Tuesday, 22 November 2011

NHG Patient Exemplary Award 2011

Peter Tang is the founder and leader of the NUH (National University Hospital) and TTSH (Tan Tock Seng Hospital ) support groups as part of NCIS (National Cancer Institute Singapore).

It is my delight to announce to you that Mr. Peter Tang won the National Health Group hospitals Exemplary Patient Award 2011.  There are 3 winners in total.

The Award is given to recognize individuals who have contributed significantly to helping other patients on a volunteer basis out of goodness of heart.  In Peter’s case, he has started the 3 NPC support groups in Singapore and has been consistent in steering the NUH and TTSH support groups every month. He has indeed gone the extra mile for the past few years and his work is now being formally recognized.

He received the award from the CEO of the NHG on the 30 September in a special NHG Quality Day Ceremony. NHG Quality Day is a day to recognize other medical and non medical personnel as well who have make a difference in running of the NHG group hospitals that comprises Tan Tock Seng hospital, National Skin Centre, National Health Group Polyclinics, NHG Diagnostics, Institute of Mental Health, National Health Eye Institute, John Hopkins Cancer Centre and a few others with a total of 9000 staffs.

Here is the newspaper abstract published in the Singapore New Straits Times on the 1st October 2011



Nominated and supported by Dr. Choo Bok Ai, Medical Adviser of NPC support group

Peter's reply:


As I sat down today to ponder how to write My thank you letter I realised that this is not just common courtesy but from-a-heart THANKS to all of you. Kind of overwhelmed  by the  congratulatory emails that I have received .

This congratulatory email  from Yian Ma ( below )  puts in perspective the winning of the award that besides the individual effort there is foremost the  team effort which adds more effort and value to the work of the NPC group and hence makes it more efficient .
  
Congratulations! Well Done! You truly...truly deserve the National Health Group hospitals Exemplary Patient Award 2011, which is nominated by Dr. Choo Bok Ai. Meanwhile, my heartfelt thanks to all other exco members - Dave, Yip, Slyvia, Moses who have come forward on a voluntary basis to make each & every NPC Support Group Event a successful one. Keep up the good work - Yian Ma

I want to convey my heartfelt thanks to the  exco volunteers and the Nuhs/Ttsh staff and doctors for the co ordinations, brainstorming of issues , sharing of knowledge and also sacrificing of time after work to provide the  admin and log support for the  npconeheart group.

The npc support committee,  staff and doctors strongly believe that  given time and effort every members who join the npc support group can be as productive, useful , whole and happy person as you were before cancer ( or even much more )

It’s a privilege for the exco to be part  of a Nuhs/Ttsh team of Dr Lee and  Dr Choo .

Thanking all the survivors and caregivers for being part of this support group

Monday, 21 November 2011

NPC Year End Party on MediaCorp Suria Main News 21 November 2011 at 8 p.m

The NPC Year End Party at NUH on 19 November 2011 was indeed a good time for staffs at NUH and TTSH to mingle with cancer survivors from all ages and races. Although only 6% of NPC patients are Malays, cancer survivors like Affendi and Samad have been coming regularly and we enjoy their fellowship.

MediaCorp Suria channel has kindly covered the story and help to raise awareness of NPC among Malay speaking residents in Singapore. It was good to see all of you joining in the line dancing. I am also very grateful to all my Radiotherapy staffs at NUH and TTSH led by Michelle as part of NCIS to volunteer help on a Saturday afternoon to make the Year End Party a success. Lastly, the organizing committee from Peter, Yvonne, Dave, Yip, Slyvia and Moses had gone the extra mile to make sure everyone had a good time. I am indeed privileged to be able to know and work with all of you.

Dr. Choo Bok Ai
Assistant Professor NUS
Consultant Radiation Oncologist NUH and
Medical Adviser of NPC Support Group NCIS

http://www.facebook.com/video/video.php?v=250145275040866



Sunday, 20 November 2011

2012 Program (January - June )


7 January  (NUH) :  Nutrition - Balancing your food choices before, during and after treatment
(Live demonstration)  - Talk by Dietition

3 February  (TTSH)  : Side effects of Head and Neck Cancer treatments - An Overview - Talk by Oncologist

3 March  ( NUH) : Maintaining Good Oral Hygiene (Useful tips) - Talk by Dentist

13 April  (TTSH) : Swallowing and Voice changes after treatment - Treatment and Exercises - Talk conducted by  Speech and Swallowing Therapist

12 May  (NUH) :  Traditional Chinese Medicine : Use of TCM in managing side effects of treatments - Talk by Registered TCM Physician

1 June   (TTSH) : Physiotherapy in Head and Neck Cancer post radiotherapy (Live demonstration) - Talk and demonstration by Senior Physiotherapist

Talks are subjected to changes depending on speaker availability.


