The Tell-tale Signs

Women with ovarian cancer often have non-specific symptoms that may also be due to non-cancerous causes. These include abdominal fullness or swelling, abdominal or pelvic discomfort or pain, pain during sexual intercourse, passing urine frequently, change in bowel habit (e.g. constipation or diarrhoea), loss of appetite or weight, feeling full after a small meal, or abdominal bloating, indigestion or “wind”. If these symptoms are new or experienced regularly or on a frequent basis, they should not be ignored. Women should consult a doctor for a physical examination and other investigations, such as a pelvic ultrasound scan, if necessary.

Reducing the Risks of Developing Ovarian Cancer

Although not preventive, some factors have been shown to be associated with reduced risks of developing ovarian cancer. For example, breastfeeding reduces the risk of developing ovarian cancer in later life. Combined oral contraceptive pills have also been shown to offer protection. Using these pills for one year confers a risk reduction of up to 10%, while five years’ usage may almost half the risk. This beneficial effect also appears to persist for many years after stopping the pill. The use of contraceptive pill also offers protection against cancers of the womb and colon. Women may speak to their doctors about their suitability for the contraceptive pill. Other factors which are associated with lowering the risk of developing ovarian cancer include having a normal body mass index (BMI), having children, fallopian tube ligation and having had a hysterectomy. A small percentage of women have familial ovarian cancer, which occurs because they have inherited genes that predispose them to cancer. Several gene types have been identified, including BRCA 1 and 2, genes that confer an increased risk of developing ovarian and breast cancer. Other familial syndromes include Lynch syndrome or hereditary non-polyposis colorectal cancer (HNPCC), which confers a higher risk of developing cancers in organs such as the colon, uterus and ovaries. Women who have strong family histories of the above cancers or who are known carriers of the above genes should speak to their doctors to assess their risk of developing ovarian cancer.

Screening and Testing Methods

There is currently no reliable screening test for ovarian cancer. A blood tumour marker for ovarian cancer, CA125, is frequently offered as part of health screening packages. It is, however, not a reliable screening tool as levels may be normal in women with ovarian cancer and raised in women with non-cancerous conditions. This test should instead be used in women who have been found to have an ovarian mass to help determine the risk of it being cancerous. It is also used to monitor progress in women already diagnosed with ovarian cancer. Routine annual ultrasound scans are not proven to be a good screening tool. They often result in unnecessary investigation and treatment for benign conditions. A normal scan does not confer protection over any length of time.

Treatment and Therapy

Women with suspected ovarian cancer should be cared for by gynaecologic oncologists, who are specialists trained to look after women with cancers of the female genital tract. Treatment will be individually tailored, taking into account patient’s general health and desire for fertility, as well as grade (cell type) and stage of disease.

Surgery

Surgery is curative only in the earliest stage. The purpose of surgery is twofold – to remove as much of the cancer as possible (debulking) and to confirm the degree of spread (stage). This usually involves excision of the uterus, ovaries, omentum and surrounding lymph nodes. Women who wish to retain fertility may have more limited surgery where the uterus and the unaffected ovary and tube are not removed. Selected women with advanced cancers may be offered more complex surgery by doctors from various surgical specialties to completely excise all the tumour – this may involve removing in addition parts of the intestines and/or the inner lining of the abdominal cavity (peritonectomy).

Chemotherapy

Chemotherapy is usually required after surgery for advanced disease or aggressive types of ovarian cancer. Patients are often daunted by the idea of chemotherapy, and many are reluctant to receive further treatment after undergoing major surgery. However, it is important to understand that chemotherapy is an essential part of treatment in these patients as surgery can only remove visible cancer cells – numerous microscopic tumour cells may remain and these can only be treated with chemotherapy. Women should discuss their concerns with their oncologists and may find that their worst concerns are not realised. Speaking to trained oncology nurses and other patients in ovarian cancer support groups usually help allay their fears.

Some women with advanced disease may undergo a few cycles of chemotherapy treatment prior to surgery. Chemotherapy given before surgery is known as neoadjuvant therapy, and helps to shrink tumour cells to make surgical removal of all visible tumour tissue more feasible. Once the patient has recovered from her surgery, she will complete her chemotherapy treatment. There are new treatment modalities being researched, including intra-peritoneal chemotherapy, where chemotherapy is administered into the abdominal cavity. Other new treatments are also available but they are only suitable for some women with ovarian cancer. The oncologist will discuss this form of treatment if it is deemed suitable for the woman.

In summary, ovarian cancer remains a cancer with high mortality rate because of its insidious symptoms and lack of screening modalities. Women with increasing abdominal girth, decreased appetite, bloating and increased urinary frequency should seek medical help to exclude ovarian cancer. Combination of surgery and/or chemotherapy remains the mainstay of treatment for ovarian cancer.

Allergies at a Glance

Allergy is our immune system’s hypersensitive reaction to protein substances that occur naturally (and usually do not trouble other people). For some reason, our immune system sometimes overreacts and confuses an otherwise safe substance, such as pollen, as harmful and attacks it ruthlessly, causing our body to react in some ways – hence the allergic reactions. Our body releases chemicals such as histamine, the same thing it releases when it fights a cold, causing a runny nose, coughing and sneezing, and swelling in our nasal passages. According to Dr Dharambir S Sethi, Senior ENT Consultant and Director at Nose, Sinus and Allergy Services, Novena ENT Head & Neck Surgery Specialist Centre, for patients to develop allergy, the allergen must enter the body to produce symptoms. “When an allergen enters the body, it incites certain cells (B cells) of the immune system to produce antibodies specific to that particular allergen. These antibodies then bind to some other type of cells called the mast cells. This binding causes the mast cells to become ‘sensitised’ to that particular allergen. When these sensitised mast cells come in contact with the allergen, they liberate histamine and other chemical mediators responsible for the symptoms of allergy,” he explained. Although not contagious, allergies can be inherited by some people. It normally takes time to go away. As long as you’re exposed to the allergen, you will have the symptoms.

Flu Malady

Flu is an acute respiratory infection caused by various types of influenza viruses. It’s necessary to understand flu symptoms so you can get proper treatment right away. Unlike allergies, influenza is a highly contagious disease that often reaches epidemic proportions. “Influenza is not just a common cold, with associations to pneumonia, circulatory and respiratory conditions, which can lead to deaths,” shared Dr Leong Hoe Nam, Infectious Diseases Specialist at Raffles Hospital. The flu viruses are very infectious and are easily transmitted from person to person through air droplets projected by coughing and sneezing. Just like with allergens, when a flu virus gets into our body, our immune system attacks it. Our body reacts the same way, with coughing and runny nose. But the symptoms normally go away after treatment. The flu can generally make you feel ill, but complications are just lurking in the corner. The most common symptoms of complications are difficulty in breathing, flu not improving and even worsening after a few days, and nausea, vomiting, high fever, chest pain, chills and coughs with thick, yellow-green mucus.

Prevention and Treatment of Flu and Allergies

Although symptoms of the flu and allergies are almost the same, their causes are entirely different. Hence, prevention also takes a different approach. To prevent allergy symptoms, avoid allergens, or substances you’re allergic to. So if you’re allergic to animal dander, for example, avoid playing with furry animals and make sure to make your house animal-dander free. Other common allergens include mould, pollen, and dust mites. On the other hand, to prevent flu symptoms, avoid the flu-causing virus from getting into your system. Stay away from people who have the flu, and practice washing hands often.

Antihistamines are effective for the treatment of both the flu or allergy symptoms. Decongestants also help relieve stuffy nose. Nasal steroids and allergy shots (immunotherapy) can also be used to treat allergy symptoms. While taking some rest, drinking lots of fluids, and taking over-the-counter nonsteroidal anti-inflammatories to treat fever and pains work for the flu symptoms. If symptoms persist or if you have a chronic medical condition, visit your doctor right away.

Dr Adrian Siew Ming Saurajen gives us a rundown about this dangerous sleep disorder.

Q. Why do people snore? Is it dangerous?

Dr Saurajen: Snoring results from narrowing and fluttering of the upper airway during sleep. Many people snore. It is estimated that 30% of all people snore regularly. It becomes dangerous if the snoring progresses to obstructive sleep apnoea.

Q. What is obstructive sleep apnoea or OSA?

Dr Saurajen: OSA is a condition where the airway obstructs or collapses during sleep, resulting in fragmented sleep and reduced oxygen levels in the body. Very simply, this could be due either to a narrowed airway, an excessively floppy airway, or a combination of both. This is basically a condition of an unstable collapsible airway during sleep.

Q. What are the symptoms of obstructive sleep apnoea?

Dr Saurajen: Nighttime symptoms include heroic snoring, restless sleep, frequent awakening, choking or episodes where patients stop breathing during sleep, frequent passing of urine at night, dry mouth or chronic mouth breathing at night, and periodic limb movements. Daytime symptoms include waking up feeling unrefreshed, morning headaches, personality change, depression, anxiety, daytime tiredness, sleepiness during the day or after meals, reduced levels of concentration and performance at work or in school. High blood pressure, heart problems, strokes, reflux disease, erectile dysfunction, and insulin resistance/diabetes are some of the medical conditions associated with OSA.

Q. Do children get this condition?

Dr Saurajen: Children should not snore. When their airways are obstructed or narrowed, they will snore but they may also present with other symptoms such as bedwetting, sleep walking, night terrors, restless sleep, nighttime sweating, head in sniffing morning air position (i.e. head extended upwards), chronic mouth breathing, and poor school performance.

Q. Should I check for sleep apnoea?

Dr Saurajen: If you have any of the symptoms described above, you should certainly consider checking with your doctor and finding out if you have sleep apnoea. Sleep apnoea is a treatable condition and unfortunately, if not treated, can result in poorer quality of life, heart problems and strokes, etc.

