short forms’ scores on caregiver characteristics. Classification by the reference values for the short forms and the full-length version were compared and agreement was evaluated.ResultsThe caregiver’s role in caring for the patient and the patient’s performance status were associated with the percentiles of the total scores and most domain scores (each Bonferroni-adjusted p-value, PB, < 0.05). Higher-educated caregivers were categorized into higher percentiles according to the SCQOLS-15 and SCQOLS-10 total scores and the SCQOLS-15 Mental Well-being and Financial Well-being domain scores (each PB < 0.05). Ethnicity was associated with the SCQOLS-15 Physical Well-being and Experience & Meaning domains (each PB < 0.05). The percentiles for the short forms showed moderate to substantial agreement with those for the full-length version in terms of classifying caregivers into percentile intervals (quadratic-weighted Kappa = 0.72 to 0.92).ConclusionReference values for the SCQOLS-15 and SCQOLS-10 were estimated in relation to caregiver characteristics to facilitate interpretation of the short form scores.

Cancer Survivors: What are Their Concerns and Quality of Life Across the Survivorship Trajectory?

Purpose: Survivors of cancer deal with a myriad of acute, chronic, and late effects of cancer and its treatment which can linger on for decades and inadvertently affect their quality of life (QOL). The aim of this study is to determine the main concerns of survivors at various stages of the cancer survivorship, and to assess whether these concerns have any effect on their QOL. Methods: A cross-sectional survey was conducted on cancer survivors diagnosed with colorectal, breast, lung, gynaecological, prostate or liver cancers (top 6 cancers in Singapore) who were seen at the National Cancer Centre Singapore between 11 April and 12 July 2017. Eligible study participants self-completed a questionnaire adapted from the Mayo Clinic Cancer Centre’s Cancer Survivors Survey of Needs. QOL was rated by participants on a scale of 0-10, with higher ratings denoting higher level of QOL. Results: A total of 1107 cancer survivors filled in the questionnaire. The top 5 concerns among all survivors were cancer treatment and recurrence risk (51%), followed by long-term treatment effects (49%), fear of recurrence (47%), financial concerns (37%) and fatigue (37%). Cancer treatment and recurrence risk, long-term treatment effects and fear of recurrence were amongst the top concerns across the survivorship trajectory. Mean QOL was 7.3 on a scale of 0-10. Completed treatment patients had higher QOL score than the newly diagnosed and on treatment patients and the patients dealing with recurrence or second cancer patients. Predictors for QOL included the economic status and housing type of patients and whether patients were concerned with pain and fatigue. Conclusion: This study reveals that cancer survivors in Singapore face multiple challenges and had various concerns at various stages of cancer survivorship, some of which negatively affect their QOL. It is critical to design patient care delivery systems that appropriately address their key concerns at different stages of their cancer trajectory so as to enhance their coping skills throughout their cancer journey.

The Experiences and Support Needs of Women With Gestational Breast Cancer in Singapore: A Descriptive Qualitative Study.

Gestational breast cancer is diagnosed during pregnancy or within the first postpartum year. There is a lack of studies on the experiences of ethnically diverse Asian women with gestational breast cancer. The aim of this study was to explore the experiences of Asian women with gestational breast cancer so necessary support can be rendered. This qualitative descriptive study used purposive sampling to recruit 7 women with gestational breast cancer who were following up at the breast center of a tertiary women's hospital in Singapore. Semistructured, individual, face-to-face, audio-recorded interviews were used to explore the in-depth experiences of these women. Data were transcribed verbatim and analyzed using thematic analysis. Three main themes emerged from the thematic analysis: (1) being a sick woman, (2) juggling between being a mother and a patient, and (3) seeking normalcy. Women had to contend with disruptive changes from gestational breast cancer, both emotionally and physically. They were constantly distressed by their altered body images, and family support was vital to help these women cope with their treatments. Alternative support sources included healthcare professionals and the Internet. Gestational breast cancer experiences varied based on the women's encounter perceptions and existing support. Their experiences may be improved through further support to mediate their coping efforts. Future quantitative and qualitative research should explore and evaluate the various aspects of the long-term disease and psychosocial effects of gestational breast cancer. Hospitals should include support strategies in antenatal classes and postnatal workshops to lessen disruptions of the motherhood experiences.