Saturday, 19 November 2011

Joy In the Journey

Yesterday, we had our Year End Party - a time to reflect and celebrate another year of hopefully cancer free. However, I knew a few of the members had relapses in the past 1 year.

It is difficult to face with cancer relapses. It is also equally difficult for me to break bad news about relapses. Yet, life goes on. We try not to think of it. When it happens, we face the cancer again and memories of the old treatments for example radiotherapy or chemotherapy flood back. Surgery may also be indicated in selected cases. There are so much uncertainty and so much fear.

I chose a song entitled "There can be miracles" sung by Whitney Houstan and Mariah Carey in the motion picture "Prince of Egypt" to sing in the Karaoke session during the year end NPC support group party yesterday. The lyrics are as follows:

Many nights we prayed, with no proof anyone could hear
In our hearts a hopeful song, we barely understood
Now we are not afraid, although we know there's much to fear
We were moving mountains long, before we knew we could

There can be miracles, when you believe
Though hope is frail, it's hard to kill
Who knows what miracle, you can achieve
When you believe, somehow you will
You will when you believe.

In this time of fear, when prayer so often proves in vain
Hope seems like the summer birds, too swiftly flown away
Yet now I'm standing here, my heart so full I can't explain
Seeking faith and speaking words, I'd never thought I'd say

There can be miracles, When you believe (When you believe)
Though hope is frail, It's hard to kill
Who knows what miracles, You can acheive (You can acheive)
When you believe, somehow you will
You will when you believe

They don't always happen when you ask (uh)
And it's easy to give in to your fear (ooh)
But when you're blinded by your pain
Can't see the way clear through the rain
A small but still resilient voice
Says hope is very near

There can be miracles (Miracles)
When you believe (Oh When you believe)
Though hope is frail
It's hard to kill (Hard to kill)
Who knows what miracles 
You can achieve (You can achieve)
When you believe (oooohhh)
Somehow you will (somehow somehow somehow)
Somehow you will ( I no I no I no)
You will when you believe (when you)
You will when you, you will when you, believe
Just believe, just believe (ooh baby)
You will when you believe. 


I took my guitar on stage, played the chords and sang the song. Half way thorough the song, I found out that the chords were wrong. I joked that it was just for warming up. I started again, having to use another set of chords. It was difficult, at least for me to sing and play the guitar at the same time. I have only sang in public in a few instances, having not have a good voice. However, I felt obliged to sing; a few of the members needed to hear the song and find encouragement. This was also my first playing of my guitar this year, having left it in the store room due to my busy work schedule. 


The "Prince of Egypt" told of the story of Moses. He received a commandment from God to led his people out of Egypt. Somehow, their journey led them to the Red Sea in order to cross over to the Promise Land. But they had no means to cross the sea and their enemies were closing in and all of them could perish. It was a hopeless situation. At the last minute, Moses needed a miracle. A miracle beyond human understanding. His followers could not see the miracle. Yet, Moses did not give up. He prayed and he had faith. And the Red Sea parted. It was amazing. It was a miracle. 


Sometimes, we are faced with the same situation. Cancer is like the Red Sea. Somehow, one of us ended up with the Red Sea in front of us. The enemy of death is at the back of us and closing in. We wanted to cross over to the opposite side desperately but the Sea seemed so big and deep and there are no means to cross over safely. We are stuck. The doctors are stuck. They tell us that the chances are not good. 


The lyrics of the song captured the Moses and his people's emotion well. Fear sets in but yet there is hope. Although hope is frail but yet it is hard to kill. In our hearts a hopeful song that we barely understood. Now we are not afraid, but yet there is much to fear. Seeking faith and speaking words we never thought we will say. There can be miracles when you believe. 


I dedicate this song to the members and their care givers who are faced with a difficult situation at the moment. As a doctor, I try to be realistic about what can be achieved medically. The medical treatment nowadays can achieve so much more than before. Yet, there is still a limit in some cases of what modern medicine can achieve in the more advance and recurrent cancer. But, as a fellow human being, I had seen miracles before that cannot be explained medically. For those who trust in God, it is divine intervention. For those for believe in karma, it is due to previous good work and a repentance of sin and finding favor to prayers. 


