Claire is a 52-year-old executive whose youngest daughter has just completed her pre-university studies and is now applying for university.
As she looked forward to the next stage of her life, she was horrified to feel a new breast lump while in the shower. She saw her GP and was promptly referred to a breast surgeon. After a series of tests and a biopsy, she was unfortunately but fortunately diagnosed with curable early stage breast cancer. Claire, being the positive and proactive person she was, bravely underwent surgery and subsequently adjuvant chemotherapy, radiotherapy and endocrine therapy to improve her chances of cure.
Although currently free of cancer, she was plagued by persistent numbness of her feet and noticed difficulties in her memory and ability to concentrate. She was gripped with the fear of recurrence, slept poorly and often felt emotionally down. For the first time, she was also physically disconnected from her husband as she felt uncomfortable with her post-cancer body image. Claire tried her best to remain positive and wanted to adopt any lifestyle measures that could aid her recovery and further reduce her risk of recurrences or any new cancers, but was disappointed and confused with the lack of reliable information on this. She initially wanted to confide in her oncologists regarding her problems and concerns, but the consultation time was often too short and almost entirely focused on screening for cancer recurrence. Claire turned to her usual GP, but she felt cancer was a highly specialised field and was not confident to advise her. Adding to this, there was also little to no communication with her GP regarding her cancer diagnosis and treatment.
It was strange and unexpected that she was experiencing such immense suffering despite being cancer free. She was supposed to be transitioning towards a better health state, but instead, she feels the worst she has ever been, confused and abandoned.
Claire’s story represents the journey of many cancer survivors in Singapore, being cancer free but still plagued with a multitude of physical and psychosocial issues from the cancer or as a result of its treatments. This results in not only a poor quality of life for survivors and their families, but also a detriment to society and the nation due to the loss of human capital and productivity. As such, care for cancer patients does not stop with anti-cancer treatments and early diagnosis, but must also encompass care to aid and promote holistic post-treatment recovery and wellness.
Cancer survivorship commonly relates to “Living with, through and beyond cancer”. This means that cancer survivorship begins at diagnosis and encompasses patients across the entire survivorship continuum, from early curable to long term survivorship or advance incurable states. The American Society of Clinical Oncology (ASCO) describes 3 distinct phases of survivorship2 (Refer to Figure 1):
The United States Institute of Medicine (IOM) highlighted the importance of dedicated cancer survivorship programmes to effectively address the supportive and survivorship care needs of all cancer survivors. The IOM, in its landmark publication, “From Cancer Patient to Cancer Survivor: Lost in Transition” highlighted 4 essential components of a cancer survivorship programme.3
1. Increasing cancer survival rates
Based on Singapore’s Cancer Registry, the estimated lifetime risk for developing cancer is about 1 in every 4-5 people. Worryingly, the incidence of cancer has increased and is likely to continue to rise with an ageing population. The crude incidence rates of all cancers in males and females between 2011-2015 were 330.7 and 338.5 per 100,000 person-years respectively. Although the Age-Standardised Incidence Rate (ASIR) for cancer in males has largely been stable between 1973 and 2012, the rate for females displays a consistent rising trend. On the whole, the ASIR in female cancers for 2008-2012 was 31.7% higher than in 1973-1977 which amounted to an average annual change of 0.8%.5
Moreover, with earlier diagnoses through screening measures and constantly improving anti-cancer treatments, the number of people surviving cancer will also increase. This is evident by improving survival rates of many cancer types in Singapore over the years.5
2. Multiple and complex needs of cancer survivors
Cancer survivors can experience a multitude of unique physical and psychosocial issues associated with cancer and its treatments. In addition to the direct physical and psychosocial toxicities of cancer and its treatments, indirect consequences of increased chronic comorbidities and second primary cancers can also occur. Adding to this complexity is the likely lack of awareness of the general medical community of the unique care needs of cancer survivors, despite cancer now being the primary source of mortality in Singapore.5 This can be illustrated in the case example below.
