We all dread that moment: the finding of an unusual lump, the diagnosis of a suspicious mole as cancerous, chest pain that has nothing to do with indigestion, abdominal pain so acute that it doubles you over. Forewarned is forearmed they say, so here’s some advice from eight Singapore surgeons from different disciplines – an auspicious number, in this part of the world! – to help you take charge of your and your family’s health.
#1 Skin Cancer Screening
With his subspecialty expertise in head and back surgery and surgical oncology, Dr Dennis Lim was happy to talk about melanoma – the skin cancer that is most feared, and with good reason.
What exactly is melanoma?
Every cancer found in the human body develops from a normal cell. Melanoma develops from a pigment-containing cell found in the skin, called a melanocyte.
Who should go for melanoma screening?
Light-skinned individuals living in the tropics, or anywhere else where their sun exposure is high, should go for screening. The same is true for anyone who notices changes in a mole, freckle or other pigmented spot on the skin.
How is melanoma screened for?
A dermatologist usually does the screening. He or she will generally do a full body screen and photo-documentation of any suspicious-looking lesions.
Say a melanoma lesion is found; at what stage is it potentially fatal?
All cancers progress through stages. Unless it’s treated, a Stage I melanoma will almost always progress to Stage II and so on.
What is the treatment for melanoma?
The treatment of melanoma is based on the stage it is at. Stages I and II are treated with surgery, Stage III usually with combination of surgery and chemotherapy, and Stage IV usually with chemotherapy and immunotherapy.
How can melanoma screening save lives?
The earlier melanoma is detected, the better the outcome of treatment. That’s because the survival rate of melanoma greatly depends on the stage when it is identified. There is a 95 percent five-year survival rate for someone whose melanoma is picked up at Stage I; if identified at Stage II this drops to about 75 percent; the figure at Stage III is about 50 percent; and by Stage IV it’s about 20 percent.
Your message to our readers?
The diagnosis of melanoma is not as pessimistic as it was 10 years ago. That’s because of the rapid progress we’ve made in accurately identifying the stage of the cancer. Procedures and treatments such as sentinel lymph node biopsy, immunotherapy and targeted therapy have significantly improved the outcome for patients with melanoma.
Dennis Lim Surgery
#11-09 Mount Elizabeth Medical Centre
#2 Cardiac Screening
We’ve all read the news stories where apparently super-fit athletes drop dead from heart failure during a race. Whether you’re a super-fit athlete, or just an average Joe or Joanne, suffering a heart attack may be the first (and last) manifestation of ill health, warns Dr Rohit Khurana of The Harley Street Clinic.
As opposed to general health screening, tailored cardiac screening is important for several reasons:
* One third of adult mortality is attributable to heart disease and stroke, which are driven by common risk factors that may not be immediately apparent.
* By the time symptoms occur, the processes that lead to cholesterol-rich plaque accumulation in the coronary arteries are at an advanced stage that requires multiple medications to prevent a heart attack.
* A cardiac screen will identify risk factors in more detail. Signs of early vascular damage may be detected, providing a “wake up call” to implement a healthier lifestyle, including regular aerobic exercise. In some cases, aspirin and/or medication to lower cholesterol and blood pressure may be prescribed as a primary preventative strategy.
Who needs it
Generally speaking, says Dr Khurana, men older than 45 and women older than 50 should undergo annual cardiac screening. “It’s well documented that women are protected until menopause. But when their natural oestrogen levels subside, the incidence of heart attacks in women rises to meet that of men.”
Anyone who has high blood pressure or elevated LDL-cholesterol, who smokes or is diabetic, or has a family history of heart disease occurring at a young age (under 40) is at higher risk of heart attack and is strongly encouraged to go for cardiac screening even earlier. Be aware, too, of the dangerous effects of professional stress, frequent travel, poor dietary habits and insufficient sleep.
