National Cancer Centre Singapore shares about the common side late effects and management measures to help GPs optimize their care for their patients.
Systemic cancer treatments have increased tremendously in the last decade and with high survival rates general practitioners are more than likely to have cancer survivors as patients, as such knowledge of the common side late effects and management measures will help GPs optimise their care for these patients.
BASIC STATISTICS OF CANCER IN SINGAPORE
Cancer has ranked consistently as the principal cause of death in Singapore, with 26,891 deaths reported in 2022, attributing up to a 25% of total deaths. The number of cancer cases have been increasing annually and is expected to continue to increase.
Between 2017-2021, 84,002 cancer cases were reported in Singapore. Between 2018 – 2021, the National Cancer Centre Singapore (NCCS) has seen more than 6,000 young adults with cancer. Out of this, 80-85% of cancer patients, especially in the younger adults, is expected to have long-term survival. There is a difference in the types of cancers seen across the age groups, and across genders.
TYPES OF TREATMENTS AVAILABLE IN SINGAPORE FOR CANCER TREATMENT
Cancer treatment can be broadly divided into systemic treatment, surgical treatment and radiotherapy. We will focus on systemic treatment in this article. The types of systemic cancer treatment have increased tremendously in the last decade. Beyond the usual chemotherapy that is usually cancer-agnostic, there is now a whole host of different kinds of anti-cancer treatment available.
This includes immunotherapy, targeted therapy, hormone therapy, stem cell transplants, CAR-T (Chimeric Antigen Receptor T-Cell) Therapy, monoclonal antibodies, checkpoint inhibitors, cytokines, angiogenesis inhibitors and PARP (Poly ADP-ribose polymerase) therapies. There are also increasingly more clinical trial drugs that are available to our patients.
Impact on patients
With each treatment, there exists certain specific side effects and also some general toxicities. For some patients, these toxicities are slight and do not affect their overall quality of life. They will likely be able to return to regular life. However, for others, the toxicities can be debilitating and can even be permanent.
These toxicities can be divided into early, mediumterm and late effects. This article will specifically focus on late effects.
WHAT ARE LATE EFFECTS?
In general, late effects (also known as long-term or delayed effects) can occur months or years after cancer treatment has completed.
The extent of toxicities is dependent on:
Exact type of treatment received
Duration and dose of the treatment and
The patient’s co-morbidities
This can occur in almost any organ or system and can include:
Neurological and cognitive impairments
Osteopenia and osteoporosis
Gastro-intestinal and hepatotoxicities
The reversibility of these toxicities is dependent on:
The methods to treat these symptoms may not be straightforward and may involve not medication, but also a more holistic approach that includes lifestyle changes.
WHAT IS A CANCER SURVIVOR?
Cancer survivors are defined as any cancer patient from the point of diagnosis. Broadly, this can refer to any cancer patient who is cured, in remission or has stable chronic cancer expected over a period of time.
Caring of the cancer survivors should include:
Screening and prevention of long-term side effects from a holistic standpoint
Surveillance for the original cancer to detect recurrence
Screening for secondary cancers
Care co-ordination between primary care providers and other specialists
General health management including management of risk factors and adoption of a healthy lifestyle such as regular exercise and practicing sun safety.
Concerns with reintegration into work/school/community
Psychosocial and mental health concerns
Below is a general table on some of the common late effects and the advised management.
*Definitions as adapted/taken from NCCN Guidelines Version 1.2023: Survivorship*
WHEN SHOULD A REFERRAL BACK TO THE ONCOLOGIST BE NECESSARY?
Ideally, when a patient is discharged from a cancer centre, this should be accompanied with an individualised care plan. This care plan should include details of the cancer and treatment, including what needs to be monitored at what intervals. There should also be clear guidelines on when to refer back, with clear points of contact to reduce the difficulties in referring back to the oncologist.
Should there be no such care plans given, it would be a good idea to get in touch with the primary oncologist for a full report. This will definitely help in the long-term holistic management of the patient, and aid to keep the patient in primary care. It would also be helpful to consider referring young adults cancer survivors to cancer survivorship clinic dedicated for young adult cancer survivors.
A patient’s cancer journey does not start and stop with a cancer diagnosis and treatment. Once a person has been diagnosed with cancer, it will likely result in a lifelong change. It will inevitably lead to a lifetime heightened risk of anxiety and fear, with the need to be more prudent/cautious with health. Inevitably, survivors are also at heightened risks of long-term toxicities and secondary malignancies.
We would want to be able to return our survivors back into community well and be able to function. This need to be able to right-site them is imperative, helping the country to move towards its goal of HealthierSG.
NCCN Guidelines Version1.2023 Survivorship
NCCN Guidelines for Adolescent and Young Adult (AYA) Oncology
Cancer Statistics article from NCCS website (https://www.nccs.com.sg/patient-care/cancer-types/cancer-statistics)
UpToDate – Metabolic Syndrome (insulin resistance syndrome or syndrome X)
Asst Prof Eileen Poon is a consultant with Medical Oncology at NCCS. She sees lymphoma, sarcoma and melanoma patients. Her passion is in working with Adolescents and Young Adults (AYAs) with cancer. This is a field in its infancy, especially in Asia and combines both the science and art of Oncology and Medicine. Dr Eileen is looking to revolutionise the care that AYAs receive to empower them to live well through a cancer diagnosis.
GPs can call the SingHealth Duke-NUS Blood Cancer Centre for appointments at the following hotlines, or click here to visit the website:
Singapore General Hospital: 6326 6060
Sengkang General Hospital: 6930 6000
KK Women's and Children's Hospital: 6692 2984
National Cancer Centre Singapore: 6436 8288