Don't give up. There are excellent hospital staffs and skillful doctors who can help. Many of us will go the extra mile. Cancer is a devastating disease. We understand. There are also people like Peter who is a cancer survivor who can provide support emotionally if needed and his committee. Pray. Have faith. Miracles can happen no matter how rare it can be. Cherish life. Love your families. Eat well, exercise well and live well.  This is the motto of NPC One Heart.


Dr. Choo Bok Ai
Consultant Radiation Oncologist
Medical Adviser of NPC support Group











Wednesday, 21 September 2011

I DID NOT WALK MY NPC JOURNEY ALONE



Many years ago I remember a friend’s husband passed away of bone cancer. My wife Orris and I were not aware of his disease until his funeral. So were many of our friends. As for me, most of my friends knew about my NPC diagnosis, treatments and recovery throughout my journey.

It all started with a significant visible lump on the left side of my neck, discovered by Orris in early October 2009. My normal GP could not tell me what it was and neither could my annual health screening on 23 October 2009. Both doctors did advise me to seek medical specialists in hospitals.

I took the Biopsy Test at the Alexandra Hospital (now Khoo Teck Puat Hospital in Yishun) on 18 November 2009. On 30 November 2009, 8 days before my next appointment, the doctor called me back urgently, informed me of my NPC diagnosis and arranged for my treatments immediately. She professionally and clearly assured me that NPC is curable. Thus my journey of fight against NPC began.

I did not walk my NPC journey alone. My wife Orris would undoubtedly be my caregiver. Despite of feeling of sadness for me, she embarked on her own journey to seek as much information as possible about the disease. She surfed the internet, looked up articles and talked to hospitals, relatives and friends. Apart from my brother-in-law in Malaysia who also had NPC, no one else in my family has NPC or any other cancer before. Therefore, we relatively walked into the unknown territory.

Many friends came forward to offer advices and directions, including consultation with a TCM doctor. I consulted an oncology TCM at Singapore Chung Hwa Medical Institution at Toa Payoh prior to, during and after my NPC treatments. I am still consulting him monthly.

On Christmas Eve 2009, I received a Get Well Soon self-made personal card as my Christmas present from my in-laws’ families, giving me the encouragement to face the treatments ahead. I started my chemotherapy treatments (CT’s) on 4 January 2010 and radiotherapy treatments (RT’s) two days later at Tan Tock Seng Hospital. I completed all my treatments on 22 February 2010 and therefore my Chinese New Year festive celebration that year was burned, which was nothing compared with the troubles Orris has endured to make sure I had the best possible treatments and on the right path to fight my NPC. Until today she still wakes up very early every morning to boil the TCM for me.

At the start of my NPC treatments the nurses introduced us to TTSH’s NPC Support Group and we attended almost all their talks whereby the members shared their own NPC journeys. I also attended many talks of the NCC NPC Support Group. The support groups has played a great role helping me and fellow sufferers to understand the disease better, cope with the side effects following the treatments and move forward with our lives. Both support groups under the leaderships of Mr Peter Tang at TTSH and Mr Teo Thiam Chye at NCC have been great sources of useful information for NPC patients indeed.

During the treatments I met an ex-project team member who opened up himself as a NPC survivor and comforted me, “It’s a long and tough journey but you’d prevail.” Another friend brought her NPC survivor friend to my home and explained the process and the side effects of the NPC treatments, preparing myself for the fight ahead. One more friend and her family visited me every weekend to comfort me.

My colleagues were all very understanding and equally supportive. My directors had said clearly to me that I concentrated on my treatments and got cured before thinking of reporting to work again. I stopped works for more than 6 months for treatments and recuperation. They stopped sending business emails to me almost immediately so as not to worry me about my project and works. They also visited me at home on few occasions. I felt relieved and comfortable and proceeded with my treatments without interruption and worries.

The supports I received from all definitely fully eradicated my walking on this journey alone. It helped lifting up my spirit and kept me going. “Come on!” each of my supporters always encouraged. In fact one year later I could not quite remember all the side effects and sufferings which I had gone through because with so much supports, I was not depressed and always looked forward to recovery. In my opinion, the supports were important in helping in my NPC recovery. The two to three month journey did not seem that lengthy anymore.

Perhaps TCM has helped me tremendously in my NPC treatments. I believe so. I encountered a number of side effects like any sufferers undergoing the same NPC treatments and I thought my side effects were minimal or manageable. My mouth ulcers were barely visible though I could feel it and they lasted a couple of days only as far as I could remember. Saliva loss would be apparent after 2 weeks of treatments, doctor said, but after the third week, I still felt much saliva in my mouth. I believe TCM helped boost my body’s immune system against these side effects and provided the goodness for me.