Presentation of breast cancer, help seeking behaviour and experience of patients in their cancer journey in Singapore: a qualitative study

BackgroundLittle is known about the presentation, help seeking behaviour for breast cancer in Singapore. Nor was there a study exploring the experience of patients in their breast cancer journey.MethodsA qualitative interview study with thematic analysis, conducted with 36 patients.ResultsThere is no clear pattern of presentation for breast cancer by cancer stage at diagnosis, age and ethnicity in the cancer journey of this group of patients. Patients were diagnosed with early to advanced stages cancer regardless of when they presented or took up treatment in their cancer journey. The reasons patients sought medical attention also did not appear to differ between the stages of cancer diagnosed, ethnic and age. Without setting a measure to define early and late presentation, we found that women shared similar experience in their breast cancer journey, regardless of age, ethnicity and stage of cancer at diagnosis. Poor knowledge of breast cancer (symptoms and causes); few practised regular BSE; denial of symptom; fear of hospitalisation, diagnosis and treatment; worries and stress over financial burden of treatment; misinformation in magazine and online sources; diet; stress; caring responsibility; support network; and use of alternative medicine before and after diagnosis were identified in patients’ narratives. Strong social support; fear of being an emotional and financial burden for the family; and financial worries during treatment were also the recurring themes after diagnosis.ConclusionA measure of breast cancer presentation - that accounts for the patient’s experience in the cancer journey, the time interval and tumour biology – that is meaningful to patients, clinicians and researchers is needed. For research on late and delayed presentation, details on BSE practice – how often, when and was it done correctly – will improve the accuracy of time delay interval. For the public, concerted efforts to improve knowledge of breast cancer, survival and prognosis for early-diagnosed cancer, and the importance of regular and correct technique to perform BSE, are critical and urgent to address the rising breast cancer incidence in the country.

Abstract PO-35: Prognostic significance of MYC, BCL2, and BCL6 colocalization at single-cell resolution in DLBCL

Abstract MYC, BCL2, and BCL6 are commonly used markers for immunohistochemistry of Diffuse large B-cell lymphomas (DLBCL). Coexpression of MYC and BCL2 in particular constitutes a subgroup of “double expressor lymphomas” (DEL) with a distinct poor clinical outcome. However, it is not known if MYC and BCL2/BCL6 coexpression occurs in the same cell or in different cells within the tumor, as traditional immunohistochemistry (IHC) is limited by the number of markers that can be simultaneously assessed within formalin-fixed, paraffin-embedded (FFPE) samples. We set out to discover the clinical significance of MYC, BCL2, and BCL6 colocalization at single-cell resolution using multiplexed quantitative immunofluorescence (qIF) based on sequential OPAL-TSA staining and spectral microscopy on the Vectra platform. The initial discovery cohort comprised 90 cases of DLBCL from NUH Singapore with adequate clinical follow-up after R-CHOP therapy. We stratified each DLBCL tumor into 8 “clonal fractions” based on the possible permutations of MYC (M), BCL2 (2), and BCL6 (6) colocalization: M+2+6+, M+2+6-, M+2-6+, M+2-6-, M-2+6+, M-2-6+, M-2+6-, and M-2-6-. Interestingly, even within cases that fit traditional IHC criteria for “positivity” of MYC, BCL2, and BCL6, only a subset of cells within each case expressed multiple markers concurrently. Using the fraction of each of these clones as a continuous variable, Cox regression analysis revealed that the percentage of M+2+6- cells in a case was most predictive of poor survival. Importantly, the same clonal fraction (M+2+6-) was a significant poor prognostic feature in 2 smaller validation cohorts from SGH Singapore (n=41) and MD Anderson Cancer Centre USA (n=36). The single-cell staining pattern of these markers revealed a stark contrast between healthy tonsil tissue and DLBCL tissue. In the tonsil, colocalization of each marker was nonrandom (mutually exclusive BCL2 positivity in B cells outside the germinal center and BCL6 positivity inside the germinal center), whereas in DLBCL samples the mutual exclusivity pattern noted in the tonsil was lost, leading to a random distribution of colocalization of MYC, BCL2, and BCL6. The random nature of this colocalization allowed us to mathematically predict the “extent” of these 8 subclones from any data set with quantitative data of each single marker (MYC, BCL2, and BCL6). We therefore attempted to evaluate this model in RNA expression datasets of DLBCL cases with clinically annotated data. Remarkably, in concordance with our IF data, the “predicted” M+2+ 6- subgroup consistently was associated with an unfavorable prognosis in 3 independent mRNA datasets (GSE10846 n=233, GSE117556 n=469, GSE32918 n=140). In summary, we have for the first time assessed the expression of MYC, BCL2, and BCL6 at the single-cell level in DLBCL. These results may explain the apparent protective function of BCL6 expression in prior cohort studies of DEL, and provide a quantitative tool for the identification of DLBCL cases with poor survival on R-CHOP. Citation Format: Michal Hoppe, Shuangyi Fan, Patrick Jaynes, Phuong Mai Hoang, Liu Xin, Sanjay De Mel, Li Mei Poon, Esther Chan, Joanne Lee, Yen Lin Chee, Choon Kiat Ong, Tiffany Tang, Soon Thye Lim, Nicholas Francis Grigoropoulos, Sheng-Tsung Chang, Shih-Sung Chuang, Joseph Khoury, Hyungwon Choi, Wee Joo Chng, Siok-Bian Ng, Claudio Tripodo, Anand D. Jeyasekharan. Prognostic significance of MYC, BCL2, and BCL6 colocalization at single-cell resolution in DLBCL [abstract]. In: Proceedings of the AACR Virtual Meeting: Advances in Malignant Lymphoma; 2020 Aug 17-19. Philadelphia (PA): AACR; Blood Cancer Discov 2020;1(3_Suppl):Abstract nr PO-35.

