Singapore Cancer Research Articles

Surgery for early breast cancer in the extremely elderly leads to improved outcomes – An Asian population study

AimThe optimal treatment of breast cancer for extremely elderly patients (aged ≥ 80 years) is debatable. With an aging population, management of this group of patients will be increasingly common. This study aims to compare the survival outcomes of extremely elderly patients against younger ones, following different treatment modalities within each stage. The differences in treatment patterns across different stages have also been examined. MethodsFemale Singapore Citizens and Permanent Residents diagnosed with breast cancer from 2003 to 2014 were identified from the Singapore Cancer Registry. Patients were divided into 2 age groups, below 80, and 80 and above years old, and categorized into 3 main treatment groups, namely surgery, non-surgical treatment, and no treatment. Analysis was made on their survival outcomes. Results19,314 patients were diagnosed with breast cancer during the 12-year study period. 1482 patients were excluded due to unknown stage. 673 patients were aged 80 years and above, while 17,159 patients were aged below 80. Elderly patients presented with later stages of disease, and were less likely to have surgery. In Stage I and II, the difference in 5-year breast cancer specific outcome following surgery, was small between the 2 age groups. Among the elderly group, surgery resulted in improved survival. Those who did not have surgery performed better with endocrine therapy than with no treatment. ConclusionsExtremely elderly patients, especially those with Stages I and II breast cancer do not fare worse than younger patients, and should be offered surgery if they are fit.

Improved Survival of Advanced Lung Cancer in Singapore Over the Past Decade

We reviewed changes in clinical characteristics, treatment and survival of lung cancer patients in Singapore over the past decade. We reviewed all primary lung cancer cases from January 2004 to December 2013. Basic demographic, clinical and treatment data were extracted from the database. Overall survival (OS) was calculated using Kaplan-Meier method; survival curves were compared using log-rank test. Linear regression trend lines were estimated using least squares approach, and Cox regression analyses were performed to identify prognostic factors. Among 6006 lung cancer patients, the median age was 68 years old, 65% were males, 88% were Chinese, 92% had non-small-cell lung cancer and 76% had advanced stage IIIB/IV. There were proportionally more adenocarcinomas diagnosed over the years, while that of squamous cell carcinoma (SCC) and small-cell-lung cancer (SCLC) have remained stable. The median OS of all patients increased from 9.2 months in 2004 to 11.5 months in 2013. This survival improvement was statistically significant among patients with stage IIIB/IV (6.7 to 8.7 months; P = 0.005) and adenocarcinoma (12.7 to 15.4 months; P = 0.041). There was no improvement in median OS for SCC or SCLC. The use of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR TKI) (hazard ratio [HR] 0.68; 95% CI, 0.63 to 0.73) and pemetrexed (HR, 0.69; 95% CI, 0.63 to 0.76) were significantly associated with improved OS. Survival of patients with advanced stage IIIB/IV lung adenocarcinoma has improved over the past decade, and is potentially associated with the use of EGFR TKI and pemetrexed.

Colorectal cancer screening.

Colorectal cancer, which is the leading cancer in Singapore, can be prevented by increased use of screening and polypectomy. A range of screening strategies such as stool-based tests, flexible sigmoidoscopy, colonoscopy and computed tomography colonography are available, each with different strengths and limitations. Primary care physicians should discuss appropriate screening modalities with their patients, tailored to their individual needs. Physicians, patients and the government should work in partnership to improve uptake of colorectal cancer screening to reduce the morbidity and mortality from colorectal cancer.

The Challenges, Emotions, Coping, and Gains of Family Caregivers Caring for Patients With Advanced Cancer in Singapore: A Qualitative Study.

Caring for a family member with advanced cancer at home is demanding as the ill family member is likely to have complex physical and emotional needs. There is a paucity of studies on the experience of home family caregivers of people with advanced cancer in the Asian region. The aim of this study was to describe the experiences of family caregivers caring for a person with advanced cancer at home in Singapore. This was a qualitative study; data were collected by semistructured interviews and analyzed using content analysis. A purposive sample of 19 family caregivers who were taking care of a family member with advanced cancer were recruited from home hospice care services in Singapore. Most of the caregivers were female (n = 14), ranging in age from 21 to 64 years (mean, 46.4 [SD, 10.5] years). Four themes were generated from the data: (1) caregiving challenges, (2) negative emotions, (3) ways of coping, and (4) positive gains of caregiving. This study generated insights into the challenges, emotions, and coping of Asian family caregivers caring for patients with advanced cancer. Such understanding could help in developing appropriate intervention for caregivers to reduce their burden and stress. Caregivers require knowledge on resolving family conflicts and about communicating and enhancing closeness with the ill family member. Support from healthcare professionals is essential even if caregivers have support from family members and friends; nurses can make conscious efforts to show concern for caregivers as well as for patients.