What is measured
Taking just two-to-three hours, cardiac screening entails taking a detailed history, a physical examination and fasting blood tests. These blood tests look more deeply into the biomarkers of cardiovascular risk than is usually requested in a basic general screen, explains the doctor. You’ll undergo an ECG, an exercise treadmill or “stress” test and ultrasound scans of the heart and neck arteries. A CT scan can be done, too, in order to detect calcium deposits in the coronary artery walls.
Fit to run?
Exercise is integral to a healthy heart, agrees Dr Khurana, helping us maintain a healthy weight, reducing high blood pressure, lowering levels of unhealthy cholesterol and more. Fortunately, most of us can exercise without risk. Any symptoms such as dizziness, chest discomfort, inappropriate breathlessness or palpitations (an awareness of the heart beat), however, mean you should see a cardiologist.
It’s difficult to explain the rare paradox of sudden cardiac death amongst elite athletes and marathon runners, he says. But cardiac screening of athletes participating in endurance and competitive sports is becoming increasingly accepted. This screening includes an ECG, and an ultrasound scan to rule out structural abnormalities of the heart muscle and valves, and electrical conduction defects.
The Harley Street Clinic
6A Napier Road
#02-38/41 Annexe Block, Gleneagles Hospital
6472 3703 | heartandcancercentre.com
#3 Keeping Abreast
Empathetic breast and general surgeon Dr Georgette Chan why regular breast examinations – from monthly self-exams to high-tech mammograms and ultrasound – could save your life. Not because examinations prevent breast cancer (they don’t), but because early detection and treatment could save your life.
Remind us why and how we should be checking our breasts ourselves every month.
It’s very important, because it allows us to detect even subtle changes – things like lumps, or nipple discharge. Young women should ideally start doing this in their twenties, so to become familiar with how their own breasts feel. Seven to ten days after the start of your menses is the best time to do it, because that’s when the breasts are least sensitive.
What should I do if I find an unfamiliar lump – panic?
No, don’t panic, because about 90 percent of lumps detected are benign. If you find one while you’re close to your menstrual period, it could be due to temporary hormonal changes, so I suggest waiting until after your period to see if it’s still there. If it is, go to see your GP.
When should we start going for medical breast examinations?
From the age of 40; but if someone in your family has had breast cancer, it’s advisable to come 5 to 10 years earlier than your relative was when her cancer was diagnosed.
How effective are mammography and ultrasound?
Mammography has an accuracy rate as high as 90 to 95 percent and has proven effective in detecting cancers early; simply detecting tumours early is associated with a 20 percent drop in breast cancer mortality. Ultrasound, though not effective on its own as a screening tool, is a good supplementary tool because it is better at detecting little delineating nodules. Depending on the age of patient and the density of the breast, I may choose to do both mammogram and ultrasound.
Some worry that compressing the breasts between the two plates of the mammography machine could do harm – even increase the risk of cancer. Radiation exposure from frequent mammograms is another concern.
Though mammography can be uncomfortable, it’s limited to 15 seconds and is not harmful. As for the amount of radiation, it’s a very low dose, akin to that of a couple of chest x-rays and much lower than a PET scan or a CT scan. So the risk of harm is low, especially if done only yearly (from 40 to 50) and then every two years (from 50 onwards), as we recommend.
How can breast cancer screening save my life?
It’s all about early detection. Screening cannot prevent cancer, but early treatment gives you a better chance of survival.
Georgette Chan Consultancy
#11-09 Mount Elizabeth Medical Centre
#4 Metabolic Surgery
Dr Ganesh Ramalingam is a specialist in general surgery, bariatric surgery and advanced laparoscopic surgery. A founding member of the national committee for obesity – the OMSSS (Obesity and Metabolic Surgery Society of Singapore) – he tells us how bariatric or weight-loss surgery is now saving the lives of people with early Type 2 diabetes. He takes a holistic approach, however, believing that any weight management programme needs to be tailored to the whole individual.