Decubitus positioning, a free method to allow access, organ protection in thermal ablation and exclusion of liver involvement of an anterior cortex renal tumour

Renal tumours are getting detected earlier and smaller owing to increase in imaging volume with renal cell carcinoma as one the top 10 most common cancer in Singapore. With ageing population, this is expected to be seen in patients with multiple co-morbidities raising challenges for surgical management.

Cost-effectiveness of ribociclib as initial treatment for premenopausal women with advanced breast cancer in Singapore.

BackgroundCDK4/6 inhibitors have shown promising results for treating advanced breast cancer (ABC) and are routinely used in Singapore. In view of their high costs, it is important to assess their relative value compared to existing standards of care in the local setting.AimsThis study evaluates the cost‐effectiveness of adding ribociclib to goserelin and a nonsteroidal aromatase inhibitor or tamoxifen as initial therapy for premenopausal women with hormone receptor‐positive (HR+), human epidermal growth factor receptor 2‐negative (HER2−) ABC in Singapore.MethodsA partitioned survival model with four health states (progression‐free on first‐line treatment, progression‐free on second‐line treatment, progressed disease, and death) was developed from a healthcare system perspective over a 10‐year time horizon. Key clinical inputs were derived from the MONALEESA‐7 trial, and survival curves were extrapolated beyond the trial period. Health state utilities were derived from the literature and direct medical costs were obtained from local public healthcare institutions. A discount rate of 3% was applied to both costs and outcomes. One‐way deterministic and probabilistic sensitivity analyses were conducted to explore uncertainties.ResultsThe base‐case analysis resulted in an incremental cost‐effectiveness ratio (ICER) of SGD197, 667 per quality‐adjusted life‐year. Sensitivity analyses showed that the ICER was sensitive to the survival parametric distribution, ribociclib price, time horizon, and utility weights used. Even when these were varied, ICERs remained high and not cost‐effective in the local context.ConclusionAt its current price, adding ribociclib to endocrine therapy is unlikely to be cost‐effective in Singapore for HR+, HER2− ABC. Results from this study are useful to inform future funding decisions for CDK4/6 inhibitors alongside other factors including clinical effectiveness, safety, and budget impact considerations.

Understanding the Psychological Impact of COVID-19 Pandemic on Patients With Cancer, Their Caregivers, and Health Care Workers in Singapore.