Q. I suspect that I may have sleep apnoea. What should I do?

Dr Saurajen: You should consult your family doctor for an assessment. Your doctor will probably refer you to a sleep specialist. Various specialties deal with sleep. This could range from the Ear Nose and Throat surgeon (who can assess the various obstructive sites in the airway) to a respiratory physician or neurologist trained in sleep.

Q. How will they check if I have sleep apnoea?

Dr Saurajen: Apart from the physical examination, you will have to undergo a sleep test. This is a one night study which is either done in the hospital or done at your home. There are several types of sleep tests available now. These range from the traditional tests where you are hooked up via wires to newer devices where your blood vessel tone and oxygen levels are monitored with a portable device.

Q. What sort of treatments are available for sleep apnoea?

Dr Saurajen: Basically, treatment is targeted at improving the airway size and reducing the airway floppiness. Treatment options include conservative measures (including medication), continuous positive airway pressure (CPAP) therapy, oral appliances,
and surgery.

Q. What are some of the simple measures I can do to help my sleep apnoea.

Dr Saurajen: Irrespective of the severity of the sleep apnoea, we always start out with simple measures. These include losing weight and exercising especially if overweight, sleeping on the side, medications to help clear the nose and airway, reflux medication, and avoidance of alcohol, sleeping pills, and eating late.

Q. What about CPAP therapy? What is it and does it work?

Dr Saurajen: Continuous positive airway pressure therapy or CPAP therapy is very effective. This is the first-line of therapy and has been shown to be effective in treating the obstructive events and hence improve the symptoms and conditions associated with obstructive sleep apnoea. It is basically a face mask that you wear at night which is connected to a small machine. This machine blows out air through the mask which then keeps the airway open. There are different types of masks available depending on size, preference and comfort levels. Nowadays, there are different machines which are small and very portable. There are also smart machines or auto-CPAP machines which can determine how much pressure is required to keep the airways open. As these are not invasive procedures, we generally use CPAP as the first-line treatment for sleep apnoea in adults. For children, we would still consider this but we would frequently operate on the nose, adenoids and tonsils if they are obstructing the airway.

Q. How does the oral appliance work?

Dr Saurajen: The oral appliance is a dental device which you can wear at night when you sleep. Most of these devices need to be fitted by a dentist and the aim of this device is to push your lower jaw slightly forward so as to open up your airway a little bit. This is used more for simple snoring or for mild to moderate sleep apnoea.

Q. What about surgery? Does it work?

Dr Saurajen: Surgery is considered especially if the patient is not able to comply with the CPAP machine or other more conservative measures. It is aimed at treating the sites of obstruction. The sites of the obstruction can broadly be identified at the levels of the nose, the throat, and the tongue. These are identified by performing endoscopy in the ENT doctor’s surgery. It is best to have this surgery by someone who is trained in sleep surgery. For children, surgery is generally the first-line of treatment and this is where the nose, adenoids and tonsils are surgically treated.

Don’t Let the 
Sound Fade
Typically, a person seeking help with their hearing had the problem for many years. The longer problems are unresolved, the more complicated the solution becomes. This unfortunate fact holds true for untreated hearing loss. As hearing loss gradually worsens, sounds slowly fade into the distance until they simply no longer exist and are soon forgotten.

After years of hearing sound in a muted fashion, we tend to remember sounds with the same muted quality and we become almost hyper-sensitive to the presence of these sounds when they are again made audible. Our brain’s re-awakening to the awareness of sound often results in the perception that they are too loud.

We typically lose hearing in the high pitches first. So gradually, the world of sound that constantly surrounds us becomes dull and flat, then we start to remember sounds in that fashion. With the reintroduction of proper pitch, the brain again overreacts. This can result in the perception that things sound tinny and sharp.

Re-acquiring the Sense of Hearing

For years, our brain has been telling us that the world of sound is muted, dull and flat. With hearing aids, we hear sounds that were “never” there (forgotten sounds), the sounds that we do remember were never that loud (muted), and they sound artificial (base/treble). What do we do now? Fortunately, there are several tools at our disposal to help patients navigate this reacquired sense of hearing.

First, it is the responsibility of the audiologist to ask about your hearing world. The audiologist will then be in a position to help you anticipate experiences and special circumstances you may encounter.

Secondly, the available technology can be extremely sophisticated. Many hearing aids can monitor the sound around you, record any changes that you make, self-adjust, and even suggest changes based on this information. Some hearing aids have the capacity to be pre-set to make specific changes based on hours of use or over a period of months. This can save you time and in some cases, a trip to the audiologist for an adjustment.

Finally, you must become actively involved in the process of better hearing. Use your hearing aids daily and keep track of your new hearing experiences. Then share these experiences, both good and bad, with your audiologist so that they can ensure you are getting the most out of your hearing aids.

If hearing instruments are used consistently and with determination, adaptation will eventually take place and sounds become normal again. With the sophisticated technology that is available, and a skilled audiologist, you will be able to make the transition to better hearing comfortably.

There must be some point in our lives when we think taking multivitamins is the answer – from bad hair days to nutritional deficiency to ‘irregular’ bowel movement. Although there are no definite studies regarding the benefits of multivitamins in the prevention of cancer and chronic diseases, we still take them exactly for this reason.

According to the 2010 Dietary Guidelines for Americans, “For the general, healthy population, there is no evidence to support a recommendation for the use of multivitamin/mineral supplements in the primary prevention of chronic disease.”1 Until, of course, The Physicians’ Health Study II.

Cancer Prevention

Just last year, after several clashing reports on whether multivitamins can fend off cancer and other chronic diseases, a study found that regular multivitamin intake can help reduce cancer risk in men by up to 8%.

The Physicians’ Health Study II was presented at the American Association for Cancer Research conference on cancer prevention in Anaheim, CA, and was published online2 in The Journal of the American Medical Association (JAMA). The study followed almost 15,000 male doctors from 1997 to 2011 and found that those who were taking a daily multivitamin experienced 8% fewer cancers than the subjects who were not. The study was supported by the National Institutes of Health and a grant from the chemical company BASF, and the multivitamins were provided by Pfizer.3

According to Dr John Michael Gaziano, a cardiologist at Brigham and Women’s Hospital and the VA Boston Healthcare System and the lead author of the study, “The reduction in total cancers was small but statistically significant. It certainly appears there is a modest reduction in the risk of cancer from a typical multivitamin.”3

What’s in Your Pill

Ideally, we get all the nutrients our body needs from the food we eat. This is possible, but not easy. With our busy schedule and on-the-go lifestyle, who has the time to keep track of what goes into our mouths?

Although health experts agree that multivitamins are not a replacement for a good, well-balanced diet, they’re a good way to help supplement a diet for those who don’t always have time to eat a healthily. You may supplement the areas where your diet lacks the necessary vitamins and minerals. Before raiding the nearest pharmacy for a bottle of multivitamins, however, it is necessary that you find the right multivitamin for you. There are pills for men, women, kids, pregnant women, vegetarian, and the elderly, among others.

Although multivitamins are helpful in supplementing nutritional deficiencies, and now with the study proving that taking them daily helps reduce the risk of having cancer, Dr Gaziano advised in an article from New York Times that there are other more effective means to prevent cancer than the daily intake of multivitamins. “It would be a big mistake for people to go out and take a multivitamin instead of quitting smoking or doing other things that we have a higher suspicion play a bigger role, like eating a good diet and getting exercise,” Dr. Gaziano said.3 “You’ve got to keep wearing your sunscreen.”

References: 1 US Department of Agriculture and US Department of Health and Human Services. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010. http://www.cnpp.usda.gov /DGAs2010-DGACReport.htm. Accessed October 8, 2012. 2 http://jama.jamanetwork.com/article.aspx?articleid=1380451 3 http://www.nytimes.com/2012/10/18/health/daily-multivitamin-may-reduce-cancer-risk-clinical-trial-finds.html?_r=0

The overall incidence of cervical cancer in Singapore has consistently declined in the last three decades. In the Singapore Cancer Registry Interim Annual Registry Report for 2006 to 2010, cervical cancer is now the eighth most common cancer in women. The incidence has declined to 10.8 per 100,000 women.

Screening and Detection

There is no organised cervical screening programme in Singapore. Cervical screening is opportunistic and ad-hoc. Women seeing their general practitioners or seeking gynaecological services are encouraged to participate in cervical screening.

In 2004, the Health Promotion Board launched a National Cervical Cancer Screening Programme called Cervical Screen Singapore (CSS). Women aged 25 to 69 were invited to undergo cervical screening every three years. Recent analysis showed that there is an increased detection of the pre-cancer stage of disease known as Cervical Intraepithelial Neoplasia (CIN). There is also a steady decline in the incidence and deaths from cervical cancer. This clearly demonstrates that attending for regular cervical screening has led to an increased detection of the pre-cancerous disease. Treatment of the pre-cancerous disease leads to a decline in the incidence of cervical cancer.

What is cervical screening?

Cervical screening takes a sample of cells collected from the cervix for analysis under the microscope. The cells can be collected by two different methods. They can be collected using a wooden spatula and transferred onto a glass slide for reading under the microscope. This method is called the conventional smear and is largely used in polyclinics. The other method collects cells using a brush which is then placed in a liquid medium where the cells are spun down in the laboratory and transferred onto a glass slide for reading. This new method is called liquid based cytology.

Who should be screened?

Women above 25 who have been sexually active should be offered cervical screening. Women, under the age of 25, should not be routinely screened as this can lead to overtreatment of the cervix, which may affect future fertility. However, if they have abnormal bleeding, they should be examined for cervical abnormalities. Screening can be stopped at the age of 70, according to the local screening guidelines.

How does screening reduce incidence of cervical cancer?

Cervical screening is not a test for cervical cancer but a screen for pre-cancer disease. However, early detection and treatment of CIN leads to reduction in the incidence of cervical cancer. CIN does not usually present with symptoms, so women with CIN would not be aware that they have a problem. Women with abnormal cervical smears should attend a colposcopy clinic, where the cervix can be examined using a magnifying glass to identify any pre-cancerous abnormalities. Abnormal areas that are identified may need treatment.