Is obesity a problem in Singapore?
In 2010, it was estimated at more than 10 percent of the population; that’s more than half a million people. Severe obesity or morbid obesity is likely to be about 1.5 percent.
What are the various procedures that you perform?
Firstly, to help you lose a few kilograms over a maximum of six months, the intra-gastric balloon allows you to eat only small amounts, slowly, to you get used to eating smaller, healthier portions. For the morbidly obese, a laparoscopic sleeve gastrectomy involves removing about 60 percent of the stomach, reducing the volume of food that can be present in the stomach at one time; or there’s a laparoscopic gastric band (lap-band), placed around the top part of the stomach to form a small pouch, slowing the rate of food entering the stomach to a slow trickle.
Finally, a laparoscopic gastric bypass entails bringing the small bowel up to the stomach, so that food from the stomach is rerouted directly into the small intestine, bypassing the liver-pancreas complex. When this weight-management procedure is used as treatment for Type 2 diabetes, it is known as metabolic surgery, because it almost instantly cures the trio of disease associated with metabolic syndrome: diabetes, high blood pressure and high cholesterol.
Exactly how does a laparoscopic gastric bypass cure diabetes?
Diabetes is when your pancreas burns out and is no longer being able to supply sufficient insulin to control blood sugar levels. Surgically bypassing the liver-pancreas complex relieves the stress on the pancreas and reverses the diabetes immediately, even without weight loss.
So effective is this surgery that the International Diabetics Federation recommends it for the management of early Type 2 diabetes. Some of the major medical insurance companies are even starting to pay for it, though they have not paid for weight-loss surgery in the past. That’s because the high cost of a one-off surgery like this is much lower than the long-term medical costs of diabetes and its complications.
Dr Ganesh Ramalingam
3 Mount Elizabeth, #11-13/14 Mt Elizabeth Medical Centre | 6737 8538
#5 Colonoscopy screening
As Dr Quah Hak Mien reminds us, colorectal cancer is the top cancer in Singapore. Not just that, but the incidence is increasing. Globally, it is more common in developed than developing countries, the highest rates being found in Australia, New Zealand, Europe and the US.
He emphasises that colorectal cancer is almost entirely preventable. One of the biggest problems is that so many patients are diagnosed only at the advanced stage of the disease. That’s because you don’t experience any symptoms during the early stages of this cancer; it’s a silent disease, and that’s what makes screening so important.
Most cancers of the large intestine develop from small polyps. Colonoscopy detection and removal of polyps result in a reduced colorectal cancer risk. A polyp removed is a potential cancer prevented.
The three main screening options are:
* stool occult blood testing,
* colonoscopy, and
* CT scan virtual colonoscopy.
A stool test checks for traces of blood in the stools, so minute that they’re usually not visible to the naked eye. If found, a colonoscopy is recommended. If the stool test is normal, it needs to be repeated every year.
The “gold standard” for screening, colonoscopy is considered the most accurate examination of the colon and rectum. Biopsies and removal of polyps are possible through the colonoscope. And, in experienced hands, it’s a very safe procedure.
CT scan virtual colonoscopy is a minimally invasive imaging test of the colon and rectum for large polyps and cancer. Its drawbacks are that it’s expensive, it’s associated with radiation exposure, and if any abnormal growths are detected during the procedure, they can’t be simultaneously removed.
Timing and risk
Colorectal cancer may occur at any age, says the doctor, but around 90 percent of patients are over 50. Risk increases with age.
“You’re at average risk if you have no relatives with colorectal cancer and have no symptoms at all. For an average-risk person, screening should begin at the age of about 50 years.”
Having one or more close relatives with colorectal cancer puts one at high risk, he explains. In this case, you should undergo colonoscopy at an earlier age.