PURPOSEThe coronavirus disease 2019 (COVID-19) pandemic has had a global impact, and Singapore has seen 33,000 confirmed cases. Patients with cancer, their caregivers, and health care workers (HCWs) need to balance the challenges associated with COVID-19 while ensuring that cancer care is not compromised. This study aimed to evaluate the psychological effect of COVID-19 on these groups and the prevalence of burnout among HCWs.METHODSA cross-sectional survey of patients, caregivers, and HCWs at the National Cancer Centre Singapore was performed over 17 days during the lockdown. The Generalized Anxiety Disorder-7 and Maslach Burnout Inventory were used to assess for anxiety and burnout, respectively. Self-reported fears related to COVID-19 were collected.RESULTSA total of 624 patients, 408 caregivers, and 421 HCWs participated in the study, with a response rate of 84%, 88%, and 92% respectively. Sixty-six percent of patients, 72.8% of caregivers, and 41.6% of HCWs reported a high level of fear from COVID-19. The top concern of patients was the wide community spread of COVID-19. Caregivers were primarily worried about patients dying alone. HCWs were most worried about the relatively mild symptoms of COVID-19. The prevalence of anxiety was 19.1%, 22.5%, and 14.0% for patients, caregivers, and HCWs, respectively. Patients who were nongraduates and married, and caregivers who were married were more anxious. The prevalence of burnout in HCWs was 43.5%, with more anxious and fearful HCWs reporting higher burnout rates.CONCLUSIONFears and anxiety related to COVID-19 are high. Burnout among HCWs is similar to rates reported prepandemic. An individualized approach to target the specific fears of each group will be crucial to maintain the well-being of these vulnerable groups and prevent burnout of HCWs.

The management of BRCA1 and BRCA2 carriers in Singapore.

Singapore is a densely populated small island nation, with a multiethnic and multireligious population. Cancer is the leading cause of death in Singapore. The population is well educated and coupled with greater awareness, there is an increasing demand for genetic testing for hereditary cancer syndromes. In Singapore, the Singapore Cancer Action Network (SCAN) guidelines for referral for genetic testing serves as a guide for clinicians on appropriate referral. We examined the important factors in genetic counselling in such a diverse population, such as acknowledgement of psychosocial impact of BRCA1/2, cultural sensitivity and upskilling of healthcare professionals. Access to genetic services in Singapore is widely available, though the number of patients who undergo testing is lower due to need for out-of-pocket costs and lack of funding from government agencies and insurance companies. The delivery of clinical care and research accrual is performed concurrently in our centre. All patients undergo pre-test counselling before giving informed consent for germline genetic testing and post-test counselling for interpretation of test results. Patients who test positive for BRCA1/2 continue to be on follow up with the cancer genetics clinic for risk-management. Predictive testing is discussed and facilitated for all at-risk relatives. Challenges faced by cancer genetics professionals in Singapore include the high rate of variant of uncertain significance (VUS) and low predictive testing rates. We hold regular support group activities for patients to seek mutual support and to raise overall awareness of BRCA1/2. We believe our comprehensive cancer genetics service serves as a useful model for other Asian countries looking to set up their own unit. We continue to aspire to empower patients, family members and healthcare professionals with cancer genetics knowledge to improve personal and public health.

Cost-effectiveness analysis of osimertinib for first-line treatment of locally advanced or metastatic EGFR mutation positive non-small cell lung cancer in Singapore