Human Papillomavirus

Human Papillomavirus (HPV) is a very prevalent virus which is transmitted through intimate contact. Infection with HPV does not cause any symptoms and can sometimes remain dormant for years before causing any changes in the cervix. It is a common infection but is often transient, and cleared by the body without causing harm. There are over a hundred subtypes of HPV, but only about 13 types will cause changes that will lead to the development of cervical cancer. HPV subtypes 16 and 18 cause about 70% of cervical cancers worldwide. Testing for high risk HPV is now available and can be done as part of the Pap smear screening. It is a good test to identify women who need to be screened more regularly. A negative HPV test puts the woman’s risk of developing cervical cancer at very low in the next three to five years. This low risk is not lifelong, so regular Pap smears and HPV tests are still mandatory to detect early changes in preventing cervical cancer. A positive HPV test does not mean that the woman is going to develop cervical cancer. It means that the woman has been exposed to the high risk HPV subtypes and will need to be examined using the colposcope to look for pre-cancer changes. Most women, however, will clear the HPV infection and not go on to develop pre-cancer or cancer. Annual testing is recommended until the infection is cleared.

Modes of Treatment

Pre-cancer changes (CIN) are treated by excising or destroying the abnormal areas. This procedure involves destroying the cells by ablating them or excising the area of abnormality using laser, a loop of heated wire (LEEP) or a knife. This can be offered under local anaesthetic or general anaesthetic, depending on the size of the abnormal area or according to the patients’ preference.

Fertility Sparing

Very early cancer can be treated using the methods mentioned above. However, occasionally, the lymph glands will need to be removed too. In stage 1 cancers that are slightly bigger, an operation to remove the cervix and/or uterus (womb) together with the surrounding tissue and lymph glands is recommended. The decision to conserve the womb is dictated by the woman’s wish to retain her fertility. This procedure is limited to very small cancers that have not spread to the surrounding tissues or lymph glands. The procedure is called a trachelectomy. There has been success with pregnancy following this treatment, although babies are delivered by caesarian section and often prematurely. If fertility is not an issue, women will be offered an operation to remove the womb, surrounding tissues and lymph glands. Very occasionally, some patients will require radiotherapy following the operation. If the cancer shows signs of spreading beyond the cervix, the preferred method of treatment is radiotherapy. Chemotherapy is also offered together with radiotherapy if the patient is able to tolerate the treatment. The response to treatment is usually encouraging unless the cancer is in its advanced stages.

Ovary Sparing

With radiotherapy, women are rendered menopausal. As some patients are very young, the ovary can be removed for cryopreservation (freezing). On completion of treatment, the ovarian tissue can be replaced. The CARE centre in Singapore General Hospital has had recent success with this procedure.

Vaccination

Vaccines have been developed against the two most high-risk HPV strains. All girls should be vaccinated to protect them against infection and ultimately from developing cancer. Women who have been exposed to the HPV virus can still get some benefit from this vaccination. So in conclusion, cervical screenings with regular Pap smears have led to increased detection of pre-cancer. Screening for HPV infection will help identify those at a higher risk for closer follow up. Detection of pre-cancerous disease through screening and treatment has led to a decline in the incidence of cervical cancer. This, coupled with vaccination against high risk HPV subtypes, will lead to further decline in the incidence and deaths from cervical cancer.

Dr Chew Ghee Kheng (MBBS, MD, FRCOG) is a Senior Consultant at the Department of Obstetrics & Gynaecology, Singapore General Hospital.

Allergic rhinitis implies an inflammation of the mucosal lining of the nasal airways primarily caused by an “allergen”. It is one of the most common medical conditions encountered globally. It affects 10% to 40% of the population in industrialised countries. The incidence of allergic rhinitis in the US is about 17% of the population; and in Singapore, a study showed the incidence to be around 13%. The economic impact of allergic rhinitis in the United States is estimated to be roughly 8 billion dollars annually. The time lost from work is estimated at 10 million days a year; and for children the time lost from missing school is 2 million days a year.

The Development of Allergy

For the patient to develop allergy, the allergen must enter the body to produce symptoms. The most common portal of allergy is the respiratory route – in other words, most of the times we inhale the allergens. Not surprisingly, most symptoms caused by inhalant allergens occur in the respiratory tract.

When an allergen – something that one is allergic to – enters the body, it incites certain cells (B cells) of the immune system to produce antibodies specific to that particular allergen. These antibodies then bind to some other type of cells called the mast cells. This binding causes the mast cells to become “sensitised” to that particular allergen. When these sensitised mast cells come in contact with the allergen they liberate histamine and other chemical mediators responsible for the symptoms of allergy. This process is triggered when the allergen enters the body and binds to the specific antibodies already present on the surface of the mast cells.

The structure with which the public most commonly associate with allergy is the nose. But in actual fact, allergy may be the root cause of a wide variety of complaints presenting to a doctor in ENT practice. Unknown to the patient and sometimes the physician, allergy may be lurking in the background as the great masquerade for a wide variety of presenting symptoms.

Types of Allergens

For practical purposes, the inhalant allergens are generally divided into two types: perennial and seasonal. Perennial offenders are present throughout the year. These include house dust, which has been considered as the universal antigen. The best known antigen present in house dust is the mite Dermatophagoides. Other allergens include insects such as cockroach and cricket.

Epidermal allergens include hair of furry animals where cats and dogs top the list. The dander and other allergens produced by the furry animals are light and become an intimate part of the drapes, carpets and other décor.

Mould allergy is worldwide and present in all seasons. Moisture and decay promote mould growth. Area around plumbing and water pipes is subject to condensation and accumulates major amounts of mould growth. There are currently more than 80,000 species of mould identified!

Food allergy includes allergy to milk, wheat, corn, yeast, egg and soy. Food allergy is even more insidious. Its manifestations have been well described by the term “many syndrome” i.e. many symptoms, many organ symptoms, many physicians, many tests, many failures.

Inhalant allergy may vary in its manifestation depending on the type of allergen. In perennial allergic rhinitis, the signs and symptoms may be indistinguishable from the common cold. The patient often complains of a “cold that never goes away”.

Diagnosing Allergy

The presumptive diagnosis is usually made from history and physical examination.

Skin Prick Test

Among the tests to confirm the diagnosis of allergy, the skin prick test is quite popular. This test is inexpensive and can be safely performed in the clinic. The skin prick test is very sensitive but is, however, subject to a variety of external influences. Antihistamines, several tranquilisers, cough medications, and drugs with similar actions may depress skin activity making readings unreliable. The skin tests can also be time consuming.

Radioallergosorbent Test

For patients not suitable for skin prick test, a blood test is available. This is called the Radioallergosorbent Test (RAST). Each antigen produces an antibody specific to the antigen. This test measures the serum level of that specific antibody. This test overcomes or entirely eliminates the variability of the skin tests. It saves time and causes less discomfort to the patient. The cost, however, may be a concern as it can be expensive to test a whole panel of allergens. It is also not as sensitive as skin prick test.

Treatments of Allergic Rhinitis

Once the allergen/s is/are identified, some definitive form of therapy is planned. In most cases, more than one approach will be needed before the patient reaches the maximal benefit. Treatment includes environmental control, pharmacotherapy, and immunotherapy.

Ideally, allergy should be controlled by elimination of the offenders. Inhalant allergens consist of pollen (in seasonal countries), moulds and various members of the dust group including animal dander. Unfortunately, elimination of these from the environment is far from easy. Pollen allergy is not common in Singapore, but dust, mould and animal dander are abundant.

Pharmacotherapy includes antihistamines, decongestants and steroids. Antihistamines have been in general use since the 1940s. Chemically, they compete with histamine for attachment sites on the target organs. Antihistamines function best when administered before allergen exposure. Almost all antihistamines tend to be sedative in nature; therefore, operating machinery and driving a vehicle may be dangerous while on antihistamines. Steroids exert probably the most profound effect on both allergic and other related inflammatory conditions of any drug available. Over a short period they are also among the least likely to produce side effects. The most appropriate use of systemic steroids is the short burst necessary to control an intolerable acute condition.

Immunotherapy aims at hyposensitising the patients to the allergens and offering a reasonable possibility of a cure at least for a time. It is a form of immunisation which is accomplished by intentional exposure to regular, progressive doses of the same specific aeroallergens that are responsible for producing symptoms. It results in down-regulation of the immunologic response and control of symptoms associated with usual levels of environmental exposure to the treated allergens. It is, however, expensive and may take as long as three to five years to be effective. Therefore, a firm commitment from the patient is necessary before considering this mode of treatment.

Allergy Can Affect Any Part of the Body

• Nose. In the nose, allergy causes inflammation of the nasal passages and is usually associated with runny nose, sneezing, itchy and blocked nose.
• Ears. In the ears, allergy may be the cause of “otitis externa” i.e. chronic inflammation of the pinna or the ear canals. Allergy may also cause “glue ear”, recurrent ear infections, barotrauma and Eustachian tube dysfunction.
• Throat. The throat is not as commonly involved as the nose and ears, but allergy can be the cause of chronic sore throat in some patients. The sinuses may be affected as well.

One of the most common problems men face, Male Pattern Hair Loss (MPHL) is hair loss with a specific pattern occurring in men only. Fifty percent of men have this problem, and it usually starts occurring before 30 years old. In fact, it is so common that nobody takes a second look when they see a man with Male Pattern Hair Loss. MPHL is written in your genes, which means that if your father or brothers have it, most likely you will have it as well.

The Tell-Tale Signs

The first sign of MPHL is the receding hairline at both temples, a condition which is present in 95% of Caucasian men! Without treatment, the hairline progresses higher up the middle of the scalp in an M-shaped pattern. The last stage leaves only a thin U-shaped strip of hair at the back of the head (refer to Stage VII in the below classification chart). The hair in this area is not affected because it is resistant to balding.