Estimation of lung cancer burden in Australia, the Philippines, and Singapore: an evaluation of disability adjusted life years.

Objective:Lung cancer is one of the leading cancers and major causes of cancer mortality worldwide. The economic burden associated with the high mortality of lung cancer is high, which accounts for nearly $180 billion on a global scale in 2008. This paper aims to understand the economic burden of lung cancer in terms of disability adjusted life years (DALY) in Australia, the Philippines, and Singapore.Methods:The years of life lost (YLL) and years lost due to disability (YLD) were calculated using the formula developed by Murray and Lopez in 1996 as part of a comprehensive assessment of mortality and disability for diseases, injuries and risk factors in 1990 and projected to 2020. The same formula is represented in the Global Burden of Disease template provided by the World Health Organization. Appropriate assumptions were made when data were unavailable and projections were performed using regression analysis to obtain data for 2015.Results:The total DALYs due to lung cancer in Australia, the Philippines, and Singapore were 91,695, 38,584, and 12,435, respectively, and the corresponding DALY rates per a population of 1,000 were 4.0, 0.4, and 2.2, respectively, with a discount rate of 3%. When researchers calculated DALYs without the discount rate, the burden of disease increased substantially; the DALYs were 117,438 in Australia, 50,977 in the Philippines, and 16,379 in Singapore. Overall, YLL or premature death accounted for more than 95% of DALYs in these countries.Conclusions:Strategies for prevention, early diagnosis, and prompt treatment must be devised for diseases where the major burden is due to mortality.

498PD_PR Prevalence and types of distress among Adult and Young Adolescent (AYA) newly diagnosed with cancer in Singapore

498PD_PR Prevalence and types of distress among Adult and Young Adolescent (AYA) newly diagnosed with cancer in Singapore

498PD_PR Prevalence and types of distress among Adult and Young Adolescent (AYA) newly diagnosed with cancer in Singapore

498PD_PR Prevalence and types of distress among Adult and Young Adolescent (AYA) newly diagnosed with cancer in Singapore

Caregiving and Its Resulting Effects-The Care Study to Evaluate the Effects of Caregiving on Caregivers of Patients with Advanced Cancer in Singapore.

Informal caregivers (IC) are key to enabling home deaths, where preferred, at the end-of-life. Significant morbidity from advanced cancer can make caregiving burdensome. However, knowledge about the nature of the caregiving burden for caregivers in Singapore is limited. Hence, the key objective in this study was to examine the impact of the caregiving burden on quality of life (QOL), mental health and work capacity among local ICs. Eligible English-speaking ICs of hospitalized advanced cancer patients were recruited through non-random sampling. The Zarit Burden Interview (ZBI), Caregiver Quality of Life Index—Cancer (CQOLC), Center for Epidemiologic Studies Depression Scale—Revised (CESD-R), and Work Productivity and Activity Impairment Questionnaire (WPAI) were interviewer-administered to eligible ICs. Altogether, 16 ICs were surveyed. The mean age of ICs was 43.8 years. Most were children of patients (43.8%), and eight ICs had high burden (ZBI > 17). Those with ZBI > 17 had lower QOL, higher depression scores as well as greater work and activity impairment. In conclusion, high caregiver burden has adverse effects on QOL, mental health and work productivity. Non-physical elements of caregiving (particularly financial and decision-making) and increased number of care roles undertaken by a single IC contribute to high burden. Future interventions for caregiving burden in Singapore should also address the financial and decision-making aspects of caregiving. Outsourcing selected aspects of the caregiving role to community services may reduce the number of caregiving aspects undertaken by a single IC and caregiver burden.