Only until my 22nd out of 33 daily RT’s I could see some of my neck skin peeled off whereas other patients said to have this side effect after the 7th RT. I did vomit few times despite of taking anti-vomit pills prescribed by the CT doctor. The pain in my throat was quite unbearable and so much so whatever food I took was vomited out. I lost more than 10 kg. Now I have ideal weight contrary to the previous periods when the annual health screening doctor always reminded me of my overweight issue. “You look great, slimmed.” now all my friends say.

Doctor gave me morphine to ease my throat pain. Morphine seemed to glue my mouth. I found difficulty to open my mouth and when I forced open it, cracks split each side of it. More pain! Morphine also caused constipation. I could not pass motion for a full week and panicked. I required anti-constipation pill in my anus to help, like a small child. Fortunately it was not hard to do.

My worst nightmare was my frequent dreams of eating. I missed many favourite foods. During my sleep, while dreaming of foods, I swallowed my saliva and it hurt my painful throat. Dry mouth or dry throat is another side effect. It may or may go away for years. Until today I still have it but it does not feel so hurting now. At that time due to the hurt of dry throat, I woke up few times at every two or three hour intervals. Sleep was never peaceful then, leading to tiredness and psychological loss of the warfare.

There would be hair loss behind my head. Orris brainwashed our daughter not be alarmed at the sight. In fact our daughter laughed at it when it happened. We were restful that she was not scared after all.

Generally the doctor said that I was coping well and above average in terms of sufferings from the side effects. Time indeed passed swiftly, for which I was thankful for all the supports from the doctors, family and friends alike. I must look after my health from now by changing my lifestyle.

I have changed my food diets. I do not eat or eat less of what I used to take previously, i.e. meats, especially steaks and roasted meats, curries, deep dried stuffs, sweet deserts and other unhealthy foods. I take more vegetables and fruits and drink more fresh fruit juices and “kosong” (without milk and sugar) drinks. I still drink a packet of Ensure Plus milk almost everyday. No more fresh milk to accompany my daily breakfast. And definitely no more soda and alcohol drinks for me. You may say that my stable meals now are rice, mee hoons and breads. I drink my TCM every morning and evening after meals.

I used to sleep late at midnight. I have changed to one to two hours earlier after sometimes accompanying my daughter’s reading and spending quality time with her. I wake up early and go for my daily walking/jogging for half hour at about 6:00 a.m. in time for my office works to start at 8:00 a.m. The daily exercise does refresh me and I do not feel much tiredness during my works nowadays. During the exercise, I also stretch my limps, neck and mouth or jaw and do tongue exercise as recommended by the members of the NPC support group.

My NPC has also changed my outlook of life. I must treasure my life and whatever I have now – family, friends, works, possessions and most importantly time. I make sure I spend enough quality time with Orris and our daughter Mei Jia, doing things together more than before. I do not take my family and things for granted now. I do not take troubles seriously so as to stress myself out. I start to return to attending church and join in the fellowship with fellow church members. Happiness comes first above all things.

Kong Peng Sun
20th month NPC survivor



Saturday, 17 September 2011

My experience with radiotherapy for NPC - using TomoTherapy

"Hi, my name is Sylvia, I was diagnosed with NPC stage 1 in Mar 2010; and went through 35 radiotherapy treatments. I'd say I was lucky in that Tomo Therapy was recommended to me by my Radio Oncologist.  This treatment targets at the tumour with lesser dosage on the surrounding organs resulting to me having minimal side effects.

After seven weeks of Radio therapy, I was left with only darker shades of skin on my neck, but with my deligent application of Aloe Vera gel and Vit E cream, my skin recovered in 6 months.  I had only 1 day of ulcer infection and recovered the next day.  I experienced lost of taste buds (recovered), mild dry throat/mouth, and needless to say the nose is the most affected in that I had to douch my nose to clear crusts twice a day.  I would say that I was lucky to have started TCM prescription in preparation of the radio therapy way before my treatments started.  I continued to receive TCM advice and herbal prescriptions till today.

You wouldn't believe, my tongue was 'purplish blue" in colour after the radio therapy.  According to the TCM physicians whom I've consulted, both said they have never seen such an "ugly" tongue - this denotes that my metabolism rate was low resulting to the toxin from the radio therapy not being expelled in time and accumulated in my system.  I'm glad to say that today, my tongue is as pink as the roses in my garden !!