When you see a man in the later stages of balding, you will subconsciously have the impression that he is old. This is a common misconception. Hair loss progression is closely related to genetics rather than age. A young man may have severe male pattern hair loss, whereas a mature man may have hair loss only in the first stage. That is why many young men with late stage MPHL choose to shave their heads instead, to avoid looking old.

A thick crop of luscious hair is extremely valued by most men. According to an online survey conducted in Asia in 2011 by Merck, seven in 10 Singaporean men think that “thin hair” is not cool and makes them unattractive to the opposite sex, and five in 10 Singaporean men with balding said that their self-esteem was hurt.

Yet, only one in five Singaporean men has consulted a doctor for his hair loss condition, with the rest relying on over-the-counter remedies or trichologists’ services. One of the key barriers to seeking medical advice was the embarrassment involved, as well as the cost and uncertainty of finding the right doctor.

Modes of Treatment

Much like hypertension and diabetes, MPHL is a chronic, progressive condition which requires skilled medical treatment. Not consulting a doctor with a keen interest in hair loss is akin to ignoring a small fire – the condition gets worse by the day as the “fire” spreads through the forest.

Finasteride (Propecia) is the number one FDA-approved treatment for MPHL. It directly blocks the enzyme producing dihydrotestosterone (DHT). DHT is the main culprit hormone that causes hairs to thin and the scalp to lose hair density. Thus, Propecia is the top agent that stops MPHL at its root. It is proven to restore hair density over the vertex and the crown area. Obvious results start to show only after three to six months, and one should not stop it as the condition will worsen otherwise. Side effects wise, 1% to 2% of men on Propecia may get decreased libido and erectile dysfunction. Fortunately, these side effects are only temporary and disappear once it is stopped. Even if Propecia is continued in this small group of men, the side effects will also wear off in a few months. The other 98% of men taking Propecia have no side effects and swear by it to be their hair saver.

Minoxidil 5% hair lotion is the second-line FDA-approved medication for MPHL (over the crown and vertex areas). It increases blood flow to the scalp to support hair growth metabolism. Take note to rub 1mL of the lotion thoroughly into the balding scalp twice daily and do not wash your hair for at least four hours thereafter.

Next are scalp regrowth injection treatments. Growth-stimulating vitamins and proteins are injected into the scalp over the affected areas. This treatment provides essential nutrients to the scalp, blocks harmful free radicals, and converts hair follicles from inactive to active growing phase. Each session takes only 10 minutes. A course minimum of 10 sessions (one session per week) is needed initially. The frequency is then tailed down according to the response. These also revitalise the scalp and greatly improve scalp health, allowing Propecia and Minoxidil to work their magic.

Lastly, iGrow home-use hands-free laser helmet is US FDA-approved for proven results (with multiple scientific studies). iGrow stimulates the scalp with a combination of laser and red light. By using it for 20 minutes three times a week, one can see obvious hair regrowth results after six months. The results are better for the earlier stages of hair loss, thus early treatment is important.

A combination of the above treatment options simultaneously usually brings very good results. Do take note that the above therapies do not have much effect on the temple and front hairline regions. For those regions, only a hair transplant can regrow the front hairline, which helps to frame the face and create an impressive aesthetic effect.

Hair Transplant

Hair transplant is needed for men with hair loss at the temples and front hairline, as these areas do not respond to the above treatments. Men with balding at the vertex or crown region usually respond well to the above treatments. Only in a few cases when the regrowth is not thick enough do we transplant the hair to the vertex and crown areas. Hair Transplant is a safe, uncomplicated day surgery done under local anaesthesia. One can go home right after surgery and return back to work the next day if needed. Just take note to protect the newly planted hairs for the first two weeks after surgery as they try to survive in the new scalp area.

During the surgery, balding-resistant hair is taken from the back of the head and then carefully implanted onto the temples and upper forehead region to re-create a new youthful looking hairline. A good example is Wayne Rooney, who looks much younger after his hair transplant. Singapore medical guidelines do not allow displaying of before and after pictures, but anyone can search online for overseas hair transplant results to witness the dramatic improvement in one’s looks after a hair transplant.

MPHL is one of men’s greatest fears, affecting self-confidence, self-esteem and one’s looks. Established medical treatment and hair transplant options are available with proven results. One just needs to find a doctor with a keen interest and training in hair restoration to regrow that thick crop of luscious hair and be that suave, confident, youthful-looking man once again.

The inability to conceive is something many couples never expected to face when they make the decision to start a family. However, the reality is that, in most populations, at least one in six couples has issues conceiving a child. If this problem does not get resolved and childlessness becomes a prevailing situation, couples fall into despair and hopelessness – that is indeed a life crisis.

Thankfully, since the birth of the world’s first in-vitro fertilisation (IVF) baby more than three decades ago in July 1978 and with the advent of modern science, there have been great strides in making the dreams of childless couples to have a child come true.

Issues in the Early Years of IVF

The early years were fraught with poorer success rates and a very arduous and uncomfortable journey for women who might, unfortunately, not end up having a baby. In addition, the two big problems associated with IVF are one that involves daily injections to stimulate the ovaries in producing follicles or egg-bags (which contain the eggs, where problems can arise when there is overproduction), and the other is when too many babies from too many embryos transferred cannot be accommodated in the womb (resulting in the serious risks of premature births). Consequently, the very premature baby needs special intensive care to address the medical conditions which may be associated with not only permanent long-term neurological handicap, but physical and mental life-long problems as well.

In recent years, stimulation of the ovaries to produce eggs has been simplified. The medications are now injected under the skin of the abdomen – literally painless – for a shorter duration, to allow egg “pickup” or collection. The most critical issue, however, is that of excessive “ovarian hyperstimulation syndrome or OHSS” which can occur in about 1% to 2% of cases, sometimes with dire consequences. In this condition, there is fluid accumulation into the abdomen, as a result of a shift of fluid (containing proteins) from the blood stream, into the abdomen. This results in the thickening of the blood and an increased risk of blood clotting (thrombosis). If clots occur in the vital organs (e.g. the brain), this can result in a stroke; or can cause heart malfunction, if in the pulmonary (lung) blood vessels.

The Role of Antagonists in OHSS Prevention

The recent introduction of a medication called “antagonist” efficiently prevents the egg from being released before they are ready for collection. Egg collection is a minor surgical procedure. A thin needle is passed through the vagina and the eggs are aspirated (withdrawn through suction) from each follicle. The eggs collected are handed over to the embryologist (a laboratory expert) for processing and inseminating with the sperm in the laboratory, and eventually growing them into embryos. The embryo is then transferred back in into the womb.

However, the dangerous problem of OHSS, has been for many years, is that it is consistently hard to predict or circumvent. Now with the use of antagonists, rather than using the more traditional “agonist” method where there is a longer duration of injections to quieten-down the ovaries, “antagonist cycles” are more compact and easier for patients. The major advantage of the “antagonist cycle” is that we can ripen the eggs (takes 36 hours) by using a high dosage of agonists as a single injection. OHSS is a situation likened to a race car that has been driven to maximum speed (i.e. production of eggs) but the engine begins to overheat in the process. Using the antagonist, one can just turn off the engine and then use a fast high impact “ripening” injection (i.e. the “agonist”) to trigger or set-off ripening rather than the traditional lingering-effect type of trigger (e.g. Pregnyl or chorionic gonadotropin) that continues to run the engine despite the overheating. By using an antagonist, the system is shut down after collecting the eggs, inseminating them and creating embryos out of them. The resulting embryos can be frozen, so that when the engine cools down, the womb can be prepared with hormones to receive the embryos after they have been taken out of storage. This whole process totally averts the risk of OHSS!

A Lot Simpler and Safer IVF

The other perennial problem used to be high order multiple pregnancy (i.e. triplets and beyond) which is risky to both mother and child. This is truly something avoidable. By growing embryos longer in an extended laboratory environment and selecting the very best embryos, we can get good pregnancy rates, and at most have twins (but not more than that) if only two embryos are replaced each time. This means we get good pregnancy rates and yet minimise the premature births of babies and the possible associated long-term disabilities.

Another reason why IVF has become a lot safer and more patient-friendly is because of the shortened duration of injections which are literally pain-free, thus very easy these days for women to self-administer. A recent advancement is to use a long-acting singular injection that lasts seven days and after an additional two or three days of “top-up”, the stimulated ovaries are ready for collection of the eggs. This is a convenient way for most working women, as reducing the need for daily injections minimises the risks of mistakes. These developments have made IVF a less stressful and arduous journey of getting couples realise their dreams of being a “mum” and “dad” to little babies growing up into healthy children.

STARTED IN 2006, World Kidney Day is celebrated every year on the second Thursday of March. Its mission is to raise awareness on the importance of our kidneys and the impact of kidney diseases worldwide.

Do you know that three people lose the use of their kidneys in Singapore daily? This means over 1,000 cases of kidney failure a year! With the average waiting time for a kidney transplant being nine years, dialysis is the next treatment option for patients whose kidneys have failed. Currently, there are two forms of dialysis treatment available, namely haemodialysis and peritoneal dialysis. Haemodialysis (HD) requires patients to travel to a dialysis centre for treatment. In contrast, peritoneal dialysis (PD) can be carried out at home, at work, or on trips.

How does Peritoneal Dialysis work?

A PD catheter is inserted permanently at the abdomen to allow filling and draining of about two litres of PD solution into and out of the peritoneum or abdominal cavity, which is surrounded by the peritoneal membrane. The peritoneal membrane then filters waste and fluids from the blood into the solution. The PD solution is allowed to remain in the abdomen for four to six hours before it is drained and replaced with fresh PD solution. The replacing of fresh PD solution with the used PD solution is called an exchange. Each exchange takes about 30 minutes. PD patients perform an average of four exchanges per day.

Different types of PD have different schedules of daily exchanges.

