Vivianne Shih

Complementary and alternative medicine (CAM) usage in Singaporean adult cancer patients

BACKGROUND In multiracial and multicultural Singapore, patients are exposed to complementary and alternative medicine (CAM) from both eastern and western cultures. Although studies have shown that CAM usage is highly prevalent among cancer patients, no study on the prevalence of CAM in Singaporean adult cancer patients had been published. PATIENTS AND METHODS 403 adult cancer patients treated at the Ambulatory Treatment Unit of National Cancer Centre Singapore completed an interviewer-administered questionnaire. RESULTS Median age of patients was 56 years old (range 22-84). Fifty-six percent of patients reported CAM usage and the most commonly used CAM include Traditional Chinese Medicine, birds nest and special diet. CAM use was found to be associated with race, education level and prior CAM use before cancer diagnosis. Fifty-four percent of respondents informed their oncologists regarding CAM usage and 66.4% of oncologists were agreeable for CAM usage. However, most patients (63%) did not verify information on CAM before usage and a majority of patients taking CAM felt it was effective. CONCLUSION Majority of adult cancer patients used CAM and it is important for health-care professionals to keep abreast of research on CAM, to actively illicit information regarding usage and to provide appropriate advice and counseling.

Clinical Predictors of Chemotherapy-Induced Nausea and Vomiting in Breast Cancer Patients Receiving Adjuvant Doxorubicin and Cyclophosphamide

Background: Patients with breast cancer often receive emetogenic anthracycline–based chemotherapy as part of their treatment. Chemotherapy-induced nausea and vomiting (CINV) has been commonly reported as one of the distressing adverse effects among patients with cancer. Despite the advent of newer antiemetics and better understanding of the CINV pathophysiology, total eradication of CINV has yet to be achieved. Objective: To assess the incidence of nausea and vomiting in patients who have breast cancer and are receiving adjuvant doxorubicin and cyclophosphamide (AC) bolus chemotherapy, ascertain patients’ risk factors affecting CINV response, and study patient adherence to delayed antiemetics. Methods: This was a single-institution, prospective, observational study conducted at an outpatient cancer center in Singapore from December 2006 to December 2007. Clinical events such as CINV were collated using a standardized diary. Use of rescue antiemetics and unscheduled clinic visits due to CINV were documented. Results: Of a total of 108 participants, 16 patients were lost to follow-up and 1 provided incomplete information; thus, 91 patients were included in the analysis. Delayed antiemetics were given according to the institutions guideline and only 9 (9.9%) patients received aprepitant. Neither acute nor delayed vomiting was reported by a majority of patients and only 4 (4.4%) experienced grade 3 vomiting. The incidence of severe nausea was highest on day 3 of chemotherapy and affected 14.3% of patients. Anxiety and history of chemotherapy-induced nausea were associated with both acute and delayed nausea, and history of motion sickness was associated with delayed vomiting. Approximately 65% of patients were adherent to their prescribed delayed antiemetics. Conclusions: Most of our patients adhered to their antiemetics and tolerated AC chemotherapy reasonably well, without vomiting; yet nausea persisted. To improve CINV control, clinicians must actively communicate with patients to facilitate accurate assessment of risk factors and CINV response and to encourage adherence to delayed antiemetics.

Liposomal doxorubicin-associated acute hypersensitivity despite appropriate preventive measures

Liposomal doxorubicin is becoming popular as a chemotherapeutic agent in the treatment of multiple malignancies. This paper describes an episode of hypersensitivity reaction associated with the infusion of liposomal doxorubicin in an ovarian cancer patient, despite preventive measures being undertaken during her first cycle of chemotherapy. Clinicians may overlook the possibility of hypersensitivity reactions associated with liposomal doxorubicin because routine prophylaxis is not provided and reactions are infrequently observed in practice. Close monitoring during the first 15 min of infusion for signs of hypersensitivity should be mandatory for patients receiving their first dose of liposomal doxorubicin. Further research should identify patients who are at risk of experiencing such hypersensitivity.

Clinical pharmacy services and research for lymphoma patients at a cancer center

At the National Cancer Centre Singapore, which is currently the largest ambulatory cancer centre in Singapore, clinical pharmacists have taken upon responsibilities to provide direct pharmaceutical care in the center’s lymphoma team since 2006. Given the complexity and intricacies of lymphoma treatments, clinical pharmacists are often positioned to ensure supportive care is optimized among these patients. Besides management of chemotherapy-related and supportive care issues, clinical pharmacists play a pivotal role in guiding cost-effective and safe prescribing. In collaboration with the medical team, they are also involved in conducting practice research in order to optimize the delivery of pharmaceutical care. In this report, the dedicated services and research activities conducted by clinical pharmacists of a lymphoma team will be discussed.