During my treatment days, besides vegetable juicing, I would double boil soups alternate days.  Let me share some of the soups I believe helped in my speedy recovery which I hope you will find useful:

Boil for 3 hrs
Chinese pear ('xue li")
('nan pei xin")
white fungus
"Yu Ju"
Honey date (optional)
Water

I drink this 3 times a week and gradually reduce to twice a week; and now I drink only if I find it necessary..

Other soups which I frequently boil are:

Water cress with pork ribs, almonds ('Nan Bei Xin"); and honey dates.
Fresh "huai San" with pork ribs, and cordecep flowers ("dong chong cao hua")
"Qing Shan Xue Lian" with pork ribs
"Fen ke" with pork ribs

I'm now into meditation for better health !!




Sylvia

18 months NPC cancer survivor

Friday, 16 September 2011

NPC Public forum 25 September 2011 at Tan Tock Seng Hospital

I have just finished my slides to talk on "Coping with cancer - what helps and what doesn't". It is a difficult topic. There is no standard textbook answer. I am still learning everyday how my patients tell me how they cope. I begin to imagine too how I would react if I have cancer. Cancer is becoming more common as people now lived longer due to better lifestyle and healthcare. The life expectancy now is 78 years old. A century ago, it was less than 50 years. People are living longer and hence there is a higher risk of developing cancer. It is like an old car; sooner or late, there will be problems. The incidence of cancer is 1 in 4 and 1 in 3 people dies of cancer. Cancer is like an "epidemic". Everyone knows someone who has cancer.

I had first hand experience on coping with my own nephew's death due to a brain tumor this year. He was 11 years old. It was the most difficult and darkest time of my life. Being a oncologist and a specialist in cancer, there was little I can do to help. The cancer was very aggressive and resistant to chemotherapy and radiotherapy. Surgery was not possible due to the location of the tumor. Yet, he was the most remarkable and courageous patient that I had ever knew. He never complains of his symptoms, although being well chair bound and seeing double vision. When he eats, it will take him an hour to swallow and food and water droop on the left side of his lips. The brain tumor had affected his cranial nerves and he was like a stroke patient. He was dependent on the wheelchair and was unsteady on his feet. Yet, he never complains and fought to live a normal life. He consoled his parents, asked them not to worry and he worried about the costs of his own medical expenses as the family was not well off. He taught me lots. He taught me that whatever situation that I am in now, there could be far worse. So,  give thanks for what you have, fight on to live a normal live, spend time with your family and never let cancer defeat you to the extend that you stop living when you are still alive. Fight cancer till the end and never ever give up.

Come to the NPC public forum. My session will be an interactive session with cancer survivors and caregivers to share their own experiences in dealing with cancer. It will be a heart warming experience.

Dr. Choo Bok Ai
Consultant Clinical Oncologist and
Assistant Professor
NUHS

Tuesday, 30 August 2011

Nose block and mucus


Sharing by Mr. Dave Cheow - cancer survivor (28/08/2011)

" My name is Dave - an NPC Stage-2 Survivor for 9 yrs. My treatment was radiotherapy only. I signed on for a 'guinea pig" treatment program (in medical term, a clinical trial) which gave a double dosage of radiotherapy daily in the second 3 weeks of the full 6-week radiotherapy treatment. I was informed that this treatment had a higher recovery rate, as previously tested in Germany.

Since the treatment ended until now, my nose has been accumulating lots of mucus and have to blow out my mucus regularly. I never had this mucus problem in my life until this side effect kicked in immediately after my treatment. As my NPC tumor was found in my right side of the nasopharyngeal, the right of my nose is probably more damaged then the left side. Hence more mucus accumulates in the right side of my nose. When I'm normal and well, the mucus is clear. The mucus turns yellowish if I'm having a cold or flu. When I'm down with a bad flu, the mucus color changes to dark yellow and looked very gloomy. However, the mucus has never smell bad until about 1 year ago.

Over the last 1 year, I realized the mucus from the right side of my nose has changed or I can say - 'mutated'. When I am down with flu with symptoms of blocked or running nose, the mucus from the right side of the nose becomes dark yellow and the mucus smells bad. The mucus is thinner, but it can drip freely without me realizing it. When it does drip, I'll have to bend down and tilt my head downwards to blow hard on the right side of the nose to get rid of the mucus. It is only in this position that I can effectively clear the mucus from the right side of my nose by blowing hard repeatedly. It is also in this position that I experience the worst ever smell that I can ever imagine coming from my body, i.e from the mucus from the right side of my nose. The stench from the mucus also affects my breath very much that I have to keep going to the toilet to wash up.