Continuous Ambulatory Peritoneal Dialysis (CAPD).

This is the manual way of performing PD exchanges. Using the PD bag system, CAPD patients perform PD exchanges four times daily. No PD exchange is required when the patient is sleeping.

Automated Peritoneal Dialysis (APD).

PD exchanges are performed by connecting the patients’ PD catheters to a cycler for 10 hours. APD patients start their therapy by programming the cycler to perform PD exchanges for them while they sleep.

What do PD patients need to remember?

• Be diligent to stick with their PD prescription. Adhering to their PD prescription daily has a direct impact on their wellness.

• Manage their diet. It is very important to follow the meal plan recommended by their dietitian, so that they can stay healthy physically and mentally.

• Stay active by doing sports and exercise after checking with their doctor.

• Plan ahead. If they need to travel, they will need to bring their dialysis supplies along and may even need to have some sent to their destination in advance.

Advantages of PD

 No need for vascular access and needling. In haemodialysis, two needles are inserted every session to allow blood to drain and return to the body after filtering. Vascular access-related complications are the most common causes of hospitalisation in haemodialysis patients.

 Better time flexibility. PD patients are not restricted to dialysis centre schedules. They can fit PD into their work schedules as it is home-based.

 Better quality of life. Patients can enjoy the independence of being in charge of their own treatment. However, they will need to work closely with their healthcare team including the nephrologist, dialysis nurse and dietitian to do well on PD therapy.

PD Community Support Programme

In view of the increasing incidence and prevalence of kidney failure patients, the National Kidney Foundation (NKF), the largest dialysis provider in Singapore, launched the PD Community Support Programme, where experienced PD nurses visit patients regularly at their homes to ensure good PD self-management and provide advice and care.

The Role of Vitamin K2 in Healthy Bone

The holes left by osteoclasts are prepared for remodeling by osteoblast cells. The osteoblasts secrete a protein called osteocalcin, which when activated (or carboxylated) enables new calcium to be laid down into the bone. The calcium-binding properties of osteocalcin require vitamin K, whereas the synthesis of osteocalcin itself requires vitamin D3.

Vitamin K thus protects against excess bone degradation (resorption) by turning off excess osteoclast activity. It then supports the critical role of new bone formation by enabling osteocalcin to pull calcium from the blood and layer it on to
the bone.

Maintenance of healthy bone density requires adequate levels of calcium, vitamin D, and vitamin K. Without vitamin D, there will be no osteocalcin for vitamin K to work on. Without vitamin K, the osteocalcin that is produced will be inactive. And, of course, without calcium, there will be no minerals for the activated osteocalcin to attract to the bone for structural density.

As Effective as Prescription Drugs

Vitamin K2 has proven to be as effective as prescription drugs in reducing the incidence of bone fractures. A Japanese study in postmenopausal women compared the effect of K2 (MK-4) with the drug etidronate (Didronel) on the incidence of vertebral (spine) fracture. Women taking vitamin K2 at a dose of 45mg per day experienced a fracture rate of 8.0% compared with 8.7% for those taking the etidronate drug therapy. Furthermore, women taking both MK-4 and the drug experienced only a 3.8% fracture rate. In a placebo group that received neither K2 nor drug therapy, nearly 21% of women experienced bone fractures.

Source:
Effect of continuous combined therapy with vitamin K(2) and vitamin D(3) on bone mineral density and coagulofibrinoolysis function in postmenopausal women. Maturitas 2002;41:211-221.

Fibroids

Fibroids are lumps that grow on your uterus. You can have fibroids on the outside, inside or in the walls of the uterus. Fortunately, fibroids are not cancerous. More often than not, you do not need to do anything about them unless they give you problems. Fibroids are very common in women in their 30s and 40s.

It is still difficult to establish the root cause of fibroids, however, it is suggested that it is the female hormones (oestrogen) that contribute to their growth. During the reproductive period, the fibroid will grow and may cause symptoms such as heavy menstrual bleeding, abdominal discomfort or urinary frequency. Fortunately, fibroids usually shrink after menopause and their symptoms subside.

Most women with fibroids, especially if the fibroid is small, typically have no symptoms. Occasionally, fibroids may lead to mild symptoms such as abdominal heaviness, heavy menses and frequent urination. In some women, heavy bleeding during their periods may lead to anaemia. Fibroids may also make it harder for some women to get pregnant.

Diagnosis of Fibroids

To find out whether you have fibroids, your doctor may need to perform a pelvic examination to assess the size of the uterus. Otherwise, you may need to have an ultrasound of the pelvis that shows a picture of your uterus and the fibroids. A blood test is also useful to check for anaemia.

You need not necessarily seek treatment for fibroids if they are not bothering you. However, your gynaecologist should monitor them on your routine visit to check if they have grown significantly. If your symptoms include pain or heavy menses, medications (e.g. synflex) may alleviate the symptoms. Oral iron supplements and maintaining a healthy diet may be sufficient to manage anaemia.
Occasionally, if the symptoms appear to be worsening or affecting your daily activities, you may want to consider surgery. As fibroids take time to manifest until they are of an operable size, you have ample time to consider your surgical options.

Surgical Treatments

There are two main types of surgery for fibroids, namely, myomectomy or hysterectomy. The decision will depend on your age, size/location of fibroids, and your reproductive intent.

Myomectomy is a surgery to remove the fibroids from the uterus. This option may be viable if you still intend to have children. In fact, it may even improve your chances of conceiving. However, it is not uncommon to find that the fibroids may grow back over time.
Hysterectomy refers to the removal of the uterus. This is the most common surgical method for removing fibroids and is a definitive option, as it is the only way to make sure your fibroids will not come back again. Your symptoms will go away, but you will not be able to bear children.

In the last few years, advancement in laparoscopy has enabled the method to be performed via a single incision or single “hole” (SILS). The advantages of SILS are its cosmetic outcome as the single scar will be well “hidden” within the umbilicus. Recovery and pain control are improved using this approach. Alternatively, in some patients, innovative approaches using 3mm incisions or “minilaparoscopy” may help to reduce the morbidities associated with the punctures of the abdominal wall.

Endometriosis

Endometriosis occurs when tissue from the uterine lining, the endometrium, is found in an abnormal location outside the uterus, such as ovaries, pelvic area, bowel and bladder. Endometriosis is one of the most common gynaecological conditions in the world. With the advancement in medical technology, we are able to diagnose an increasing number of women with endometriosis.

While some women show no symptoms of endometriosis, others may only find out that they have the disease when trying to conceive. The principal symptoms of endometriosis are chronic pelvic pain, dysmenorrhoea, dyspareunia, bowels or bladder dysfunction. Endometriosis is found in up to 45% of women presenting with chronic pelvic pain. Occasionally, these symptoms may be debilitating, affecting the woman’s physical, mental and social well-being.

There seems to be low awareness of this condition in our country. For this reason, the National University Hospital (NUH) launched Singapore’s first endometriosis awareness campaign in 2012. The month-long campaign included educational talks and activities to raise awareness of endometriosis in our population. March 2013 will mark the second year NUH will be holding the campaign to engage and educate young Singapore women – who make up a significant proportion of endometriosis patients – that endometriosis, while difficult to detect, can be overcome with disease awareness.

Diagnosis of Endometriosis

Laparoscopy is the gold standard in diagnosing this condition. In addition, it provides an opportunity to obtain histological confirmation, including treatment of the disease at the same setting. With improved techniques such as single incision laparoscopic surgery and reduced anaesthestic morbidities, it is expected that the condition can be diagnosed early. Medical options that aim to suppress the endometrial proliferation and inflammation are appropriate initial treatment. Unfortunately, this option does not eradicate the condition and more often than not, the recurrence rate can be as high as 68% upon stopping the treatment. For those who wish to conceive, medical treatment may delay the opportunity as the medicines used in treatment of endometriosis inhibit pregnancy.

Endometriosis remains an enigmatic disease which significantly affects the quality of life of our patients. As gynaecologists, we can help our patients cope with this recurrent illness by providing a holistic approach and customised treatment plan for the condition.
On the same note, nursing and peer support groups can help those affected to cope with and ease its effect on her quality of life.

The Procedure

Two common surgical procedures for getting one’s “tubes tied” are laparoscopic tubal ligation and postpartum sterilisation. These are minor operations that allow most patients to return home within the same day.

Laparoscopic tubal ligation (in non-pregnant women) is done by application of small ligation clips on the isthmic portions of both tubes, thereby closing off the lumen. This procedure is often carried out via a two-port “key-hole” surgery. More recently, with the availability of a single-port device, the same procedure can also be carried out via a single “key-hole” instead.
In postpartum sterilisation, a small incision (of about 1 to 2cm) is made at the belly button after childbirth. This is usually done in the operating theatre under general or regional anaesthesia. Either a small section of the tubes is cut or ligation clips are applied to both tubes.

Sterilisation can be performed any time during a woman’s menstrual cycle, although it is usually recommended that the procedure is carried out just after her menstrual period, as there is a low chance that she could be pregnant at the time of the surgery. In postpartum sterilisation, the procedure is usually performed the next day after childbirth.

Common Questions About Female Tubal Ligation

How effective is sterilisation?

In most cases, female sterilisation is close to 100% effective where a woman has a one in 200 (or 0.5%) chance of falling pregnant after undergoing the procedure. These surgical sterilisations are effective immediately after the surgery.

Should I be concerned about any complications?

While surgical sterilisation is considered a relatively low-risk surgery, there is still a possibility of complications to occur. These include (but are not limited to) anaesthetic reaction, bleeding, and wound infection. In very rare cases, there may be injuries to the bowel, bladder, uterus or blood vessels, which may require additional surgery to repair the injured organs.

In every one to four out of every 100 sterilisations performed through the abdomen, complications may develop. Death resulting from sterilisation is extremely rare and is usually caused by a reaction to general anaesthesia.

How about pain and recovery?

