“Cancer is the leading cause of deaths in Singapore. It had overtaken cardiac diseases for a decade and a half now. 1 in 4 Singaporeans died due to cancer. 40% cancer disease occurs in people aged 70 and above, and there are 14 cancer deaths every day.” said Dr. Ravindran Kanesvaran, a geriatric oncologist during one of his talks at the ESMO Asia Congress on December 18, 2015. He summarised that the cancer rates are rising concurrently with ageing population in Asia, and Comprehensive Geriatric Assessment (CGA) has played a role in assessing Asian elderly cancer patients of any population.

1. What will you say is the awareness level of oncology in Southeast Asia (SEA) region compared to other regions such as Europe and America?

Geriatric oncology is a very new field in SEA. In fact, Singapore was the first country in the region to have developed this field as part of a clinical service. Overall, the level of awareness of geriatric oncology in the region is still quite low. In order to increase awareness, Singapore Society of Oncology (SSO) together with the International Society of Geriatric Oncology (SIOG) organised the first SIOG Asia Pacific meeting in Singapore in July 2014, which was successful in attracting many oncologists from the region to participate and interact with the best minds in geriatric oncology in the world. This helped to promote its awareness in the region. Geriatric oncology (GO) is very well developed in Europe and North America since its inception in those regions over 30 years ago.

2. Could you share more about the Geriatric Oncologist Programme in your centre, the only programme in Southeast Asia?

The Geriatric Oncology (GO) Program at the National Cancer Centre Singapore (NCCS) is a unique program focused on assessment and treatment of older cancer patients who present to our centre. We define elderly as patients who are 70 years and older.

This aim of this program is to identify the multiple medical problems that afflict and are unique to the elderly and to address them appropriately. This comprehensive assessment, known as the Comprehensive Geriatric Assessment (CGA), has been used in the non-cancer elderly population for many decades now and it was thought that this tool would be very relevant to the elderly cancer population as well. CGA has been shown to not only predict survival but also predict treatment toxicity and change treatment decisions as well.

At NCCS, we have been using CGA on a select group of patients since the inception of the GO program in 2007. Over 600 patients have benefited from this assessment thus far. A major component of the program is its research element. A lot of valuable information has been gleaned from research on the elderly cancer patients in our program that has helped us treat these patients better.

3. You mentioned that CGA might reduce mortality by 14%, but how does it work to reduce mortality? Have you ever applied Comprehensive Geriatric Assessment (CGA) for the cancer patients at NCCS?

CGA has been shown to change / modify treatment decisions in about 20% of the elderly population (based on a French study). These treatment modifications can potentially reduce mortality by reducing treatment toxicity and in some instances enabling us to give higher dose of treatment to fitter patients, hence increasing their treatment response and survival.

We use the CGA on about 10 selected patients a week at NCCS. Currently, the limitation we have is the limited manpower to do these assessments. I hope to expand this service to enable CGA on a larger group of patients in the future.

4. Could you explain the “normogram” used by NCCS to assess the cancer elderly patients?

The “normogram” is a simple tool we devised that can help predict prognosis in elderly cancer patients. This easy-to-use prognostic tool can help the treating physician discuss potential treatment options with patients based on the predicted survival using clinical factors that are easily available to them.

(Recommended reading: Analysis of Prognostic Factors of Comprehensive Geriatric Assessment and Development of a Clinical Scoring System in Elderly Asian Patients with Cancer, published in the Journal of Clinical Oncology in 2011)

5. Some elderly cancer patients in Singapore visit TCM doctors because they are convinced that TCM medications can alleviate some symptoms caused by chemotherapy. Do you think TCM is a good alternative?

The use of TCM is very common in the local population due to centuries of belief in its benefit. TCM may become a good alternative only when there is more research done regarding its benefit and side effects. Till we have that evidence, I only agree to use it when all known evidence-based treatments have failed.

6. The aging population in this modern era leads to increasing need in geriatricians in the coming decades. Yet, there is only about 70 certified geriatricians and no registered geriatric oncologists in Singapore. What approach would you suggest to encourage people to join the workforce in this field?

I think the latest geriatrician numbers have increased to 90, and yes, there are no registered geriatric oncologists in Singapore as there is no registry for such specialists. I was fortunate to have received specialized geriatric oncology training at the Duke University Medical Centre, US in 2011 and am the second person in Singapore to have such training. The first was Dr Donald Poon who received his training at the Moffit Cancer Centre, US. Dr Poon is now in private practice at the Raffles Cancer Centre.

I think the key now is to train every oncologist on the principles of geriatric oncology so that they can apply some of the basic principles of GO on their patient population. This alone can improve the care of the elderly cancer patient population substantially. Should a handful of them be keen to do more and receive more comprehensive training, I will be happy to have them come for attachments at NCCS. Over the years I have taken on nurses and medical students on such attachments with great success.