Objective Non-small cell lung cancer (NSCLC) accounts for 80–90% of all lung cancer cases and is usually associated with a poor prognosis. However, targeted therapy with first and second generation tyrosine kinase inhibitors (TKIs) has so far improved progression-free survival of epidermal growth factor receptor (EGFR) mutant NSCLC patients. Osimertinib, a third generation EGFR TKI has recently shown improved overall survival of 6.8 months in previously untreated EGFR mutant NSCLC patients. We assessed the cost-effectiveness of osimertinib versus standard EGFR TKIs (gefitinib or erlotinib) as first-line treatment for advanced or metastatic EGFR mutant NSCLC patients in Singapore. Methods A partitioned survival model with three health states (progression-free, progressive disease, and death) was developed from the Singapore healthcare payer perspective. Survival curves based on the overall trial population from the FLAURA trial were extrapolated beyond trial period over a 10-year time horizon to estimate the underlying progression-free survival and overall survival parametric distributions. Health state utilities were derived from the literature and direct costs were sourced from public healthcare institutions in Singapore. Deterministic and probabilistic sensitivity analyses were conducted to explore the impact of uncertainties and assumptions on cost-effectiveness results. Results Compared with first or second generation TKI, osimertinib had a base-case incremental cost-effectiveness ratio (ICER) of SG$418,839 (US$304,277) per quality-adjusted life year gained. One-way sensitivity analysis showed the ICER was most sensitive to time horizon and variations in progression-free utility values. Scenario analyses showed that a 50% reduction in the cost of osimertinib was still associated with a high ICER that was unlikely to be deemed cost effective. Conclusions Osimertinib is not cost effective as a first-line treatment compared to standard EGFR TKIs in advanced EGFR mutant NSCLC patients in Singapore. The findings from our evaluation, alongside other considerations including the lack of survival benefit in the Asian subgroup of the FLAURA trial, will be useful to inform policy makers on funding decisions for NSCLC treatments in Singapore.

Abstract 4646: Association between dietary vitamin B intake and risk of endometrial cancer in the prospective Singapore Chinese Health Study

Abstract Background: Endometrial cancer (EC) is the 6th most common cancer worldwide. However, only few studies addressed dietary factors influencing EC risk in Asia. We explored the association between dietary risk factors and endometrial cancer in the prospective Singapore Chinese Health Study. Methods: A population of 34,028 ethnically Chinese women aged 45-74 residing in Singapore were enrolled in a longitudinal prospective cohort study between 1993 and 1998, and followed up to Dec 31, 2010. Data on baseline demographics, dietary, and reproductive factors were collected via a structured questionnaire. Endometrial cancer cases were identified from the Singapore Cancer Registry. Poisson regression was used to estimate the incidence rate ratio (IRR) on established and dietary risk factors. Results: 166 EC cases were identified (age 53.6±7.2; BMI 24.1±3.3). Obesity (IRR=1.84, 95%CI 1.06-3.06) and having a higher number of live births (IRR=0.43, 95%CI 0.24-0.79, 5+ vs nulliparous) were associated with EC. Overall, compared with the lowest quartile, elevated risk of EC was observed for the highest quartile of dietary thiamine (IRR 1.74, 95%CI 1.02-2.58), riboflavin (IRR 1.58, 95%CI 1.01-2.53), vitamin B6 (IRR 1.71, 95%CI 1.07-2.80), and folate (IRR1.56, 95%CI 1.00-2.47). The highest quartiles of riboflavin (IRR 1.74, 95%CI 1.00-3.12), vitamin B6 (IRR 1.91, 95%CI 1.04-3.65), and folate (IRR 1.89, 95%CI 1.01-3.64) were associated with elevated EC risk in postmenopausal women, but not among premenopausal women. Conclusion: Obesity, parity, and higher intake of dietary vitamin B were associated with elevated EC risk in our analysis. More studies are needed to evaluate the association of supplementary vitamin B complex and EC risk. Citation Format: Ming Lei, Shalkar Adambekov, Robert Edwards, Renwei Wang, Jianmin Yuan, Samia Lopa, Faina Linkov. Association between dietary vitamin B intake and risk of endometrial cancer in the prospective Singapore Chinese Health Study [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4646.

Abstract 4641: Association between dietary tomato intake and the risk of hepatocellular carcinoma: Findings from a prospective cohort study