The administration of general anaesthesia allows the patient to sleep through the procedure. She may experience some soreness in the throat, slight pain around the incision, dizziness, abdominal fullness or pain at the shoulder tips after surgery. However, these effects usually do not persist, and the patient should recover fully in a day or two and usually can resume all normal activities after two to five days.

Will the procedure affect one’s sex life?

Sterilisation will not affect one’s sexual life nor will it affect sexual desire or performance. In fact, many couples report that they have more sexual pleasure because they are no longer burdened by the risk of unwanted pregnancy.
Sterilisation also does not affect the female hormones – as they are still produced from the ovaries – nor will it cause weight gain. Similarly, the procedure will not cause premature menopause. Most women who are sterilised continue to have their normal periods.

Who should consider sterilisation?

Sterilisation is a major decision. It means that a woman and her partner must decide mutually that their family is complete, and that they no longer intend to have children.
If you are considering various methods of contraception and have concerns about their side effects, or are in a state of health that will raise risks for future pregnancies, you may consider undergoing sterilisation.

What else should women note about sterilisation?

Sterilisation does not protect against sexually transmitted infections (STIs), including HIV. Occasionally, sterilisation may fail. If pregnancy does occur, the risk that it will be an ectopic pregnancy is increased over that in the general population.

A Common and Safe Contraception Method
Surgical sterilisation is one of the common methods of contraception practiced by women in many countries. It is a safe, highly effective and convenient method. As it is often considered as a permanent method, appropriate counseling prior to the procedure is recommended to avoid regret at a later point in life.

What you need to know about the top cancer killer in women today

by Dr Ho Gay Hui and Dr Yong Wei Sean

THE MOST COMMON cancer among Singaporean women is also the top cancer killer today. Each year, more than 1,500 women are diagnosed with breast cancer. Each day, four women are given the bad news while one dies from it. The incidence of breast cancer has tripled in the last three decades and is still on the rise. The good news is that early detection of breast cancer saves lives; and many breast cancer survivors are able to live life with zest and joy afterward.

All women, in particular those above 40 years old, are at risk of developing breast cancer. The risk increases as one gets older, and especially after menopause. Other risk factors include having one or more close relative with breast cancer, having a mutation in the breast cancer genes, and previous breast biopsy showing changes known as atypical hyperplasia and lobular carcinoma in-situ (LCIS). Onset of menstruation before the age of 12, reaching menopause after age 55, never had children, being overweight after menopause, and regular consumption of alcohol may increase breast cancer risk, too.

Breast Screening – Is It Necessary?

In its early stage, breast cancer is most often painless and may not present any symptoms. When detected early, patients have more treatment options, require less radical surgery and have a better chance of complete recovery.

The best chance of detecting breast cancer early is to do a regular mammography when one turns 40 even if she does not have any symptoms. A mammography can detect breast changes before they can be felt. Women aged 40 to 49 should have one annually, while those 50 and above should have it once every two years. Women who are at a higher risk may be recommended to start earlier.

Monthly Breast Self-Examination (BSE) and clinical breast examination by a doctor cannot replace screening mammography. However, if a lump in the breast or axilla, bloody discharge from the nipple, a persistent rash over the nipple/areola, or retraction of the nipple is noted on BSE, one should see a doctor immediately even if the mammogram turns out normal.

How is a Breast Cancer Diagnosis Made?

Usually mammography and breast ultrasound are performed. In some situations, magnetic resonance imaging (MRI) may be required. To make a definitive diagnosis of cancer, a biopsy is required. This involves obtaining tissue from the abnormal area in the breast for microscopic examination. There are various methods of biopsy such as fine needle aspiration, core needle biopsy, and surgical or excision biopsy. The recommended method at the National Cancer Centre Singapore (NCCS) is a core needle biopsy of the abnormality in the breast by the surgeon or radiologist, and may be performed with X-ray or ultrasound guidance if the abnormality is not palpable. This procedure is done under local anaesthesia and takes no more than 20 minutes, leaving only a small scar or puncture mark on the skin of the breast.

How is Breast Cancer Treated?

Surgery is the cornerstone in the treatment of breast cancer; and it can involve a lumpectomy (removal of cancerous growth with a margin of normal breast tissue) or mastectomy (removal of the entire breast). When the tumour is large or there is spread of cancer to the axillary lymph nodes, axillary clearance is performed. Side effects include wound pain, some restriction of shoulder joint movement and arm swelling (lymphoedema). Chemotherapy uses drugs to kill cancer cells and is usually given by injection into a vein. Chemotherapy is given in cycles. Each cycle comprises a treatment period followed by a resting period, which allows the body to recover before the next injection. Common side effects are hair loss, nausea, loss of appetite, change in bowel habits, and numbness in the fingertips and toes.

Targeted therapy uses antibodies or small molecules that bind to specific sites on the cancer cells to slow or stop the growth of cancer cells. There are several drugs available; some are given intravenously and others orally. Side effects include fever and chills, weakening of heart muscles, rashes and diarrhoea. Radiation therapy uses high-energy rays to kill or stop cancer cells from growing further. This therapy is given to the affected breast after a lumpectomy. In some cases, it is given to the chest wall after a mastectomy. Common side effect is “sunburn” to the skin of the breast or chest wall. There may be swelling and decreased sensitivity, too.

Hormonal therapy is recommended to women whose tumours are hormone-receptor positive. There are various types of hormonal therapy and are usually taken orally. Side effects may include menopausal symptoms, mildly increased risk of formation of blood clots in the legs and womb cancer, joint pain and stiffness, and increased risk of osteoporosis.

New Radiotherapy Treatment

Women who choose breast-conserving surgery or lumpectomy require 30 sessions of radiotherapy, given over six weeks after the surgery. Some patients have found the daily visits to the centre very inconvenient. As a result, some have even opted for mastectomy so as to avoid the need for radiation treatment.

NCCS has recently introduced a new radiotherapy treatment, Intra-Operative Radiotherapy (IORT), for a select group of patients with early breast cancer undergoing breast-conserving surgery. This technique allows the delivery of radiotherapy immediately after the cancer is removed, in the operating theatre while the patient is under general anaesthesia. IORT reduces the six-week course to a single session which lasts 30 to 50 minutes. This new technique reduces the length of treatment and inconvenience for patients, while minimising side effects. It is suitable for older women with breast cancer measuring no more than 3cm and with no evidence of cancer spread to the lymph nodes in the axilla.

Post-treatment Care

Besides supporting the patients throughout the treatment period and managing the associated side effects, doctors have to be mindful of the psychosocial challenges that their patients may face. They may be affected by the physical changes in the body, resulting in low self-esteem and sexuality issues. They may worry about the care of the family and young children, as well as loss of income. Patients should be reviewed at close regular intervals as part of surveillance for recurrence of the cancer in the initial five years. They should report any unusual or persistent symptoms to their doctor or breast care nurse. They are encouraged to lead a healthy lifestyle by having a healthy diet with lots of vegetables and fruit and regular exercise. Some studies suggest that regular exercise may reduce the risk of death from breast cancer. Survivors are also encouraged to keep an active mind by being socially active and spending time with family and friends.

Dr Ho Gay Hui and Dr Yong Wei Sean are Senior Consultants at the Department of Surgical Oncology, National Cancer Centre Singapore.

Treatments and Medications

Sinusitis occurs when there is inflammation of the sinus lining. This swelling obstructs the sinus openings and prevents normal mucus drainage, causing mucus and pressure to build up. Symptoms include facial pain or pressure, nasal blockage or discharge and reduction or loss of smell. While acute sinusitis typically lasts four weeks or less, chronic sinusitis is characterised by symptoms that last longer than 12 weeks.3

Medications for chronic sinusitis include antibiotics, nasal steroids, and over-the-counter (OTC) medicines. These help to reduce inflammation of the sinus and minimise infections. Research shows that medications fail to relieve symptoms in approximately 60% of patients, in which case, surgery is recommended.4 Conventional sinus surgery aims to clear blocked sinuses and restore normal sinus drainage by removing bone and tissue to enlarge the sinus opening, which may lead to pain, scarring, bleeding and an extended recovery period.

A Minimally Invasive Treatment Option

Dr. A. B. John, consultant and Ear, Nose and Throat surgeon at Mount Elizabeth Medical Centre says that many of his patients don’t look at conventional surgery as an option because of the fear of perceived pain and trauma, as well as the extended recovery time. “There are other options,” says Dr John. “Balloon Sinuplasty technology is a minimally-invasive way of performing sinus surgery, so there is far less pain and a much faster recovery time.”

Balloon Sinuplasty technology works by widening constricted sinus passages, in many cases, without tissue or bone removal. Clinical studies have demonstrated that patients undergoing sinus surgery with Balloon Sinuplasty technology experience meaningful improvements in their quality of life.5

“From a physician’s perspective, Balloon Sinuplasty technology provides me with another tool to manage chronic sinusitis, with the benefit of being able to preserve as much bone, structure and the natural function of the sinuses,” said Dr. Adrian Siew Ming Saurajen, consultant and Ear, Nose and Throat surgeon at Mount Elizabeth Medical Centre.

Patients who have been diagnosed with chronic sinusitis and are not responding well to medications can ask their general practitioner for a referral to an Ear, Nose and Throat specialist to determine if Balloon Sinuplasty technology is suitable for them. To find a list of Ear, Nose and Throat surgeons in Singapore who are trained in Balloon Sinuplasty technology, visit http://www.sinusrelief.com.sg.

References:

1 Data on file. Survey conducted in 2011 by Frost & Sullivan and commissioned by Johnson & Johnson Pte Ltd.

2 Gliklich RE, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg. 1995 Jul; 113(1):104-9.

3 European Position Paper on Rhinosinusitis and Nasal Polyposis. Rhinology, Supplement 20, 2007; www.rhinologyjournal.com; www.eaaci.net.

