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Treating patients, not the disease

Oncologists are now able to take quality of life concerns into consideration – thanks to better treatment options.

With new surgical options, better chemotherapy drugs, focused and accurate radiotherapy, and new treatment regimens, doctors can ensure that in fighting cancer, they are also able to preserve the quality of life for their patients.

“Now, we are not treating the disease, we are treating patients,” said Dr Ang Peng Tiam in his talk on changes in cancer treatment in Singapore in the last three decades.

He gave this talk at a seminar titled “Understanding Cancer and Beyond”, which was held earlier this year and covered topics such as advanced molecular tests for cancer screening and the use of immunotherapy for solid tumours and blood cancers.

He cited the example of cancer of the voice box. Previously, it would have been necessary to remove the entire voice box. “Now you may not even require surgery when you have cancer of the voice box,” he said.

Dr Ang used the example of his cousin, a lawyer, who had been diagnosed with cancer in the floor of the mouth five years ago. The ENT (ear, nose and throat) surgeon his cousin consulted, recommended surgery. As a lawyer, this would have severely affected his ability to work. Dr Ang, however, started his cousin on chemotherapy. After the treatment, the tumour disappeared completely. “We followed up with radiation treatment, and he is completely cured.”

Another patient he treated was a negotiator, who had advanced tongue cancer that had spread to the lymph nodes. The treatment was a combination of chemotherapy and radiotherapy which eradicated the disease. There was no need to remove even part of the tongue, said Dr Ang.

This is possible because doctors now understand the strengths and weaknesses of different treatment regimens on certain kinds of cancer. Chemotherapy can be used to shrink the tumour, then focused radiotherapy on what is left of the tumour. This approach removes the need for surgery.

“These are only possible because the drugs today are much better than in yesteryear. They are not only very effective, they are low in toxicity.”

And for patients who do not want chemotherapy, there are alternatives as well. In the past, lung cancer was treated mostly with chemotherapy. However, today, doctors understand that there are different types of lung cancer, and for one type, adenocarcinoma, chemotherapy is not even necessarily the first option.

The development of targeted agents which go after specific mutations has given doctors more options, he said. These options also have milder side effects compared to chemotherapy.

“You may have a few skin problems, but otherwise, the quality of life is extremely good, compared to patients on chemotherapy,” he said.

New treatments also offer hope for late-stage cancer patients. He cited the example of a woman who was diagnosed in 2015 with colon cancer that had spread to the lymph nodes in the neck.

She wanted to be treated aggressively, so after her operation, she was put on chemotherapy, and then radiotherapy. She is still alive today and she now travels around the world. “She says, ‘I don’t know how much time I’ve got, so I must enjoy myself.’”

The discovery of immunotherapy drugs has also made a difference.

Dr Ang described a patient with Hodgkin’s lymphoma who had been treated with chemotherapy. “Every time I give chemotherapy, the cancer disappears. Every time I stop the chemotherapy, the cancer comes back.” However, with immunotherapy, the tumours disappeared and have not returned.

In addition to better treatment, there have been significant advances in the area of detection as well. Advances in diagnostics have helped doctors get a better understanding of cancer. “Pathologists now play a cornerstone role that tells us about the genetics of cancer and appropriate treatment.”

And while previously, there was a need to have tissue to do a biopsy, this is not always needed anymore. “Nowadays, you may not even need tissue, you may just need a sample.”

The easy access to PET-CT scans has also helped with diagnosis, to see how far the cancer has spread. This is important because it determines how to treat a patient. In the case of lung cancer, for example, surgery is used in the early stages but not in the later stages, so it is important to know whether it has spread.

In the past, it was very hard to even schedule a CT scan because there were so few in Singapore. Today, PET-CT scans are available in many hospitals in Singapore.

Thanks to all these advances, the situation for doctors and patients today is very different from 30 years ago. He said: “Oncology has changed from what has been, in the past, a disease of ‘sure to die’, to that of hope.”

Written by Jimmy Yap