I also take longer time to recover from the flu since. Instead of taking just 1 antibiotic to recover in the past, now I may have to resort to taking 2 types of antibiotics at the same time. On the advice of my doctor, I'll now turn to more frequent flushing of my nose with the recommended nose wash and hopefully this helps to slow down the worsening of this particular side effect."

Mr. Dave Cheow – 9th year cancer survivor

Swallowing - An Annoyance

Sharing by Mr. Peter Tang (30 August 2011) - NPC cancer survivor  


Last year I was having lunch at the food center. I ordered my food from a “ zhi cha” stall selling all kind of cook food. As part of my healthy eating regime, I usually order vegetables, steam egg and a fish. I would remind the cook’s assistant twice, to add generous amount of gravy to the dishes so that the rice will not be dry. If the stall gives a free bowl of soup, I will be very happy and appreciative and will make a point to always patronize the stall for lunch again just because of that bowl of soup.

Moving to the nearest empty table, I began my lunch. Two gentlemen came to share the table with me a few minutes later.  Looking at their food, I realized that they have ordered from the same stall.  One of them looks like in his late 40s the other in his 60s. Five minute later, they have literally finished what were on their plates and I was still struggling to finish the last portion of my food.

I have noted that for the past two years, lunching out has began to be a chore for me not because of being unable to decide what to eat but more because the act of eating has began to be a task and a challenge. Twenty years after completing radiotherapy for my nose cancer, I realized that swallowing food (especially food with dry texture like chicken, fish or some type of vegetables) has to be deliberate, occasionally forceful (if the food gets stuck in the throat even after washing it down with fluid). Sometimes I gag suddenly because of small remnants of the food (e.g. Kit Kat) get stuck in the dry areas of the throat. However eating food that is watery will eliminate most of these unpleasant experiences

Late last year, I requested for a medical test to check the strength of my throat muscles in swallowing different kinds of food.  I called it a Barium Meal as the radioisotope barium liquid was added into each of the three categories (meat, salad and bread) to see the swallowing motion on X-ray. I was told to chew them and swallowed them when I was ready. The strength of the muscles was captured on dynamic X-ray film and this was recorded. The results showed that overall; my throat muscles were still functioning well although there were some signs of muscles fibrosis.  I will be repeating another similar test again soon.

Swallowing for me is an ANNOYANCE but it is not a major ISSUE. Notwithstanding, I am appreciative that I am able to eat and enjoy the food (although at a lesser extent) and more importantly to be able to eat with the people I want.  One of my house rules is that I make it a point to eat out once a week with my family because this is the time for my family bonding. For me, this reason far outweighs the small annoyances of swallowing.

Finally let me end with this Charlie Brown’s quip which I believe, resonates loudly not only with me but with all nasopharyngeal cancer survivors.

Lucy remarked: “ I am making a list of all the things that I have learned in life, well actually, I am making two lists.” Charlie enquired, “ Why is one list longer than the other? ”. To which Lucy replied, “ These are the things I have learned the hard way!”


Peter Tang

19th year old NPC cancer survivor. Treated with radiotherapy.  

Thursday, 25 August 2011

Hearing loss after radiotherapy for NPC

Total hearing loss is uncommon. Reduced hearing loss either on one side of ear or on both sides can happen during and after chemotherapy and radiotherapy for NPC.

Causes of hearing loss DURING concurrent Cisplastin chemotherapy and radiotherapy is due to Cisplastin chemotherapy side effect that can cause high frequency hearing loss and tinnitus (ringing in the ear). If these symptoms happen, the patient need to alert the doctor. Most of the tinnitus and high frequently will resolve once the chemotherapy has been stopped. Some patients have to discontinue the chemotherapy early if the hearing loss is severe. Persistent hearing loss can happen in some patients when the chemotherapy was continued and not stopped despite the onset of hearing loss. It is very unusual for radiotherapy to cause hearing loss DURING radiotherapy. Radiotherapy however can cause a late onset hearing impairment.

Causes of hearing loss AFTER completion of treatment from 3 months onward to lifelong could be due to several factors:

1) After effect of Cisplastin chemotherapy that has persisted since during chemotherapy. This usually improved with time over the next few months but in a small number of patients, persistent high frequency hearing loss will continue for life.