Colonoscopy is a specialised investigative procedure to check the colon and rectum directly. In the endoscopy centre, a soft and flexible telescope camera tube is inserted through the anus and advanced into the rectum and colon. The lining of the colon and rectum is carefully inspected while inserting and withdrawing the scope. The surgeon is looking out for polyps, tumours, infection or any abnormality. A biopsy may be taken when necessary.
Any polyps found are removed by means of special instruments through the scope and then sent to the laboratory for a detailed microscopic analysis called biopsy. Biopsies do not mean cancer! – most polyps are benign. Removing polyps essentially prevents the progression of the polyp and development of colorectal cancer.
Quah Hak Mien Colorectal Centre
6 Napier Road
#05-01 Gleneagles Medical Centre
#6 Gastric Cancer Screening
Much like colorectal cancer, says Dr Andrea Rajnakova, gastric cancer is eminently curable – but only when detected early via endoscopic screening. It begins when cancer cells start growing in the inner lining of the stomach, and usually develops slowly over many years.
How common is gastric cancer?
Though the incidence is decreasing worldwide, it remains the second leading cause of cancer death. Traditionally, gastric cancer has a poor prognosis because of its late presentation. Early detection means better outcome, and endoscopy is the current standard diagnostic tool for gastric cancer.
What are the symptoms?
In the early stages, stomach cancer may cause indigestion, bloating after a meal, heartburn, slight nausea and loss of appetite. As stomach tumours grow, the symptoms worsen to include stomach pain, indigestion, loss of appetite, vomiting, weight loss, vomiting, fatigue, anaemia, blood in the stool and more.
5 Lifestyle Factors
* The dramatic decline of stomach cancer in the past several decades is thought to be a result of improved standards of living, hygiene and methods of food preparation.
* The rise in food preservation techniques such as freezing and refrigeration have largely replaced unhealthy salting, pickling and smoking.
* A diet high in naturally occurring antioxidants, vitamins and fibre such as found in fresh fruit and vegetables also lowers your risk of stomach cancer.
* Being overweight or obese may add to the risk of stomach cancer. On the other hand, being physically active may help lower your risk.
* Smoking increases the risk of stomach cancer, as with many other types of cancer, and is responsible for about a third of all cancer deaths.
How do you screen for gastric cancer?
Early gastric cancer can be very difficult to detect. In recent years, however, several new endoscopic imaging modalities have been developed. Once detected, anyone with signs of early gastric cancer needs to receive more targeted screening and be carefully monitored.
Who should go for it?
Singapore’s Gastric Cancer Epidemiology and Molecular Genetics Program (GCEP) identified five risk factors for the development of gastric cancer, as follows: Chinese males over 50; a family history of gastric cancer; helicobacter pylori infection; smoking; and the presence of atrophy gastritis and intestinal metaplasia.
How is gastric cancer treated?
That depends on the stage, the site, and whether it has spread. Early gastric cancer can be removed through an endoscope and does not require surgery – much like colonoscopy. This technique was developed in Japan, where stomach cancer is often detected at early stage during screening.
A deeper tumour will require surgery, often combined with chemotherapy or radiotherapy or both. Once the cancer has spread to other organs, a cure is no longer possible.
Andrea’s Digestive, Colon, Liver and Gallbladder Clinic
#12-10 Mount Elizabeth Medical Centre
3 Mount Elizabeth
#7 Kidney Stones
Not just a source of excruciating agony, unmonitored kidney stones can wreak silent damage to your kidneys, explains urologist Dr Sam Peh – even leading to kidney failure.
Signs and symptoms
Often, the first the patient knows about a kidney stone is when it moves from the kidney into the ureter, the narrow tube that connects each of the kidneys to the bladder. Though kidney stones are often silent when in the kidneys, a urine test may show tiny amounts of blood or tiny stone crystals in the urine. When a stone lodges in the ureter, it often causes obstruction, and this causes sudden severe pain radiating from the loin to the groin on the affected side.