4 Hamilos, D. Chronic sinusitis. J Allergy Clin Immunol 2000; 106: 213-227; Stankiewicz, J., et al, Cost Analysis in the Diagnosis of Chronic Rhinosinusitis. Am J Rhinol 2003;17(3): 139-142; Subramanian, H., et al. A Retrospective Analysis of Treatment Outcomes and Time to Relapse after Intensive Medical Treatment for Chronic Sinusitis. Am J Rhinol 2002; 16(6): 303-312; Hessler, J., et al. Clinical outcomes of chronic rhinosinusitis in response to medical therapy: Results of a prospective study. Am J Rhinol 2007; 21(1): 10-18; Lal, D., et al. Efficacy of targeted medical therapy in chronic rhinosinusitis, and predictors of failure. Am J Rhinol Allergy 23, 396-400, 2009.

5 Long term outcome analysis of balloon catheter sinusotomy: Two year follow-up – Weiss et al. Otolaryngol Head Neck Surg. 2008 Sep;139(3 Suppl3):S38-46.

Pulmonary hypertension is a lung disorder affecting the pulmonary arteries. The arteries become narrowed, thereby restricting blood flow, resulting in abnormal high blood pressure in these arteries. This causes undue strain on the right ventricle of the heart, causing it to expand in size. Stressed, overworked and enlarged, the right ventricle gradually becomes weaker, and its ability to pump blood through the lungs is compromised.

In a healthy person, deoxygenated blood flowing through the pulmonary arteries becomes oxygenised when it reaches the lungs. This oxygenated blood then returns to the left ventricle where it is pumped to the rest of the body. Pulmonary hypertension decreases the efficiency of this cycle of blood flow.

With pulmonary hypertension, the layer of cells that line the small blood vessels of the lungs are stiff and unable to expand. In some cases, they might even be blocked. This impairs and restricts blood flow, limiting the body’s oxygen supply. Exercise and physical activity become difficult due to the body’s inefficient transmission of oxygenated blood. As such, the right ventricle works harder to pump more blood through the pulmonary arteries, overworking itself – becoming weaker – until it loses its ability to pump enough blood to the lungs. If left untreated, this eventually leads to the development of right heart failure.

Signs and Symptoms of Pulmonary Hypertension

The signs and symptoms of pulmonary hypertension do not usually occur until the condition has progressed. Although one may develop pulmonary hypertension out of the blue, there are some early tell-tale signs and symptoms that are commonly associated with pulmonary hypertension. These include shortness of breath during routine activities, fatigue, angina, tachycardia and feeling faint. Often, these symptoms become worse when engaging in strenuous physical exercise. Eventually, even everyday activities become difficult to execute. Overtime, the condition deteriorates and, if left untreated, pulmonary hypertension can result in heart failure, which may also lead to oedema, paroxysmal nocturnal dyspnea, nausea and persistent cough.

Causes and Categories of the Disorder

Pulmonary hypertension is essentially caused by changes to the cells that line the pulmonary arteries. This results in the vasoconstriction of the blood vessels connected to and within the lungs. There are a myriad of reasons that cause these changes.

The World Health Organisation (WHO) has categorised pulmonary hypertension into five distinct groups based on their underlying cause:

Pulmonary arterial hypertension (PAH). PAH may result from no known cause, or the condition may be inherited. There are diseases and conditions that may also lead to PAH such as HIV infection, sickle cell anaemia and congenital heart disease. PAH, unlike other types of pulmonary hypertension, can be treated directly as it is the core medical problem. In other cases, the underlying cause is treated first.

Associated with left heart disease. As blood flows from the pulmonary arteries to the lungs and then back to the left heart, a problem with the left heart could have an effect on the pulmonary arteries. Left heart diseases such as mitral valve disease or long-term high blood pressure have been known to lead to pulmonary hypertension. Associated with lung diseases and/or hypoxemia. Lung diseases that restrict the amount of oxygen getting into the lungs and therefore into the blood, such as chronic obstructive pulmonary disease and interstitial lung disease, may lead to pulmonary hypertension.

Due to chronic thrombotic and/or embolic disease. Pulmonary embolism may also lead to the development of pulmonary hypertension.

Due to other causes. Other less common causes of pulmonary hypertension include sarcoidosis, histiocytosis X and a compression of the blood vessels in the lungs caused by, for example, a tumour.

Mending a Broken Heart

Unfortunately, there is no sure-fire way to cure pulmonary hypertension. The goal of treatment is to ensure that no lasting damage is done to the pulmonary arteries, if possible, and to treat any symptoms that arise from the condition. Essentially, there are many ways to treat pulmonary hypertension. The method of treatment is usually determined by the medical practitioner based on the uniqueness of each case.

Drug Therapy

Anticoagulant medicines reduce the likelihood of blood clots restricting the supply of blood. Diuretic medicines are commonly used to treat the fluid retention and oedema that occurs during pulmonary hypertension. Diuretics may disrupt and affect kidney functions; thus they are closely monitored when prescribed.

Digoxin is used to prevent heart failure as it increases the contractility of the heart while slowing it down and preventing the heart from overworking. Oxygen therapy is very helpful in improving symptoms. Calcium channel blockers are used to relax the muscles of the arterial walls thereby reducing pulmonary pressure. Sildenafil is a selective vasodilator that prolongs the action of cyclic guanosine monophosphate by selective inhibition of PDE5. This action amplifies the effect of endogenously produced nitric oxide in the lungs, which results in pulmonary vasodilation; thus improving one’s ability to engage in physical activity. Sildenafil citrate, often sold as Viagra, is often used to treat pulmonary hypertension.

Prostaglandins are a type of targeted therapy for the treatment of pulmonary hypertension. The three types of prostaglandin currently used to treat PAH are epoprostenol, iloprost and treprostinil. They are often considered the most effective treatment for PAH. This form of therapy is aimed at slowing down the progression of PAH and may even reverse any damage to the heart and lungs.

Surgical Treatments

Surgical Treatments include Atrial Septostomy, lung transplantation, and Pulmonary Thromboendarterectomy (PTE). Atrial Septostomy is a surgical procedure that relieves pressure on the right ventricle at the cost of lowering oxygen levels in the blood. Lung transplantation is perhaps the surest way of curing pulmonary arterial hypertension but may expose the patient to the complications that arise with a transplant. It should be noted that patients with the transplant have a post-surgical median survival of just over five years. PTE is a surgical procedure that is used to treat chronic thromboembolic pulmonary hypertension. It involves the surgical removal of an organised thrombus along with the lining of the pulmonary artery. Although an extremely high-risk and delicate procedure, case series show remarkable success in most patients.

RSI, also known as cumulative trauma disorder (CTD), occupational overuse syndrome (OOS) and musculoskeletal disorder (MSD), is an umbrella term for a group of disorders caused by repetitive movements that affect muscles, tendons and nerves which often occur over an extended period of time. These repeated movements can be actions, tasks, or exposure to compressive or vibratory forces, or sustained awkward posture.

RSIs can occur in any parts of the body, but the most common places are back (low back pain), neck (neck strain), elbow (Golfer’s Elbow, Tennis Elbow), wrist (de Quervain’s, Carpal Tunnel Syndrome), and fingers (Trigger Fingers).

What Are The Common Causes of RSI?

Usually, the type of RSIs that one suffers from is very specific to one’s occupation and work, poor postural or ergonomical habits, and presence of stress and/or poor stress management.

Occupational and Work Related RSI

The type of job one does matters. For example in an office, personnel who are predominantly long-term computer users often suffer from back and neck pains as well as non-specific shoulder and elbow pain. Administrative staff may suffer from very specific RSI type, such as carpal tunnel syndrome, de Quervain’s or Trigger Finger from their daily use of stapling, filing. Cleaning aunties often develop Golfer’s and Tennis Elbow from the pushing and pulling loads and incessant mopping.

Poor Postural Or Ergonomical Habits

Sometimes, it is poor habits that contribute to the development of repetitive strain injuries, such as clamping our phones between our shoulder and neck when conversing on a telephone call, reading articles on our phones with extreme neck flexion or “over-doing” a task by taking 10 steps to finish it when it can be finished in seven steps with the same results.

Stress Increases Risk of RSI

Stress caused by fast work pace, ambiguity in roles, work-related anxieties, and monotonous tasks are associated with RSI, especially so if the individual feels overwhelmed at work. Higher stress levels often correlate directly with increased intensity of executing job functions, e.g., typing, filing or stapling harder, strained necks, and decreased rest time increases risks.

“Gan cheong” personality-types or people who tend to be more anxious are more prone to developing repetitive strain injuries. They are often more anxious, aggravated, impulsive and want to do today’s tasks like they were due yesterday – causing the physical body to be more tense. This has a cascading effect of additional strain and load on the muscles, joints and other soft tissues.

Lastly, one can also sustain a repetitive strain injury through a direct trauma, such as accidents and falling on a specific body part, or being hit by an object(s) directly at a body part.

Whatever It Is, It Can Hurt A Lot

Depending on the type of repetitive strain injuries, symptoms during an acute bout of RSI can include short bursts of severe cramping and excruciating pain over a specific location; pain intensifies with activities or use; and noticeable weakness in the affected limb. Some can have numbing sensation or electrical, shooting-like pain that travels over a location. Some people get severe headaches.

What You Can Do

• Pay a visit to your physician and/or visit your physiotherapist to assess the severity of the condition, and they can provide you the appropriate medicine or rehabilitation program to treat
the problem.

• “RICE” Method

1. a. Rest the painful area, avoid or minimise using the affected area for about two weeks.
2. b. Ice it intermittently with an ice pack wrapped in a towel for about five minutes.
3. c. Compress and elevate to decrease swelling.

• Lifestyle Change

1. a. Micro-breaks – Every 30 minutes, take one minute to stop and stretch muscles.
2. b. Adequate sleep helps your body to heal from injuries, big or small.
3. c. Exercise at least three times a week to increase your strength, stamina, and health.
4. d. Plan and Prioritise – Schedule your important tasks first, and complete them first.