PCN27 - Don't Put Off Until Tomorrow What You Can Do Today: Cost-Effectiveness of Trastuzumab Plus Paclitaxel Combination Therapy and Sequential use of Paclitaxel and Trastuzumab in the Treatment of Metastatic Breast Cancer in Singapore

PCN27 - Don't Put Off Until Tomorrow What You Can Do Today: Cost-Effectiveness of Trastuzumab Plus Paclitaxel Combination Therapy and Sequential use of Paclitaxel and Trastuzumab in the Treatment of Metastatic Breast Cancer in Singapore

PCN43 - Designing A Discrete Choice Experiment To Measure Patient Preferences And Willingness-To-Pay For Targeted Therapies For Colorectal Cancer In Singapore

Molecularly targeted therapies such as cetuximab and bevacizumab have improved survival for patients with metastatic colorectal cancer (mCRC) significantly. Understanding patient preferences for these treatments as well as their willingness-to-pay is crucial in shared decision making. Discrete Choice Experiment (DCE) is increasingly used in healthcare to elicit preferences as it can simulate real-world trade-offs between attributes. This study aims to design a DCE to measure patient preferences and willingness-to-pay for targeted therapies for mCRC. In stage 1, literature review and patient interviews were conducted to identify and define important attributes and levels. In stage 2, a draft DCE questionnaire designed based on patients’ feedback was pilot-tested. Patients with stages 2 to 3 CRC were asked to choose one out of two hypothetical drug alternatives, in each of the five choice tasks in the questionnaire. Feedback on pictorial representation, labelling and framing of attributes and dual-response none option were solicited. In Stage 1 (n=6), all except one chose progression-free-survival as being more important than overall survival. All except two preferred full description of severity of skin rashes over mere labelling as “mild”, “moderate” and “severe”. In Stage 2, 13 patients completed the draft questionnaire, comprising six attributes (progression-free survival, severity of acne-like skin rashes, severity of bleeding, out-of-pocket cost, frequency of administration and degree of independence in medical decision making) with varying attribute levels (2 to 4 levels). Patients prefer out-of-pocket cost to be presented as total cost over treatment lifetime rather than cost-per-month without a defined duration. Patients seemed to have difficulty answering the dual-response none (“Will you really buy the medication you have chosen? Yes or No?”) option. Initial lack of clarity in the DCE questionnaire was overcome. Patients were able to complete the choice tasks with little help. A full-scale study is currently in progress.

Impact of Treatment Subsidies and Cash Payouts on Treatment Choices at the End of Life

To examine the extent to which financial assistance, in the form of subsidies for life-extending treatments (LETs) or cash payouts, distorts the demand for end-of-life treatments. A discrete choice experiment was administered to 290 patients with cancer in Singapore to elicit preferences for LETs and only palliative care (PC). Responses were fitted to a latent class conditional logistic regression model. We also quantified patients' willingness to pay to avoid and willingness to accept a less effective LET or PC-only. We then simulated the effects of various LET subsidy and cash payout policies on treatment choices. We identified three classes of patients according to their preferences. The first class (26.1% of the sample) had a strong preference for PC and were willing to give up life expectancy gains and even pay for receiving only PC. The second class (29.8% of the sample) had a strong preference for LETs and preferred to extend life regardless of cost or quality of life. The final class (44.1% of the sample) preferred LETs to PC, but actively traded off costs and length and quality of life when making end-of-life treatment choices. Policy simulations showed that LET subsidies increase demand for LETs at the expense of demand for PC, but an equivalent cash payout was not shown to distort demand. Patients with cancer have heterogeneous end-of-life preferences. LET subsidies and cash payouts have differing effects on the use of LETs. Policymakers should be mindful of these differences when designing health care financing schemes for patients with life-limiting illnesses.

The prevalence and predictors of subsyndromal anxiety and depression in adult Asian cancer patients across the first year of diagnosis.

There is an increased prevalence of anxiety and depression in Asian patients diagnosed with cancers; these are known to interfere with treatment, treatment adherence and mortality. This study sought to investigate the prevalence and predictors of subsyndromal anxiety and depression in first-year Asian cancer patients. A total of 206 patients newly diagnosed with cancer in Singapore completed the Hospital Anxiety and Depression Scale (HADS) at T1 (baseline; on average 2 months post-diagnosis), T2 (3 months post-baseline) and T3 (6 months post-baseline). Subsyndromal anxiety and depression were identified using locally validated cut-offs (HADS-A ≥5 and HADS-D ≥7). Adjusted odds ratios were calculated using baseline predictors. Across the three time points, 68-69% of participants were identified as having subsyndromal anxiety and close to 27-38% participants were identified as having subsyndromal depression. Multivariate logistic regressions revealed a lack of predictors for T1 subsyndromal anxiety and depression. Participants with late/metastatic stages of cancer were almost four times as likely to suffer from subsyndromal anxiety at T2. Single participants had a 75% lowered odds, but those living in three to four room public housing were close to four times as likely to suffer from subsyndromal depression at T2. Older patients and those who had undergone surgery were found to significantly suffer from subsyndromal depression at T3. The significant levels of depression and anxiety coupled with the lack of consistent predictors across the first year following cancer diagnosis further underscore the importance of careful assessment and clinician-vigilance in recognizing and identifying Asian patients who may express these emotional sequelae following the cancer diagnosis. A better understanding of patients' pathophysiological and psychological responses and individual strengths and coping skills are thus essential.