Most kidney stones are calcium oxalate stones, and you get them from eating food rich in calcium and oxalate and consuming inadequate amounts of water. Stone disease is one of the most common problems seen in a urologist’s practice. Kidney stones are more common in men and in those who are in their 30s or older.
It ranges from not doing anything for small stones, to external shockwave therapy for a stone in the ureter close to the kidney, to minimally invasive surgery with the aim of breaking the stone in the ureter. Surgical intervention is called for when the stone is too big to pass on its own, when the urine backed up behind the stone gets infected, when the associated obstruction is deemed to be causing irreversible kidney damage, or when the patient is suffering severe and repeated attacks of pain.
Don’t think that when the pain stops, the stone has already passed. It’s important to make an accurate diagnosis using a CT scan (CT renal colic screen) to monitor the passing of the stone. That’s because a stone can stay in the ureter, not causing pain but still causing obstruction and damage to the kidney. Kidney stones are one of the causes of kidney failure.
Dr Sam Peh, PanAsia Surgery
Mount Elizabeth Hospital, Mount Elizabeth Novena Hospital and Parkway East Hospital
6333 5550 (24-hour hotline)
#8 Acute Abdomen
Unlike “a cute abdomen” (which is something to aspire to), “acute abdomen” describes a mixed bag of abdominal conditions and emergencies, most commonly presenting with abdominal pain. According to consultant surgeon Dr Melvin Look, they can be life-threatening if urgent surgery is not done.
What are the symptoms?
Apart from pain, associated symptoms include abdominal distension, fever, vomiting, diarrhoea or constipation. The distinguishing feature is that these symptoms arise suddenly and escalate in severity over a short period of time.
What’s the first thing to do?
Most people will know that they need medical attention when they have such severe symptoms. Do not self-medicate, hoping that the pain will go away. See your family doctor straight away or, better still, head to the emergency department of any major hospital. You will be referred to a surgeon who specialises in abdominal surgery.
How is the cause diagnosed?
Looking at the nature of your symptoms, together with a detailed clinical examination, an experienced doctor can generally make an accurate provisional diagnosis. Appropriate laboratory and radiological tests are done to confirm this. An immediate CT scan of the abdomen and pelvis is often the most useful investigation, as it gives an accurate image of the abnormality within.
What are the causes of acute abdominal pain?
Free air in the abdominal cavity seen in the CT scan indicates a perforation of the gut, for example an ulcer in the stomach or duodenum that has penetrated right through the wall. Inflammatory changes can also be seen in the CT scan, and this can be in the gallbladder due to gallstones (cholecystitis), in the pancreas (pancreatitis), colon (colitis or diverticulitis) or appendix (appendicitis).
Blockage of the small or large bowel can also cause abdominal distension, vomiting and constipation. Intestinal obstruction can arise from a number of different problems, including cancers, adhesions from previous surgery or a strangulated groin hernia.
Gynaecological emergencies include a twisted ovarian cyst, pelvic inflammatory disease or even a ruptured ectopic pregnancy (that is why a urine pregnancy test is almost mandatory in any female of child-bearing age).
How is acute abdomen treated?
After making an accurate diagnosis as quickly as possible, treatment depends on the underlying cause. Conservative management with antibiotics and medication is sometimes sufficient, but surgery is often required.
In the past, surgeons often had to perform an exploratory laparotomy for diagnosis and treatment; involving a long midline incision to expose the contents of the abdomen, recovery was painful and slow. Keyhole surgery now allows us to perform almost any abdominal surgery laparoscopically, making only small incisions. So recovery is rapid, requiring only a day or two’s stay in hospital after laparoscopic surgery for appendicitis, gallbladder stones or even perforated ulcers.
Dr Melvyn Look, Director of PanAsia Surgery
Mount Elizabeth Hospital, Mount Elizabeth Novena Hospital and Parkway East Hospital
6333 5550 (24-hour hotline)
This article was first featured in the November 2015 issue of the magazine.