2) After effect of radiotherapy damage to the cochlear (inner ear) that maintain the sensory-neural conduction of hearing from ear to the brain. In IMRT radiotherapy, the radiation oncology doctor will try to spare the cochlears on both sides and avoid giving high dose radiotherapy to the cochlear. While this is in most cases possible, in patients with a large NPC cancer, this cancer can be very near the cochlear and hence cannot be spared. Fortunately, we have 2 ears and in this case, one side of the cochlear will receive a higher dose of radiotherapy to gain maximum cancer control on the side where the cancer is nearest to cochlear while sparing the other side. Damage to cochlear results in a long term hearing loss and the hearing loss is gradual and may take 6 months to life long before patient notice. It will not be apparent immediately on completion of radiotherapy.

3) The radiotherapy to the NPC will cause some radiation to mid and inner ear. Inflammation at these areas can cause fluids to built up and affect the ear drum function. Furthermore the Eustachian tube which connects the nose and the ear can be blocked leading to nasal blockage and ear ache. These areas are also susceptible to bacterial infection causing otitis. In severe causes, the ear drum may burst when the swelling builds too high and the ear pain will reduced, but the hearing will be impaired with a burst ear drum. In recurrent fluid built up, the ENT doctor will consider inserting a grommet which is a small tube at the ear drum level to drain the fluid out. When the fluid is drained and the fluid reduced over the next few months, the grommet can be removed. The ENT doctor commonly will also prescribe ear drop antibiotics and/or oral antibiotics to treat ear infections and frequently contribute to the fluid build up.

4) Ear wax can build up in the external ear causing hearing impairment and pain and the easy solution is to use some olive oil to loosen the ear wax and for it to come out gradually over the next few days or for ear syringing or a small vacuum suction tube can be inserted to suck up the wax under a ENT doctor consultation. The hearing will be back to normal immediately if it is the ear wax that is the cause of the hearing impairment.

In summary, total hearing loss is uncommon, but a certain degree of hearing impairment  is a well known side effect of after treatment of NPC and could be caused by chemotherapy, radiotherapy, inflammation or infection combination. Alerting the ENT doctor early to look into the ear with a otoscope (shining a light into the ear),  can usually find a cause. Further specialist investigations include a full hearing test to check the loss of hearing frequencies or a CT scan to look into the anatomical structure of the cochlea, Eustachian tube and the nose. In the worse case scenario, patients may need to wear a hearing aid for life. A hearing aid may work in most cases, but in certain group of patients, hearing aid will not improve the hearing back to a normal functional degree.

Wednesday, 24 August 2011

What kind of exercises are needed after radiotherapy for NPC?

Radiotherapy given to the head and neck areas can caused scarring effects in long term. So, it is of no surprise that patients can get "hardening" skin and muscles especially at the neck and jaw areas.

Hardening of the jaw areas caused trimus, a medical term describing the difficulty and inability to open the mouth fully. In a ordinary person, one can insert 3 fingers in a vertical position into the mouth. This equates to about 4-5cm of mouth opening. After radiotherapy, the temporo-mandibular joint that is the joint just underneath your ear level that acts to open the mouth can become stiff. This reduces the ability to open the mouth wide and in so doing, it can cause pain as well. The best way to stop this happening is doing periodical opening the mouth as wide as you can by inserting orange stick (ice cream stick ) into the mouth. One can put in about 10 stick stacked up together. Alternative is to use thick towel. Whatever you put into the mouth does not matter. You only need something for your front teeth to bite and grip and stretches the opening for the mouth. Chewing exercise in this case will help. Trimus can happen gradually and not immediately and hence it is good to practice some jaw and tongue exercises routinely. Come to our support group and we will show you how.

The other part of hardening is the neck muscles and patient complains of stiff neck and inability to turn in a full range of movements to look left and right. The only way to see right and left is to turn their whole body instead. Again, this can be prevented by doing routine neck exercises. The way to achieve this is to do the 6 range of movements of the neck - up and down, turn left and right and tilt left and right (ie tilt your ear to the left and right as compared to turning the neck). Try to turn until it is just a bit painful and use your hand to give it a bit more push actively to turn it more to overcome the resistance. Although this will generate a bit of initial pain, it will help to stretch the muscles more and this part is really the part that helps. As in any exercises, you need to feel a bit of muscle stress ie pain to get the benefit. But, do it in moderation. A little bit of pain and not severe pain.

The last thing you will need a a good moisturiser. The sweat gland is partially damaged by the radiotherapy is hence the skin will always tend to be more dry. Dry skin is not good and the skin feels hard. So, apply a generous amount of moisturiser - aqueous cream equivalent with Aloe Vera, Vitamin E, paraffin based are some examples. But, make sure the cream is free from perfume or only lightly scented as perfume is not good for radiotherapy damaged skin. Use it twice a day if possible.