A 35-year-old woman presents to her primary care physician with an ischaemic-like chest pain. She was previously treated with chest irradiation for Hodgkin’s Lymphoma when she was 15. Many doctors would not be aware of chest irradiation being a risk factor for an earlier diagnosis of ischaemic heart disease and may have inadvertently treated her chest pain as musculoskeletal or anxiety in source. Her risk of a myocardial infarction would actually be similar to a 55-year-old man. This emphasises the need for greater awareness amongst the general medical community of the potential issues faced by cancer survivors.6
The ASCO describes the key components as follows4:
Many of these components can be provided across both tertiary and primary care settings, but has to be tailored according to the unique care needs of each cancer survivor. A risk-stratified approach is commonly adopted where cancer survivors with more complex survivorship needs remain within the tertiary system for specialty survivorship care, and those who are more stable can receive ongoing survivorship and wellness care in the community. Such an approach would not only be more cost-effective but also allow greater personalisation of survivorship care.
Despite Singapore’s excellence in oncological care evident by comparable cancer survival rates to first world countries, significant gaps in cancer survivorship care exist. These mainly pertain to care fragmentation and the lack of skillsets and resources for optimal survivorship care within the tertiary and primary healthcare care system.
In December 2016, NCCS launched Singapore’s first Cancer Survivorship Forum, bringing together 70 oncology practitioners and researchers across Singapore, to raise awareness and discuss the future landscape of cancer survivorship care in Singapore. This culminated in a proposed cancer survivorship care model that is integrated, survivor-centric, coordinated, accessible and affordable. It also embraces the importance of collaboration between the survivor, as an active and empowered partner, and tertiary and community care providers.
The proposed model highlights the key components needed for excellent survivorship care in Singapore (Refer to Figure 2).8 NCCS in response, has reorganised its services and resources to allow a new focus on optimal survivorship care, starting with a pilot study to test the feasibility and effectiveness of this new model of care, expected to commence in 2019.
Primary Care Practitioners (PCP) have played pivotal roles in cancer survivorship in the community in first world settings in North America, Europe, and Australia. Current evidence suggest that PCPs can provide more cost-effective and equally safe surveillance care to cancer survivors with no difference in recurrence rates, time to detection of recurrence, mortality and health-related quality of life, compared to specialists.9-12
Nonetheless, a collaborative approach is still recommended for cancer survivors to tap on the preventive and wellness care skills of PCPs and cancer-specific and survivorship skills of specialists.
Many PCPs hold strong relationships with their patients and families and thus can positively impact them through education and motivation on lifestyle measures, such as exercise and healthy diets, that have been shown to promote recovery and even lower the risk of cancer.
PCPs can also use their therapeutic alliance with patients and families to promote compliance to treatments, follow-ups, and evidence-based screening for cancers and common comorbidities.
Besides preventive and wellness care, the PCP can also play a vital role in cancer surveillance as well as the monitoring and co-management of toxicities from cancer and its treatments. Indeed, if well supported through good communication, clear guidance and routes back to specialist, general practice may be a preferable place for cancer follow-up for many cancer survivors who would benefit from a broader generalist perspective.7
From a survivor’s perspective, returning to the community allows for better recovery due to more familiar and supported surroundings and promotes a wellness rather than sickness mindset as they move further on from institution-based acute care.
The push for community survivorship care is also very much in line with Singapore’s mission to empower and engage PCPs in the delivery of holistic, quality and continuing care for patients with chronic health issues and the vision of building a sustainable healthcare for the future with the 3 frameworks of “Beyond Healthcare to Health, Hospital to Community and Quality to Value”.14
NCCS’s model for optimal survivorship care (Refer to Figure 2) places great importance on community partnerships.8 For years, NCCS has been supporting this initiative through PCP education programmes and more recently, have taken steps towards understanding the barriers for PCP involvement in community survivorship care through focus group sessions with PCPs.15
Whilst discussions with key stakeholders are ongoing to address key logistical, administrative and financial issues, the next logical step would be the creation of a formal cancer survivorship training programme for interested PCPs, of which is currently being planned.
Survivorship care is an essential component of high quality cancer care due to rising cancer incidence, survival and the recognition of unique health challenges cancer survivors face. Although significant gaps still exist in survivorship care, there is an emerging focus and movement towards the development of high quality survivorship care in Singapore. High quality survivorship care is best delivered using a collaborative approach between tertiary-based specialists and community-based PCPs.