Abstract Background: Intake of tomato and/or lycopene have been found to be associated with reduced risk of several cancer types, but epidemiological data on risk of hepatocellular carcinoma (HCC) are sparse. Methods: The associations of tomato and lycopene consumption with risk of HCC were examined in the Singapore Chinese Health Study, a prospective cohort of 63,257 Chinese men and women aged 45-74 years at enrollment in 1993-1998 with 25 years of follow-up. Tomato and lycopene consumption was evaluated using a validated semi-quantitative food frequency questionnaire. Incident HCC cases were ascertained through the linkage analysis with the nationwide Singapore cancer registry. Cox proportional hazard regression was used to estimate hazard ratio (HR) and its 95% confidence interval (CI) of HCC with the consumption of tomato and lycopene among all cohort participants, and unconditional logistic regression was used to assess the association among individuals negative for hepatitis B surface antigen (HBsAg). Results: After a mean follow-up of 17.6 years, 561 incident HCC cases were identified. Higher tomato intake was associated with lower risk of HCC after adjustment for multiple potential confounders (Ptrend&amp;lt;0.001). Compared to the lowest quartile, HRs (95% CIs) of HCC for the 2nd, 3rd, and 4th quartile of tomato intake were 0.70 (0.56-0.88), 0.73 (0.58-0.92), and 0.63 (0.49-0.81). Among HBsAg-negative individuals, the inverse association remained (Ptrend=0.03). There was no association between lycopene intake and HCC risk (Ptrend=0.54). Conclusion: Tomato intake may offer protection against the development of HCC, particularly among individuals without chronic infection with hepatitis B virus. Citation Format: Claire E. Thomas, Hung N. Luu, Renwei Wang, Jennifer Adams-Haduch, Jian-Min Yuan, Aizhen Jin, Woon-Puay Koh. Association between dietary tomato intake and the risk of hepatocellular carcinoma: Findings from a prospective cohort study [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4641.

Abstract B33: Reproductive factors and risk of ovarian cancer: The Singapore Chinese Health Study

Abstract Background: Ovarian cancer (OC) is the deadliest gynecologic cancer, with varying incidence across geographic regions. Asian population is underrepresented in etiologic and epidemiologic investigations in the area of ovarian cancer. We explored association between ovarian cancer incidence and several lifestyle, dietary, reproductive, and hormonal risk factors in the Singapore Chinese cohort study. Methods: A population of 34,028 Singaporean Chinese women aged 45-74 were enrolled in the Singapore Chinese Health Study between 1993 to 1998, and followed through Dec. 31, 2010. Data on demographics, tobacco use, dietary and reproductive factors were collected. Cases of OC were determined via linkage to Singapore Cancer Registry. Poisson regression model was performed and hazard ratios (HR) and 95% confidence intervals (CI) were estimated for each variable. Established risk factors and variables showing a significant result in univariate analysis were included in the multivariate analysis. Results: 128 cases of OC were identified. No dietary factors were associated with OC incidence in this population, nor was tobacco/alcohol use. In univariate analysis, significant results included later age of menopause (RR=2.38, 95%CI 1.23-4.30), later age of first birth (RR=0.43, 95%CI 0.17-0.93) and longer period of menstruating (RR=1.48, 95%CI 1.02-2.18), parity (RR=0.37, 95%CI 0.22-0.65), and oral contraceptives use (RR=0.54, 95% CI 0.33-0.84). In multivariate analysis, higher number of children was associated with decreased ovarian cancer risk (1-2, 3-4, 5+ vs nulliparity: RR=0.45, 95%CI 0.26-0.8; RR= 0.35, 95%CI 0.20-0.51 RR= 0.32, 95%CI 0.18-0.60, respectively). Conclusions: Parity, contraceptive use, and later age of first birth decreased the risk of OC incidence, while later age at menopause and longer menstruating period increased ovarian cancer risk in Singaporean Chinese cohort. This finding is consistent with findings in Western populations. Future studies are needed to determine risk factors associated with ovarian cancer histologic types and identify markers of elevated risk, especially in Asian populations. Citation Format: Ming Lei, Shalkar Adambekov, Renwei Wang, Jianmin Yuan, Samia Lopa, Faina Linkov. Reproductive factors and risk of ovarian cancer: The Singapore Chinese Health Study [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research; 2019 Sep 13-16, 2019; Atlanta, GA. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(13_Suppl):Abstract nr B33.