The burden of filial piety: A qualitative study on caregiving motivations amongst family caregivers of patients with cancer in Singapore

Objective. This study explores (1) the motivations and challenges facing family caregiving for cancer in Singapore and (2) suggests a possible framework to guide culturally sensitive future work on caregivers.Design. Twenty caregivers of patients being treated for cancer at a public hospital in Singapore were interviewed. A semi-structured interview format and inductive thematic analysis were used to analyse the data. Caregivers were asked about their motivations for caregiving and the challenges they faced.Results. Caregivers’ motivations grouped into three categories: personal value and fulfilment, giving care because of societal expectations such as filial piety, and practical need. Challenges were grouped into interpersonal challenges, disclosure and finding balance. Caregivers with different primary motivations varied in their responses to these challenges. More autonomous caregivers cited learning points and reprioritised more effectively than less autonomous caregivers, who reported more internal conflict and less control over their situation.Conclusions. In Singapore and Asia, sociocultural values of family caregiving are not uniformly experienced as positive, and may be burdensome for caregivers who give care primarily for extrinsic motivations. As family caregiving needs increase, targeted psychosocial support for caregivers with less autonomous behavioural orientations may pre-empt caregiver burnout and burden.

Evaluation of a video, telephone follow-ups, and an online forum as components of a psychoeducational intervention for caregivers of persons with advanced cancer.

Our aim was to evaluate caregivers' perceptions of a video, telephone follow-up, and online forum as components of a psychoeducational intervention. Qualitative semistructured face-to-face interviews were conducted with 12 participants two weeks post-intervention. The study was conducted from September of 2012 to May of 2015. Family caregivers were recruited from four home hospice organizations (HCA Hospice Care, Metta Hospice, Singapore Cancer Centre, and Agape Methodist Hospice) and the National Cancer Centre outpatient clinic in Singapore. A purposive sample was employed, and participants were recruited until data saturation. Qualitative interviews were transcribed verbatim. Transcripts were coded and analyzed using content analysis. Two of the research team members were involved in the data analysis. Two-thirds of participants were females (n = 8). Their ages ranged from 22 to 67 (mean = 50.50, SD = 11.53). About two-thirds were married (n = 7). Most participants were caring for a parent (n = 10), one for a spouse, and one for her mother-in-law. Caregivers favored the use of video for delivery of educational information. They liked the visual and audio aspects of the video. The ability to identify with the caregiver and scenarios in the video helped in the learning process. They appreciated telephone follow-ups from healthcare professionals for informational and emotional support. The online forum as a platform for sharing of information and provision of support was not received well by the caregivers in this study. The reasons for this included their being busy, not being computer savvy, rarely surfing the internet, and not feeling comfortable sharing with strangers on an online platform. This study provided insight into caregivers' perceptions of various components of a psychoeducational intervention. It also gave us a better understanding of how future psychoeducational interventions and support for caregivers of persons with advanced cancer could be provided.

Incidence, Trends and Ethnic Differences of Oropharyngeal, Anal and Cervical Cancers: Singapore, 1968-2012.

In recent decades, several Western countries have reported an increase in oropharyngeal and anal cancers caused by human papillomavirus (HPV). Trends in HPV-associated cancers in Asia have not been as well described. We describe the epidemiology of potentially HPV-related cancers reported to the Singapore Cancer Registry from 1968–2012. Analysis included 998 oropharyngeal squamous cell carcinoma (OPSCC), 183 anal squamous cell carcinoma (ASCC) and 8,019 invasive cervical cancer (ICC) cases. Additionally, 368 anal non-squamous cell carcinoma (ANSCC) and 2,018 non-oropharyngeal head and neck carcinoma (non-OP HNC) cases were included as comparators. Age-standardized incidence rates (ASR) were determined by gender and ethnicity (Chinese, Malay and Indian). Joinpoint regression was used to evaluate annual percentage change (APC) in incidence. OPSCC incidence increased in both genders (men 1993–2012, APC = 1.9%, p<0.001; women 1968–2012, APC = 2.0%, p = 0.01) and was 5 times higher in men than women. In contrast, non-OP HNC incidence declined between 1968–2012 among men (APC = -1.6%, p<0.001) and women (APC = -0.4%, p = 0.06). ASCC and ANSCC were rare (ASR = 0.2 and 0.7 per 100,000 person-years, respectively) and did not change significantly over time except for increasing ANSCCs in men (APC = 2.8%, p<0.001). ICC was the most common HPV-associated cancer (ASR = 19.9 per 100,000 person-years) but declined significantly between 1968–2012 (APC = -2.4%). Incidence of each cancer varied across ethnicities. Similar to trends in Western countries, OPSCC incidence increased in recent years, while non-OP HNC decreased. ICC remains the most common HPV-related cancer in Singapore, but Pap screening programs have led to consistently decreasing incidence.