By: Dr Rose Fok Wai Yee is a Family Physician with special interests in oncology and is a strong advocate of community cancer survivorship. She is active in educating General Practitioners and Family Physicians at the post-graduate education unit of the Division of Cancer Education, National Cancer Centre Singapore. She is also a Faculty member and Tutor in the Graduate Diploma and Master of Family Medicine Programmes with the College of Family Physicians Singapore.
Dr Kiley Loh Wei-Jen is a Consultant at the Division of Medical Oncology at the National Cancer Centre Singapore (NCCS). Besides being a subspecialist in the field of breast cancers, Dr Loh is a passionate and active researcher in the field of cancer supportive care (minimising treatment side effects) and survivorship (helping people live better after a cancer diagnosis). He is also the Director of Cancer Education and Information Services at NCCS.
GPs can call for appointments through the GP Appointment Hotline at 6436 8288 for more information.
1. White, Mary C., et al. “Public Health’s Future Role in Cancer Survivorship.” American Journal of Preventive Medicine, vol. 49, no. 6, 2015
2. The American Society of Clinical Oncology. - https://www.cancer.net/survivorship/what-survivorship. Accessed 28/8/2018
3. M Hewitt, S Greenfield, E Stovall: From cancer patient to cancer survivor: lost in transition. The National Academies Press, Washington,
4. The American Society of Clinical Oncology. https://www.asco.org/practice-guidelines/cancer-care-initiatives/prevention-survivorship/survivorship/
survivorship. Accessed 28/8/2018
5. Singapore Cancer Registry: Annual Registry Report. https://www.nrdo.gov.sg/docs/librariesprovider3/Publications-Cancer/cancer-registry-
annual-report-2015_web.pdf?sfvrsn=10. Accessed 28/8/2018
6. Ullman, K. “Cancer Survivorship Gains Importance.” JNCI Journal of the National Cancer Institute, vol. 106, no. 1, Jan. 2014
7. Emery, J. “Cancer survivorship--the role of the GP” Aust Fam Physician. 2014 Aug; 43(8): 521-5.
8. Loh, Kiley Wei-Jen, et al. “Cancer Supportive and Survivorship Care in Singapore: Current Challenges and Future Outlook.” Journal of
Global Oncology, no. 4, 2018, pp. 1–8
9. Grunfeld E, Fitzpatrick R, Mant D, et al: Comparison of breast cancer patient satisfaction with follow-up in primary care versus specialist
care: results from a randomised controlled trial. Br J Gen Pract 49: 705-10, 1999
10. Grunfeld E, Levine MN, Julian JA, et al: Randomised trial of long-term follow-up for early-stage breast cancer: a comparison of family
physician versus specialist care. J Clin Oncol 24:848-55, 2006
11. Grunfeld E, Gray A, Mant D, et al: Follow-up of breast cancer in primary care vs specialist care: results of an economic evaluation. British
Journal of Cancer, vol 79: 1227-33, 1999
12. Wattchow, D A, et al. “General Practice vs Surgical-Based Follow-up for Patients with Colon Cancer: Randomised Controlled Trial.” British
Journal of Cancer, vol. 94, no. 8, 2006, pp. 1116–1121
13. Blaauwbroek, Ria, et al. “Shared Care by Paediatric Oncologists and Family Doctors for Long-Term Follow-up of Adult Childhood Cancer
Survivors: a Pilot Study.” The Lancet Oncology, vol. 9, no. 3, 2008, pp. 232–238
14. Ministry of Health Singapore: Speech by Mr Gan Kim Yong, Minister for Health, at the Ministry of Health Committee of Supply Debate
2018: Building a sustainable healthcare system for the future https://www.moh.gov.sg/content/moh_web/home/pressRoom/
speeches_d/2018/speech-by-mr-gan-kim-yong--minister-for-health--at-the-minitry-o.html. Accessed 28/8/2018
15. PROSPECT: PCPs’ Roles, Outlook, Stance, Perspectives in treating breast cancer survivors: a qualitative study: ongoing research in NCCS
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