Facilitators and barriers of Hepatitis B screening and vaccination

BackgroundHepatitis B virus (HBV) infection is the most common cause of liver disease and liver cancer in Singapore, being endemic despite availability of an efficacious vaccine. ObjectiveTo assess the factors associated with HBV screening and vaccination. MethodsUsing mixed methods analysis, focus group discussions were conducted alongside a cross-sectional study amongst 784 Singapore Citizens and Permanent Residents aged 25–69 residing in Housing and Development Board (HDB) flats. ResultsAmongst the respondents, 50.6% were screened and 37.8% were vaccinated. The self-reported prevalence of HBV infection was 3.4% and that of HBsAg seropositivity among those screened was 4.3%. Routine health screening was the most common reason cited for screening (32.9%) while doctors’ recommendation was the most common reason for vaccination (42.7%). For both screening and vaccination, knowledge and cost were the top facilitators and barriers respectively. Multivariable regression models revealed the most significant predictors for not undergoing screening to be poor knowledge (p < 0.001), the presence of stigma (p = 0.040) and not being employed in a healthcare sector (p = 0.022), while factors associated with not undergoing vaccination are that of having not undergone screening (p < 0.001) and the lack of importance placed on the knowledge of the possibility of HBV being a silent killer (p = 0.006). ConclusionSeveral facilitators and barriers are seen to regulate health-seeking behaviour towards HBV infection. Public initiatives including education and financial relief targeting specific population groups should be considered to increase the uptake of HBV screening and vaccination.

The parental experiences of caring for children with childhood cancers in Singapore: a pilot focus group study

Background: Research on the parental experiences of caring for children diagnosed with cancer in Singapore are limited and not well understood. Objectives: We conducted a pilot focus group to understand the experiences of Singaporean parents whose child had survived cancer. Methods: Using convenience sampling, five parents were invited to participate in a focus group discussion regarding the psychosocial needs at the time of cancer diagnosis and into survivorship. The discussion was transcribed verbatim and analysed using Braun and Clarke’s 6-step approach to thematic analysis. Results: The analysis revealed three major themes of intrapersonal impact, interpersonal connectedness and financial implications. Conclusions: The identified themes indicated some universal and unique caregiving experiences among Singaporean parents and those reported in western and other Asian cultures. In particular, the findings provided an update on the parental experiences of caring for children with cancer in Singapore and highlighted the need for ongoing research and the development of early and holistic psychosocial support services for these parents.

The Feasibility and Acceptability of a Cognitive Behavioral Therapy-Based Intervention for Patients With Advanced Colorectal Cancer

ContextAdvanced colorectal cancer and its treatment can bring about challenges associated with psychological distress. ObjectivesThe primary aims of this study were to examine the feasibility and acceptability of a cognitive behavioral therapy (CBT)-based intervention to improve coping with the disease. The secondary aim is to evaluate preliminary intervention efficacy. MethodsPatients with advanced colorectal cancer in Singapore (N = 60) were randomized to either receive a four-session CBT intervention immediately or be waitlisted. Intervention feasibility (i.e., recruitment and intervention adherence) and acceptability (i.e., participant satisfaction and cultural sensitivity) were assessed. Changes in psychological distress and self-efficacy were examined. ResultsThe study successfully recruited the intended sample (mean age 61; 62% men). A proportion (12%) reported Hospital Anxiety and Depression Scale scores indicative of distress at baseline. Most (88%) completed all sessions. Participants reported high rates of satisfaction (97%), helpfulness (96%), and cultural sensitivity (95%) of the intervention. The intervention group did not show decrease in psychological distress; however, self-efficacy in cancer-related coping (information seeking: effect size [ES] = 0.64; 95% CI = 0.17, 0.85; coping with side effects: ES = 0.69; 95% CI = 0.33, 0.82; and maintaining positive attitude: ES = 0.45; 95% CI = 0.19, 0.79) increased in the intervention group compared with the waitlisted group. ConclusionThe CBT-based intervention was feasible and acceptable to patients in Singapore. There is no sufficient evidence to warrant a larger trial in this sample with low baseline distress. Future work should identify and target those who are most in need of support.

Cancer Survivors: What Are Their Information Seeking Behaviours?