All this will help you get a normal skin and minimized the hardening of jaw and neck muscles. Remember that prevention is better than treatment. Get it into routine so that you will never get this problem. If problem has already developed, a physiotherapist will be able to help.

Managing dry mouth after radiotherapy for NPC.

Dry mouth is very common after radiotherapy to the head and neck area. This is due to radiation effect to the parotid, submandibular and sublingual salivary glands. These caused the reduction of saliva production resulting in dry mouth.

The first thing a patient will notice during the radiotherapy course is the thickening of saliva about 4-5 weeks after starting the radiotherapy. After completion of radiotherapy, the saliva production is reduced and becomes very thick. Due to the effect on the inner lining of the mouth and back of throat, this can further cause ulcers, inflammation and pain leading to painful swallowing.

It is common for a patient to carry small bottles of water to rinse and to drink during the process.

Patient always ask doctor 3 questions about the dry mouth:

1) Will it get better?
2) If it will get better, then when will it happen?
3) Is there any medication or food that will help the dry mouth beside drinking water?

In the older days, radiotherapy is given as a parallel opposed beams. This means the radiotherapy enters on the left side and exits on the right side and all the areas of the mouth, jaw and neck areas are treated. In modern days, there is now a better way to deliver the radiotherapy and this technique is called IMRT - Intensity Modulated Radiotherapy. What this means is really given the radiotherapy in multiple beams, like a circular beams that spread out the high doses so that to spare certain organ at risk and in this case the salivary glands. As a results of this, comparing the older radiotherapy that cause 100% salivary loss with 0% chance of recovery, it is now possible to say that with IMRT, salivary production recovery is possible to a certain degree and completely dry mouth with no salivary production at all is rare.

With IMRT, saliva recovery happens around 6 months on completion of radiotherapy and will continue to improve up to 2 years after the completion of radiotherapy. It is unusual for further recovery beyond 2 years.

To deal with the dry mouth, drinking sips of water is still the best way to wet the mouth and throat. However, water has no addictives in it. In saliva, there are multiple enzymes that protect the inner lining of the mouth and the teeth and if this is lost, there are higher chances of getting gum and teeth diseases.

There are now artificial saliva equivalent which contains salivary enzymes to help gum and teeth decay and at the same time provides relief from dry mouth. BIOTENE products from GSK are a range of products from mouthwash, gel and toothpaste that contain such enzymes and patient frequently reported good symptomatic relief and happy with these products. ORAL SEVEN are another similar range of products and both BRANDS are available for sale at pharmacists in Singapore without a doctor's prescription.

To stimulate saliva production, the act of chewing helps. Patient can chew sugar free gums or if no gums are available (since gums are prohibited from sale in Singapore), then the act of chewing, tongue and jaw exercises usually helps as well.

Lack of taste is a common complaint as well since the food cannot be mixed with saliva for the tongue to taste the food. The taste buds from the tongue are also partially destroyed by the radiotherapy. The tip of the tongue that taste sweetness usually recovers first compared with the rest.

The GC Tooth Mousse brand is a HIGH flouride mousse. It is better than normal toothpaste due to the stronger fluoride content and will fortify the teeth against tooth decay. This is available via selected dental practices throughout Singapore but not available in normal retail market.

In summary,

With IMRT (this is now the gold standard of radiotherapy in Singapore in NPC treatment), saliva production tends to recover although not completely. It takes 6 months to 2 years for the saliva production to recover slowly. In the meantime, try to chew sugar free gum, do chewing and tongue exercises to stimulate saliva production. There are multiple over the counter supportive care products that contains artificial saliva that helps and there is a need to see your dentist every 6 months for dental check. A high flouride compound is highly recommended to strengthen against tooth decay.

Wednesday, 3 August 2011

Hormonal changes after radiotherapy treatment for NPC

There will be a NPC meeting at NUH hospital at Tower Block at Level 7 between 1.30p.m to 4.30p.m Come and listen to Dr. Koh (Associate Consultant in Endocrine Medicine) as she talks on the possible hormonal changes of the pituitary and thyroid glands and signs and symptoms of the dysfunction. This talk will be useful to newly diagnosed patients and cancer survivors who had completed their radiotherapy treatments. There will be translation from English to Mandarin if necessary. Admission is free.

Thursday, 28 July 2011