•  Improve Ergonomics

Can you identify if there is a specific activity, device, or pattern you realised is causing you pain? Can you change it, replace it or modify it? Think creatively how you can do things better. An example is, if you seem to be getting numbness in your forearm because you realised that you’ve been resting your entire body weight on your forearms as you type, can you bring your keyboard tray forward for you to easily reach and type without resting your forearms and body weight on the edge of your table?

How important is lens care?
This is very important. If the lenses are not used properly,
it can lead to problems such as dry eyes and infection of
the eye.

What are the No-Nos about lens care?
Many people know what to do and what not to do as they have received the instructions from their eye care practitioner. But many will “stretch” the limits of these instructions as they have tried it and they have felt fine. For example:

• Wearing more than the hours that they should
• Wearing the lenses to sleep
• Wetting the lens with solutions other than proper contact lens solutions, for example, some use their own saliva
• Not cleaning the lenses properly

What are the best lens care systems out there? The 1-step or 2-step system?
The best way is to wear daily disposable lenses. This means that a new fresh clean lens is used each day. If daily disposable lenses are not used, then it is better to use a monthly lens rather than a yearly lens. Lenses do get dirty over time no matter how well you clean it. It is always better to use separate solutions to clean, deproteinise, rinse and store the lens. More care is needed especially if hydrogen peroxide is used as this will have to be properly rinsed off. Multipurpose solutions are convenient to use, but concerns have been raised that some of these solutions are not effective enough in getting all the dirt and protein out of lenses.

What are the most common infections with regard to lack of lens care?
Infection of the cornea occurs due to prolonged lens wear
or improper care of lenses. The infection may be caused
by bacteria, fungi or parasites. Such an infection can lead
to blindness.

Contact Lens Care Tips!

• Always wash your hands with water and soap before handling contact lenses or before touching your eyes. Dirt from your fingers can be deposited on your cornea when you wear your lens.
• If you develop any eye irritation, remove your contact lenses and discontinue use until you talk with your eye care practitioner. Wearing a contaminated pair of contact lenses will invite the infection to remain.
• Do not sleep with contact lenses in your eyes unless you are prescribed “extended wear” contacts! While the eyes are shut, tears cannot carry healthy amounts of oxygen to the eye.

Pain and Appetite

Although some studies have reported that cachexia is most commonly associated with advanced-stage cancer, Dr Correia explained that it can be present even in the early stages of the disease as well. “That is something that many people have in mind that only advanced-cancer patients present with cachexia. It happens in early stages also. It might not be shown right away, like patients may not lose a lot of weight right away, but many of them might already suffer from fatigue,” shared Dr Correia. Cachexia happens because of the disease. The disease is a foreign body, so our body tries to kick it out. “That’s why it causes inflammation,” quipped Dr Correia. The syndrome also depends on the location of the disease. For head and neck cancer, cachexia happens because it prevents us from swallowing. “Patients cannot really swallow because of pain. When you are in pain, you lose appetite,” she added. Cachexia is also very common with solid tumours, and not so much with diseases such as leukemia or Hodgkin’s disease. Dr Correia added that cancer cachexia is usually associated with tumours that you can see growing, like head and neck cancer, lung cancer, and gastrointestinal cancer. “But this is not to say that these patients don’t have it. They might also have it. I would say that majority of cancers do cause cachexia,” she explained.

Much Ado About Cancer

As the cancer grows, the more our immune system tries to fight the cancer and the more our body suffers from inflammation. Dr Correia likens our body’s response to cancer to that of a simple cold. When you have a cold, the virus infections cause inflammation, such as fever, lack of appetite, and body pain. “That’s acute response to a virus infection. Now cancer is not a virus, but it’s a foreign body. So our body responds to that exactly the same way, but in a more chronic manner. That’s why patients don’t eat. They’re anoretic and hydrometabolic because their body is subjected to inflammation,” explained Dr Correia. Cancer also releases a certain chemical called cytokines into the blood that contributes to loss of appetite. Some cancer, such as pancreatic cancer, also produces proteolysis-inducing factor or PIF. “PIF is directly produced by the cancer and also stimulates cytokines,” added Dr Correia. The most common symptoms of cancer cachexia are anorexia and fatigue. Loss of appetite, anaemia, weakness, nausea, and feeling full after eating small amounts of meal are also some indication of the syndrome.

Nutritional Therapy

To say that cachexia only makes the situation worse is an understatement. Patients respond worse to the treatment, be it surgery, chemotherapy or radiation. The earlier patients get treated for cancer cachexia the better. Aside from treatment for the cancer, there should be a separate treatment for cachexia. Nutrition therapy is definitely a big part of the treatment. “Nutrition should be seen as an integral part of cancer treatment – just like pain control, psychological support, exercising – and not only giving the patient chemotherapy or radiotherapy, or even surgery,” shared Dr Correia. The treatment depends on the patient, the type of cancer, and the treatment phase. One very same patient will behave differently according to the treatment phase, so it’s imperative that the patient see his doctor or nutritionist constantly to monitor his progress. Supplementation is another way to boost nutrient intake of patients. There are some nutrients that can down-regulate inflammation, and one of them is EPA or eicosapentaenoic acid, which is derived from fish oil. “This has been shown to work well with cancer patients because it down-regulates the inflammatory cascades. And not only that, if the patient is not eating, it adds energy and protein in patients’ intake,” quipped Dr Correia. One of the recently introduced products for cancer cachexia is ProSure, a therapeutic nutrition in liquid form that contains a combination of EPA (i.e. eicosapentaenoic acid, a type of fatty acid) with protein and energy-rich ingredients. Just like any other treatment, supplements have to be taken daily, and patients have to comply with the prescription. “Patients should not take any supplements without prescription from the doctor,” advised Dr. Correia. “It’s fundamental that they should ask for professional help, be it from a nutritionist or dietitian.”

*Fearon K, von Meyenfeldt M, Moses A, van Geenen R, et al. Effect of a protein and energy dense n-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia: a randomised double blind trial. Gut. 2003;52:1479-1486.

Cancer Cachexia - The ugly side of weight loss

Breast cancer, a malignant tumour that has developed from cells of the breast, is the number one cancer affecting Singaporean women today. A malignant tumour is a group of cancer cells that can invade surrounding tissues or spread to distant areas of the body. Each year, 1,500 new cases are diagnosed and 370 deaths occur due to the disease. Women aged 50 to 65 years old with a strong family history of breast cancer are at risk of contracting breast cancer. A diet that includes excessive alcohol and high calorie intake results in excess weight gain. It also increases the risk of the disease, especially in post-menopausal women. Other risk factors include smoking, early menstruation, late menopause, being childless or having one’s first child late. The standard medical treatment for breast cancer includes surgery, chemo/radio therapy, targeted therapy or hormone treatment. Although such treatments have been proven to be effective, some side effects (e.g. weight loss, nausea, pain etc.) are known to occur.

Common Misconceptions

Herbal remedies and dietary supplements can help treat breast cancer

No herbal remedies, dietary supplement or alternative therapy have been scientifically proven to treat breast cancer. How these alternative medicines may interact with established medicines is still not known.

A healthy diet will make me immune to breast cancer

Although diet does play a part in cancer development, no food or vitamins can prevent breast cancer. At the same time, no food is responsible for causing cancer. However, it is still important to eat a healthy and balanced diet to obtain a variety of nutrients.

Organic foods are recommended for cancer survivors

At present, there has not been any conclusive evidence to demonstrate the effects of such foods on reducing the risk of cancer. Organic foods are costly and there is concern of food hygiene safety from manure use in fertilisers. It may increase risk of infections in immune-compromised patients undergoing cancer treatment, thus patients are advised to wash, cook and store foods properly.

Sugar feeds cancer

Sugar intake has not been shown to directly increase the risk or progression of cancer. However, refined sugars and beverages have a substantial amount of empty calories which can promote weight gain and may adversely affect cancer outcomes. As a result, limiting sugary foods and beverages is recommended.

Eating fruits and vegetables lower risk of cancer occurrence

Only a few studies exist on whether a diet high in fruits and vegetables can reduce the risk of breast cancer recurrence or improve survival. Despite that, breast cancer survivors are still encouraged to consume two to three servings or more fruits and vegetables. Cancer patients with poor appetite are advised to have a nutritionally balanced diet and consume nutritional supplements.

Importance of a Good Diet

A healthy diet does not merely prevent one from contracting cancer; it also helps to manage weight, which in turn lowers cancer risk. Nutrition therapy plays a supportive role during active cancer therapy by preventing and treating nutritional problems that are caused by fatigue, nausea and vomiting. Maintaining a nutritious diet helps patients maintain vitality and build immunity to fight infections so that they can cope better with the side effects of treatments. To lower the risk of breast cancer and to prevent a relapse in breast cancer survivors, a diet consisting of mostly plants is recommended. Consumption of red meat should be limited and processed meat should be avoided. Aim for controlled food portions and avoid excess calories from sugary or food high in fat to prevent excess weight gain. For patients on tamoxifen or those who are diagnosed with estrogen receptor positive breast cancer, soy food should be avoided as research on the risks of soy on breast tumours is still inconclusive. It is important to engage in physical exercise for at least 30 minutes or more daily; to reduce the risk of breast cancer, aim to maintain a healthy weight and do not smoke tobacco. Nutritional support or nutritional therapy as a form of alternative therapy cannot replace conventional cancer treatment as a sole treatment; however, it is important to eat well during cancer treatments to obtain adequate nutrition.

Dietary Tips!
After breast cancer surgery, some patients will not encounter major eating problems, but others might experience eating difficulties due to pain/nausea/vomiting and may be malnourished or underweight. To relieve these symptoms: • Serve small portions of food frequently • If appetite is poor, take high energy/protein supplements that can be purchased in pharmacies • Eat slowly in a relaxed environment. • Allow for frequent rest periods, especially before meals.