29 Sep 2011
By: JOHN CHIA
Over dinner, a friend commented on a report in The Straits Times which indicated that Singapore’s general breast cancer survival rates lag behind those of other developed countries in the Organisation for Economic Cooperation and Development (OECD).
I was a little dumbfounded.
This contradicted what I experienced every day as a cancer specialist at National Cancer Centre Singapore (NCCS).
Here in this cramped but state-of-the-art facility, an army of highly trained doctors are waging a multi-pronged fight against a formidable foe.
Here, at each stage of the disease, our patient outcomes are not inferior to those in Britain, Italy, France or Holland.
We have excellent outcomes for early (stage 1) breast cancer and even in breast cancer in the last stage (stage 4), where the cancer has spread outside the breast to other organs. Our patients frequently fare better than those in many other European countries.
Peering into the NCCS breast cancer survival database, I found a clue to the paradox.
The answer may lie in the higher proportion of Singaporean patients coming to doctors with a much more advanced stage of cancer at the point of diagnosis, thus undermining overall survival rates.
Patients who are diagnosed with early stage cancer always have a much better prognosis than patients with a more advanced disease.
The five-year survival rates for stage 1 breast cancer is more than 90 per cent. This diminishes to 75 to 85 per cent for stage 2 and 50 per cent for stage 3. For patients with stage 4 cancer, the cancer is mostly incurable.
In our practice, it is not uncommon to see patients who notice cancer symptoms early, but wait months before they seek medical attention.
For such patients, the journey to the hospital begins only when the cancer becomes unbearable, often because it has spread to other organs.
This is a severe mistake.
Ms B. K., who is in her 40s, was one such patient, delaying medical attention for more than a year simply because she was paralysed with fear.
She came to NCCS with a breast tumour which was the size of a melon.
She had noticed the tumour growing for over a year, but sought medical attention only after it started bleeding profusely.
By that time, the cancer had already spread to her lungs.
Chemotherapy was administered and the tumours in the breast and lungs resolved completely.
More than three years on, she continues to lead a full life, with no evidence of tumour recurrence. Her cancer will be considered to be in remission if she remains disease-free for five years.
In Singapore, we are very good at treating cancer, especially in advanced stages, mainly because most of the care is delivered in high-volume hospitals.
NCCS and Singapore General Hospital have treated more than 10,000 breast cancer patients over the last 20 years.
Because of the economies of scale, NCCS is able to invest in the latest technology for diagnosing and treating cancer.
The breast unit in NCCS has run almost 40 breast cancer clinical trials, which give our patients access to state-of-the-art cancer treatment.
NCCS was part of a global clinical trial to evaluate herceptin. The trial began in 2002, five years before the Health Sciences Authority of Singapore approved it for use in early stage breast cancer.
These clinical trials give patients access to treatment before it becomes commercially available. It is frequently provided free by the pharmaceutical industry.
Access to such clinical trials can sometimes mean a difference between life and death.
Where Singapore needs to improve is helping patients arrive at their diagnoses early.
For example, although we run a one-stop breast screening service which includes a mammogram, same-day biopsy and surgeon review, the uptake has been poor, mainly due to lack of publicity.
In North Carolina, the United States, about 24 per cent of women are diagnosed with breast cancer that has spread to regional lymph nodes.
In NCCS, the figure is 48 per cent.
Such a high figure for a country as developed as Singapore is unacceptable.
As the example of Ms B. K. shows, although we have delivered an excellent cancer outcome for her as an individual, we have failed miserably at a societal level – in understanding our patients’ fears.
These fears, although difficult to articulate, are very real – often encompassing death, cost of therapy, employability, family welfare and social stigma – and may lead to patients delaying or refusing treatment.
We have not done enough to understand the psychology of our patients and push the battle to where it counts most – prevention and early detection.
And it is right at this line where the paradox of cancer care lies.
For us in the business of treating cancer, we will have served our mission to its fullest only when we put ourselves out of work.
Email: corporate@nccs.com.sg
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