Barriers to early presentation of self-discovered breast cancer in Singapore and Malaysia: a qualitative multicentre study

ObjectiveTo explore and compare barriers to early presentation of self-discovered breast cancer in Singapore and Malaysia.DesignA qualitative interview study with thematic analysis of transcripts.Participants67 patients with self-discovered breast symptoms were...

Singapore Cancer Network (SCAN) Guidelines for Adjuvant Chemotherapy in Resected Non-Small Cell Lung Cancer

The SCAN lung cancer workgroup aimed to develop Singapore Cancer Network (SCAN) clinical practice guidelines for the use of adjuvant systemic therapy for non-small cell lung cancer in Singapore. The workgroup utilised a modified ADAPTE process to calibrate high quality international evidence-based clinical practice guidelines to our local setting. Five international guidelines were evaluated- those developed by the National Comprehensive Cancer Network (2014), European Society of Medical Oncology (2014), National Institute of Clinical Excellence (2012), Scottish Intercollegiate Guidelines Network (2014), and the Cancer Care Council Australia (2012). Recommendations on the selection of patients, chemotherapy regimen, treatment for stage I disease, treatment for positive margins and treatment options for pN2 disease with negative margins were produced. These adapted guidelines form the SCAN Guidelines 2015 for adjuvant systemic therapy of non-small cell lung cancer.

Singapore Cancer Network (SCAN) Guidelines for Systemic Therapy of Colorectal Cancer

The SCAN colorectal cancer systemic therapy workgroup aimed to develop Singapore Cancer Network (SCAN) clinical practice guidelines for systemic therapy for colorectal cancer in Singapore. The workgroup utilised a modified ADAPTE process to calibrate high quality international evidence-based clinical practice guidelines to our local setting. Five international guidelines were evaluated-those developed by the National Comprehensive Cancer Network for colon (2014) and rectal (2014) cancer, the European Society of Medical Oncology for advanced (2012) and early (2013) cancer and the National Institute of Clinical Excellence (2011). Recommendations on systemic therapy in colorectal cancer were produced. These adapted guidelines form the SCAN Guidelines 2015 for systemic therapy of colorectal cancer.

Singapore Cancer Network (SCAN) Guidelines for the Use of Systemic Therapy in Advanced Non-Small Cell Lung Cancer

The SCAN lung cancer workgroup aimed to develop Singapore Cancer Network (SCAN) clinical practice guidelines for the use of systemic therapy in advanced non-small cell lung cancer (NSCLC) in Singapore. The workgroup utilised a modified ADAPTE process to calibrate high quality international evidence-based clinical practice guidelines to our local setting. Five international guidelines were evaluated- those developed by the National Comprehensive Cancer Network (2014), the European Society of Medical Oncology (2014), the National Institute of Clinical Excellence (2012), the Scottish Intercollegiate Guidelines Network (2014) and Cancer Care Council Australia (2012). Recommendations on systemic treatment for advanced NSCLC were produced. These adapted guidelines form the SCAN guidelines 2015 for systemic therapy of advanced or metastatic NSCLC.

Singapore Cancer Network (SCAN) Guidelines for Systemic Therapy of Metastatic Renal Cell Carcinoma (mRCC)

The SCAN genitourinary cancer workgroup aimed to develop Singapore Cancer Network (SCAN) clinical practice guidelines for systemic therapy of metastatic renal cell carcinoma (mRCC). The workgroup utilised a modified ADAPTE process to calibrate high quality international evidence-based clinical practice guidelines to our local setting. Six international guidelines were evaluated- those developed by the National Comprehensive Cancer Network (2014), the European Association for Urology (2013), the European Society of Medical Oncology (2012), the National Institute of Health and Clinical Excellence (2011), the Canadian Kidney Cancer Forum (2013) and the Asian Oncology Summit (2012). Recommendations on the first-, second- and third-line treatment for mRCC were developed. These adapted guidelines form the SCAN Guidelines 2015 for systemic therapy of mRCC.