QUALITY OF LIFE - National Cancer Centre Singapore

Issue No. 18 • MICA (P) 061/10/2010
AN NCCS BI-MONTHLY PUBLICATION
September / October 2011
...HELPING READERS TO ACHIEVE GOOD HEALTH
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
PAGE A3
In Focus
SALUBRIS
September / October 2011
We 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.
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”).
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”).
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”.
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”.
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 STEPPING UP ON SERVICE –
SALUBRIS
September / October 2011
THE NCCS WAY
GYNAECOLOGICAL CANCERS:
TREATMENT AND SCREENING I
PAGE B1
Looking Forward
SALUBRIS
September / October 2011
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.
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.
What 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.
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?
“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.
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”.
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.
“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.
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%
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.
As 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.
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.
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.
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.
MANAGE PAIN
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.
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.
REFERENCES
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 )
( 子 宫 )
患 者 、 肾 脏 移 植 病 人 , 以 及 接
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 。

PAGE B6
往 前 看
妇 科 癌 症 : 治 疗 与 筛 检 1
应 对 子 宫 癌
PAGE B7
温 柔 呵 护
SALUBRIS
September / October 2011
SALUBRIS
September / October 2011
( 正 常 ) ( 癌 症 )
( 低 度 ) ( 高 度 )
( 正 面 图 )
( 癌 细 胞 )
( 子 宫 颈 )
( 阴 道 壁 )
( 盆 腔 检 查 时 , 通 过 扩 张 器 观 看 的 子 宫 颈 )
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 。
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 。
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 。
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 :
• 第 1 阶 段 80-90%
• 第 2 阶 段 50-70%
• 第 3 阶 段 20-40%
• 第 4 阶 段 10-20%
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 。
以 上 文 章 由 谢 燕 妮 医 生 提 供
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
尽 可 能 保 持 活 跃 生 活
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 。
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 。
安 排 时 间 休 息
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 。
子 宫 癌 使 人 在 生 理 和 心 理 上
都 特 别 难 以 应 付 。
应 付 化 疗 的 副 作 用
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 。
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

PAGE B8
Outreach
SALUBRIS
September / October 2011
UPCOMING PUBLIC EDUCATION
ACTIVITIES / PROGRAMMES
LAYING THE TRACKS
FOR DUKE-NUS’ FUTURE
CLINICIAN SCIENTISTS
PAGE A5
People
SALUBRIS
September / October 2011
Event Name Date, Time, Venue Registration Details
NCCS TEAM LENDS EXPERTISE IN CURRICULUM DEVELOPMENT
Breast Cancer
Awareness Month
English Public Forum –
KEEP ABREAST FOR HEALTH
TOPICS:
a. Early Detection & Screening
b. Common Breast Problems & Diagnosis
c. Treatment Options
15 October 2011, Saturday
9.30am to 1.30pm
Auditorium, Level 4
National Cancer Centre Singapore
Admission fee: $5
To register, please call: 6225 5655 or register
online: www.nccs.com.sg (click events).
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.
CancerWise Workshop –
Coping with Cancer
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
22 October 2011, Saturday
Session will be conducted in English.
1pm
– Registration
1.30pm to 4pm – Workshop
Function Room, Level 4
National Cancer Centre Singapore
Admission fee: $5
To register, please call: 6225 5655 or register
online: www.nccs.com.sg (click events).
The 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.
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.
Public Forum on Pain
& Palliative Care
TOPICS:
a. Cancer Pain: Myths and Reality
b. What is Palliative Care and how can
it help?
c. Palliative Care services in Singapore
19 November 2011, Saturday
Session will be conducted in both
English & Chinese
9.00am to 3pm
The URA Centre
Function Hall (Level 5)
Maxwell Road
Singapore 069118
Admission fee: $5
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.
”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.

PAGE A6
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
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.
best of two worlds – a leading medical college and a leading
medical institution.
“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.
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.
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.”
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 Duke-
NUS 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

PAGE A8
Community
SALUBRIS
September / October 2011
BE IT THROUGH CORPORATE
OR INDIVIDUAL GIVING,
IT CAN BE YOUR WAY OF LIFE
CANCER CARE FOR THE NEEDY
CANCER RESEARCH FOR BETTER CARE & HOPE FOR CURE
Editorial Advisors
Dr Kon Oi Lian
Prof Soo Khee Chee
Executive Editors
Ms Charissa Eng
Ms Veronica Lee
Mr Sunny Wee
Contributing Editor
Dr Wong Nan Soon
Members, Editorial Board
Mr Mark Ko
Ms Sharon Leow
Dr Shiva Sarraf-Yazdi
Ms Jenna Teo
Medical Editor
Dr Richard Yeo
Members, Medical Editorial Board
Ms Lita Chew
Dr Mohd Farid
Dr Melissa Teo
Dr Teo Tze Hern
Dr Deborah Watkinson
is produced with you
SALUBRIS in mind. If there are other
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or if you would like to provide some feedback on the
articles covered, please email to salubris@nccs.com.sg.
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