This study aims to examine the information seeking behaviours and experiences of cancer survivors at various stages of the cancer survivorship trajectory in Singapore. Data was collected via a self-administered questionnaire from survivors diagnosed with the top 6 cancers in Singapore seen at the National Cancer Centre Singapore (NCCS). Cancer survivorship stages were categorized as newly diagnosed and on treatment (NT), completed treatment or cancer-free ≥ 5years (CT) and had recurrence or second cancer (RS). Out of the 998 cancer survivors, 676 (68%) had searched for cancer information since their diagnosis. About 57% of the searchers did their most recent search in the past 6months prior to the survey, with most of these survivors from the NT and RS groups. Around half of the searchers (55%) obtained cancer information from the internet. The most preferred source for cancer information was the internet (38%), followed by healthcare professionals (HCPs) (23%). About half (49%) obtained cancer information from their preferred source. Some information searchers (24%) did not do so, out of which about half used the internet to obtain information that they would have preferred to obtain from HCPs. The top 3 most commonly sought information was related to treatment, cancer and diet/nutrition. Half of the searchers were concerned with the quality of the information that they found. These information seeking behaviours and experiences were similar across cancer survivorship stages. Our study reveals that information seeking is prevalent across all survivorship stages. Patterns of information-seeking revealed a discrepancy between preferred and actual source.

Reference values for and interpretation of the Singapore Caregiver Quality of Life Scale: a quantile regression approach

PurposeThe Singapore Caregiver Quality of Life Scale (SCQOLS) was recently developed and validated in two languages - English and Chinese. The total and domain scores are scaled to range from 0 to 100. However, the scale is not at the interval-ratio level of measurement. To facilitate interpretation, we established the percentiles of the scale’s total and domain scores among family caregivers of patients with advanced cancers and demonstrate the effect size in terms of differences in relation to caregiver and patient characteristics.MethodsData were drawn from a cross-sectional survey of family caregivers of patients with stage III or IV solid cancers in Singapore. Quantile regression was used to estimate the percentiles in relation to caregiver and patient characteristics.ResultsParticipants in adjacent categories of patient’s performance status and caregiver’s having other family members to share caregiving duties differed by 3 to 5 points in median quality of life total score and most domain scores (each Bonferroni-adjusted P, P[B], < 0.05). Ethnicity was associated with the Physical Well-being and Experience & Meaning domain scores (each P[B] < 0.05), with variable direction and magnitude. Education was associated with Mental Well-being and Financial Well-being (each P[B] < 0.05). Equations and examples for calculation of the percentiles are provided.ConclusionPercentiles and effect size estimates are provided to facilitate interpretation of the SCQOLS.

Efficacy, patterns of use and cost of Pertuzumab in the treatment of HER2+ metastatic breast cancer in Singapore: The National Cancer Centre Singapore experience.

BACKGROUNDPertuzumab is a humanized anti-human epidermal growth factor receptor 2 (HER2) monoclonal antibody found in a Phase III clinical trial to significantly improve median survival in HER2 positive metastatic breast cancer (MBC) when used in combination with a taxane and Trastuzumab, and its clinical efficacy has transformed the therapeutic landscape of HER2-positive breast cancer. There are currently few reports on the pattern of use and value of Pertuzumab in real world settings. Our study describes the clinical efficacy and treatment costs of Pertuzumab in HER2-positive MBC treated in a tertiary cancer centre in Singapore in a predominantly Asian population.AIMTo investigate the clinical efficacy and treatment costs of Pertuzumab in HER2-positive MBC in an Asian population in Singapore.METHODSA retrospective study of 304 HER2-positive MBC patients seen at National Cancer Centre Singapore between 2011-2017 was conducted. Demographic and clinical data were extracted from electronic medical records. Clinical characteristics and billing data of patients who received Pertuzumab were compared with those who did not.RESULTSThirty-one (62.0%) of the fifty (16.4%) patients who received Pertuzumab as first-line therapy. With a median follow-up of 21.5 mo, there was a statistically significant difference in the median overall survival between Pertuzumab and non-Pertuzumab groups [51.5 (95%CI: 35.8–60.0) vs 32.9 (95%CI: 28.1–37.5) mo; P = 0.0128]. Two (4.88%) patients in the Pertuzumab group experienced grade 3 (G3) cardiotoxicity. The median treatment cost incurred for total chemotherapy for the Pertuzumab group was 130456 Singapore Dollars compared to 34523 Singapore Dollars for the non-Pertuzumab group. The median percentage of total chemotherapy costs per patient in the Pertuzumab group spent on Pertuzumab was 50.3%.CONCLUSIONThis study shows that Pertuzumab use in the treatment of metastatic breast cancer is associated with a significantly better survival and a low incidence of serious cardiotoxicity. However, the proportionate cost of Pertuzumab therapy remains high and further cost-effectiveness studies should be conducted.