7. How can we ensure early diagnosis and early treatment of cancer disease among elderly? What actions are Singapore government taking right now (and also other countries)?

There are 2 ways to do this. The first is to have evidence-based screening programs. It is known that screening for certain cancers can help improve survival as patients are diagnosed at an early curable stage. Examples of these cancers include colorectal and cervical cancer.

The other method is to educate the public about the common cancers and how to identify the symptoms early and seek the necessary medical attention. Education on lifestyle changes is also essential in teaching the population on how these changes can help prevent the cancers in the first place.

The Health Promotion Board of Singapore has played an important role in both areas described above i.e. in screening and lifestyle change (prevention). Other regional countries have similar authorities doing the same as well.

8. What can the young people nowadays do to reduce the risk of getting cancer as they age?

The key to reducing their risk of cancer is to inculcate good lifestyle habits as early as they can. These habits include having a healthy diet, exercising regularly, having good work-life balance and staying away from bad habits like smoking, use of recreational drugs and excessive alcohol consumption.

9. What drives your passion for oncology especially in the field of genitourinary and geriatrics?

Very early in my career I had an opportunity to get involved in a society that promoted healthy ageing. This exposure made me realise the numerous challenges that the elderly in the region faced. This made me more sensitive to their needs as well as got me interested in trying to come up with better ways to improve their lot. As such, it was only natural for me to get involved in geriatric oncology research when I became an oncologist. Many of the genitourinary patients that I see are coincidentally in the elderly category as well. Hence I am able to use the geriatric oncology tools to optimise treatment for this special group of patients.

10. As the National Representative for Singapore in SIOG, what role do you play?

As the National Representative, my main role is to promote geriatric oncology in Singapore. In essence, I hope to expose as many healthcare practitioners in Singapore as possible to the numerous benefits of practicing the principles of geriatric oncology in treating elderly cancer patients in the country. In line with this, Singapore Society of Oncology (SSO) organise workshops for family physicians, nurses, allied health professionals and medical students regularly.

11. How do you juggle with various positions/roles simultaneously?

I am fortunate to have a group of like-minded people working together with me in organising the geriatric oncology workshops. With regards to SSO, I have the full support of the capable executive committee members in running the society. We also have a full time secretariat that helps run the day to day activities of the society.

12. As an educator, what would you advise or recommend students who are interested in taking the medical path? Is Singapore a good place to take on such a path?

As I looked back at what made me decide to do medicine, the first thing that came to mind was having a keen desire to help others. This, along with a passion to provide comfort and care to those in need, are key elements in making a good doctor. Also, a student should have an interest in science and have an inquisitive mind with a constant desire to learn as medicine involves life-long learning.

Yes, Singapore is a great place to train in medicine. We have 3 well known medical schools. Two of these schools (Yong Loo Lin School of Medicine, National University of Singapore and Lee Kong Chian School of Medicine, Nanyang Technological University) are undergraduate schools with an excellent 5-year program.

The third school is a collaborative effort between the National University of Singapore and Duke University Medical School. The Duke-NUS Medical School is a unique program that caters to graduate students who are keen to pursue a career in medicine. I am currently a faculty at Duke- NUS and adjunct clinical lecturer at YLL School of Medicine, NUS.

About the Interviewee

Dr. Ravindran Kanesvaran is a Consultant in the Department of Medical Oncology of the National Cancer Centre Singapore. He is also an Assistant Professor at Duke-NUS Graduate Medical School and clinical senior lecturer at the Yong Loo Lin School of Medicine, National University of Singapore. He is actively involved in graduate medical education and is a core faculty member of the Medical Oncology Senior Residency Program and the Singhealth Internal Medicine Residency Program.

He completed his medical oncology speciality training in the National Cancer Centre Singapore. After completion of that training he followed up with a fellowship in genitourinary oncology (GU) and geriatric oncology in Duke Cancer Institute in North Carolina, USA on a Healthcare Manpower Development Program (HMDP) scholarship awarded by the Ministry of Health Singapore. His research interests include GU oncology and geriatric oncology. He has published in a number of well-known peer reviewed journals including Journal of Clinical Oncology and Lancet Oncology.

He has also been awarded a number of awards including the American Society of Clinical Oncology (ASCO GU) Merit Award 2009, American Association for Cancer Research (AACR) scholar-in-training Award 2010 and European Society of Medical Oncology (ESMO) fellowship award 2012. He is currently the President of the Singapore Society of Oncology (SSO) and the Singapore Geriatric Oncology Society. He has been appointed as European Society of Medical Oncology (ESMO) Faculty 2015-2016. He is on the Scientific and Education Committee and the National Representative for Singapore in the International Society of Geriatric Oncology (SIOG). He was recently awarded National Representative of the Year SIOG 2014 award.