A systematic review of patient-reported outcome instruments of dermatologic adverse events associated with targeted cancer therapies

PurposeDermatologic adverse events (dAEs) in cancer treatment are frequent with the use of targeted therapies. These dAEs have been shown to have significant impact on health-related quality of life (HRQoL). While standardized assessment tools have been developed for physicians to assess severity of dAEs, there is a discord between objective and subjective measures. The identification of patient-reported outcome (PRO) instruments useful in the context of targeted cancer therapies is therefore important in both the clinical and research settings for the overall evaluation of dAEs and their impact on HRQoL.MethodsA comprehensive, systematic literature search of published articles was conducted by two independent reviewers in order to identify PRO instruments previously utilized in patient populations with dAEs from targeted cancer therapies. The identified PRO instruments were studied to determine which HRQoL issues relevant to dAEs were addressed, as well as the process of development and validation of these instruments.ResultsThirteen articles identifying six PRO instruments met the inclusion criteria. Four instruments were general dermatology (Skindex-16©, Skindex-29©, Dermatology Life Quality Index (DLQI), and DIELH-24) and two were symptom-specific (functional assessment of cancer therapy-epidermal growth factor receptor inhibitor-18 (FACT-EGFRI-18) and hand-foot syndrome 14 (HFS-14)).ConclusionsWhile there are several PRO instruments that have been tested in the context of targeted cancer therapy, additional work is needed to develop new instruments and to further validate the instruments identified in this study in patients receiving targeted therapies.

A Pilot Study to Evaluate the Role of Therapeutic Drug Monitoring of Pegfilgrastim in Lymphoma Patients Receiving Chemotherapy

Background: Despite primary prophylaxis of febrile neutropenia (FN) with pegfilgrastim, studies have demonstrated a significant number of breakthrough FN events among Asian lymphoma patients receiving chemotherapy. This study was designed to investigate the association of pegfilgrastim concentrations during the lowest point of absolute neutrophil count (ANC nadir) after chemotherapy administration and the occurrence of breakthrough FN, to evaluate whether Therapeutic drug monitoring of pegfilgrastim can guide management of FN. Methods: This was a single-centre, prospective cohort study of Asian lymphoma patients who received prophylactic pegfilgrastim after completion of their chemotherapy. Pegfilgrastim serum concentrations were measured from blood samples taken during ANC nadir and at development of breakthrough FN using an enzyme-linked immunosorbent assay. Descriptive statistics, t-tests and correlation curves were used in the statistical analyses. Results: Nineteen patients were recruited from May to August 2012 and received 21 cycles of pegfilgrastim. Three (15.8%) developed breakthrough FN. The median pegfilgrastim concentration among patients who developed breakthrough FN was 0.257 (0.231–0.631) ng/ml, compared to 0.299 (0.001–0.829) ng/ml in patients who did not (p=0.740). Baseline ANC levels were significantly lower in patients with breakthrough FN (3.59 × 109/L, range 2.71–3.87) versus those who did not (5.36 × 109/L, range 2.80–16.48; p=0.014). Conclusion: There was no difference in pegfilgrastim levels during ANC nadir between patients who developed breakthrough FN and those who did not, but the study was underpowered. Therapeutic drug monitoring of pegfilgrastim cannot be recommended at this time.

Economic Evaluation of Anastrozole Versus Tamoxifen for Early Stage Breast Cancer in Singapore

OBJECTIVES In Singapore, breast cancer is the leading female malignancy and its incidence has increased threefold over the past decades. For treatment of postmenopausal, hormone receptor positive early stage breast cancer, tamoxifen or aromatase inhibitors such as anastrozole are prescribed either as first-line therapy or sequentially. Currently, anastrozole is patented with a higher drug cost compared with tamoxifen. Hence, the aim of this study was to conduct an economic evaluation of anastrozole versus tamoxifen in early stage breast cancer. METHODS A Markov model with a lifetime horizon was developed by using results from the Arimidex, Tamoxifen, Alone or in Combination trial. Direct medical costs were estimated by billing data obtained via financial electronic databases. Utility scores were elicited from 20 experienced oncology nurses using the visual analogue scale. Cost per quality-adjusted life-years was calculated by using the societal perspective. A discount rate of 3% for both charges (expressed in 2010 Singapore dollars) and benefits was used. RESULTS At an additional cost of S

3072 POSTER Impact of Adherence to Antiemetic Regimens on Outcome of Nausea and Vomiting Control Among Asian Breast Cancer Patients Receiving Anthracycline-based Chemotherapy

17,597, anastrozole treatment resulted in a gain of 0.085 life-year survival and 0.154 quality-adjusted life-year. The incremental cost-effectiveness ratio of anastrozole was S

Impact of colony-stimulating factors to reduce febrile neutropenic events in breast cancer patients receiving docetaxel plus cyclophosphamide chemotherapy

207,402 per life-year gained and S

Evolving roles of oncology pharmacists in Singapore: A survey on prescribing patterns of antiemetics for chemotherapy induced nausea and vomiting (CINV) at a cancer centre†:

114,061 per quality-adjusted life-year gained compared with tamoxifen. CONCLUSION This is the first economic evaluation that used 10-year results from the Arimidex, Tamoxifen, Alone or in Combination trial and utility elicited from the local population. If the World Health Organizations recommendation of 1 to 3 gross domestic product range is an acceptable threshold, anastrozole is deemed cost-effective compared with tamoxifen in the treatment of early stage breast cancer.