HomeInterviewsDr. Choo Su Pin, Medical Oncologist Farrer Park Medical Centre, Singapore

Dr. Choo Su Pin, Medical Oncologist Farrer Park Medical Centre, Singapore

Give us a brief account on medical oncology and your subspecialty in this field.

Medical oncologists are the doctors who look after cancer patients; we are not the surgeons and we do not give radiation. We basically focus on giving drugs such as chemotherapy drugs, immunotherapy drugs and targeted therapies. We are the ones that tend to be the main caregivers. We are not the surgeons; they will operate and then pass it on to us to handle post-op care. Similarly, the radiation doctors will come in to give the radiation. We oncologists see the patient from the point of diagnosis and all the way till the end.
I am a Gastro and Intestinal Oncologist. I am focused on the gastrointestinal tract cancers, largely like colon cancer, stomach cancer, pancreas, liver, bile duct, gallbladder, small bowel, anus, esophagus; basically you could say anything that is below the esophagus, diaphragm and above the pelvis.

What is the prevalence of GI cancer in Asia and what are the key risk factors contributing to this?

If you talk about all the GI cancers, the most common would be colon cancer, probably liver cancer in Asia and stomach cancer in certain parts of Asia. Colon cancer is highly related to lifestyle. The affluent we get, the likely chance of getting colon cancer increases. It has a lot to do with diet, lifestyle, sedentary lifestyle and so on. Eating a lot of red meat and processed food is largely associated with cancer. It does not mean that eating will lead to cancer; but there’s an increased risk. In Singapore, you will find that the number one cancer is colon cancer. In Bangladesh the numbers are not so accurate for colon cancers, however, it is on the rise. And you will see the same trend in Korea, Hong Kong and all over. Lung cancer was the number one cancer in Singapore for a long time but it has been overtaken by colon cancer. But colon cancer is the most preventable cancer, because you can screen for it unlike pancreas or others. Colon cancer always starts off as a benign polyp – a little benign tumor – in the colon; and it takes about ten years on average for that polyp to become cancerous. So if you scope and find that there’s a polyp, during the scope they can burn it off removing the risk of cancer. We have a screening program that is recommended around the world. Basically for normal risk patients, that is, people who do not have a strong family history of colon cancer, we do a screening scope – or go for a screening at 50 years old. Then you can potentially reduce the number of colon cancer cases. Besides colon cancer, stomach cancer is very prevalent in places like Korea and Japan – it is one of the top cancers there. They think it is partly due to the diet, which includes foods rich in salt content. It is so common in Japan, that they have a screening program for stomach cancer in Japan. The rest of us do not have a screening program for stomach cancer because it is not common enough to warrant the cost effectiveness for having a screening program.

Is it genetic in any way?

Most of the time it is not genetic. Genetic accounts for about 10% of all cancer cases. Majority of the time it is just random bad luck. Environment, smoking, alcohol can be contributors– I mean it is the same old stuff we have been saying for years, nothing new. Obviously, someone who smokes have an increased risk of stomach cancer. Liver cancer is still prevalent in Asia because of hepatitis B. In Japan it is hepatitis C, but outside Japan and the rest of Asia it is Hepatitis B, which is transmitted from child to mother. Now, hopefully with vaccinations administered during infancy, we are seeing that trend being reversed. But we are seeing more liver cancer, not due to hepatitis B, but due to fatty liver.

What are the various means of treatment available?

Generally, nowadays the treatment depends on what kind of cancer it is. But, generally for the GI tract cancers, surgery is still the main way. If you want to cure, you will need to operate it out. Usually radiation will not cure it, and except for very few cases, chemotherapy will not cure it. When we talk about chemotherapy, target therapy, immunotherapy and so on, this is what we call systemic therapy because it goes into the whole system and there is still going to be surgery. Let’s take liver cancer, if you can operate you will always operate. Whether you do a liver resection or liver transplant to get rid of the cancer. Transplant will not only get rid of the cancer but also the bad liver that is causing the cancer – which is the liver cirrhosis or the cirrhotic liver. Otherwise, usually treatment requires a multidisciplinary approach; it is never just one doctor. It is usually a team of three or four doctors. Let’s say, a colon cancer patient will see a surgeon, a medical oncologist for chemotherapy; and if there is a rectal tumor, they may end up seeing a radiation oncologist to follow radiation. And so they end up seeing up to three doctors, because they need multiple doctors for the treatment. We have gotten smarter, the drugs have gotten better, the anti-vomiting drugs have gotten better and the chemo itself has gotten better; the treatments, supportive treatments for the side effects have gotten better and the overall understanding of how to dose patients have gotten better. So patients having bad side effects from chemotherapy is improving. It is not acceptable to us; it is always a concern for the oncologist.

What would be the general quality of life after the recovery?

After recovery, your patients will go back to their normal lifestyle. They have to be very positive. The immune system and everything will recover. But this is for curable cancer. Advanced cancer is a different story. If it is a stage four cancer, if you do not control the cancer, the cancer will kill you. That becomes a different story as the chemo keeps going on as long as its controlling the cancer. All the side effects of any drug, the majority of the time, aside from a few isolated side effects, are all reversible.

Give us an account of your experience in conducting clinical trials for GI cancer.

I have done it for years. I used to lead the clinical trial unit at the National Cancer Center. It has been fulfilling and I think it is very important to do trials because then you start asking the right questions on how to improve treatments for the patients. When you see the patients, that’s when you have questions, such as, how could this be better, why this is happening and so on. Then you test it out on the trials. Also, trials give the patients access to the newest drugs, free of charge. For a lot of our clinic trials, the drugs are sponsored by the pharmaceutical companies, sometimes other companies sponsor for global studies, sometimes it is sponsored by grant money but the drugs come from the drug companies and the patient gets the drug for free. Sometimes these drugs can be experimental but very effective. Thus, it gives patient standard options. Sometimes in the phase one or early stage they run out of standard options for treatment, there may be a new drug for them. That is how you bring more options for the patients and at the same time, you gain more experience. For us doctors, we love it because we get to use the drug before anyone else does. For example, for liver cancer, now nivolumab was approved by the U.S. FDA for second line treatment for liver cancer. I was involved in that trial six years ago and among the first few patients that I recruited on the study is still alive! This was a stage-four cancer, and he has been alive for over three-four years now. At that time, we had told him that he had only six months to live based on our statistics at that time because there was only one drug at that time that was approved. Then he got in the study and we saw how this drug was working; four years later, he is still alive. It is wonderful for me as a trialist, the most fulfilling part is to see a drug that you have seen being developed and then to see it being approved in clinical practice after that.

Is it difficult to recruit new patients for the trial?

Sometimes the patients don’t like to be the guinea pig. But that is where we have to explain and educate them about how some trials are better than other trials. We recommend the trials when we are confident about the drug working; and other times, we tell our patients that certain trials are not working. It is all about educating the patient.

What contributed to your decision in specializing in this field?

By chance. I liked the guys in the team. By elimination of other things that I was not interested in. For GI oncology, you are focusing on not just one organ, but lots of other organs, which makes it more interesting.

What’s one piece of advice you always give to your patients?

Always be positive and always live life to the fullest, because you never know what will happen tomorrow. Don’t live in regret.

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