Page 106 - ICE BUSINESS TIMES January 2020

Interview
By Atef Ahsan
Priority
of Prognosis
Is there any particular
reason for your interest
Dr. Colin in this particular field?
There is also another portion of
Phipps Diong hematology, known as
laboratory hematology; where
Senior Consultant, Hematology blood is tested looking under a
Parkway Cancer Center,
Singapore microscope and doing
specialized tests on. These tests
are done mainly to diagnose
blood problems.
What is hematology all about? My interest in this field is
Give us a brief account of because of how vast hematology
specialization in the other is. There is a benign portion, a
subfields of your interest? malignant portion and a
Hematology is about dealing with laboratory portion. The reason I
blood problems; if you divide it, one is chose hematology is because of
benign portion – the non-cancer my interest in bone marrow
hematology, and the other one is transplantation.
malignant – the cancer part of
hematology. What are the causes and
The non-cancer part has things to do the subsequent risk
with blood transfusions because there factors associated with
are sometimes problems that require blood cancer? How
specialist input. Then there are issues prevalent is it in
such as thalassemia, thalassemia Southeast Asia?
major, blood clotting which is We don’t really know what
commonly known as DVT (deep vein exactly causes blood cancer. We
thrombosis) in hospitals. These are all know that exposure to certain
treated by hematologists. Then within things can increase the risk like
the malignant portion – which is also certain chemicals in high
my specialization/interest – are concentration like benzene, for
problems such as, leukemia, lymphoma example. But most of us won’t
(or lymph node cancer), myeloma, be exposed to such chemicals,
multiple myeloma and except for those people who
transplantations or stem-cell work in the rubber industry,
transplantations. petrochemical industry. Another
My interest is mainly in bone marrow cause that can increase the risk
or stem-cell transplantation and of blood cancer is people who
hematological malignancies. have received chemotherapy or
100
What are the treatment scopes available at Parkway? What are the
success rates and predominant side effects present (if any)?
The treatment for lymphoma blood cancer at Parkway Cancer Center is very comprehensive. We
have all the treatments available. The most common treatments for acute-leukemia, lymphoma
is either with chemotherapy or targeted therapy and transplantations. The main side effects of
treatment are usually lowering of the immune system and increased risk of infection. No
matter what blood cancer you treat, leukemia or lymphoma or myeloma, this problem is
common in all. Because you are using chemotherapy and target therapy and blood cancer
invariably effects immune cells. So when you target those immune cells, the cancer cell die and
the immune system will drop overall. Thus the main risk is the increased risk of infections.
So as you have said previously, patients have undergone chemotherapy
are exposed to risks of developing blood cancer. For anyone suffering
from blood cancer, how are they affected by the chemotherapy and is
there a chance of blood cancer coming back?
The blood cancer for acute-leukemia is a very aggressive disease; so patients who don’t
respond or where the relapse is very fast, their life expectancy is very short. But if patients
respond positively, then they can go on to live longer
lives. But leukemia can always come back. The reason
why we do transplant for most adult patients with
radiation for other cancers. It’s because chemotherapy and acute-leukemia is to lower the risk of relapse. For
radiation can affect the stem cells in the bone marrow. Even acute leukemia, we don’t measure the severity
according to stages, because it is in the blood and it is
though you are targeting for say, lung cancer, chemotherapy everywhere. So we have to look at the chromosome,
can affect the stem cells in the bone marrow. Subsequently
the genetic makeup of the leukemia cell and based on
after a few years of receiving chemotherapy – the timeframe those tests whether they are positive or negative, then
is usually 3 to 5 years – these patients can develop leukemia. we stratify them according to high risk, intermediate
In South-east Asia, we don’t really know the exact prevalence risk and low risk. For the high risk one, there is
as there is no proper database or registry capturing definitely a chance of relapse.
occurrences of such cancers. In Singapore, it is mandatory by
the government to report every single cancer – be that lung What are your current research interests
cancer or leukemia. However, Singapore is a small country in an academic sense? More so, give us an
and it is not a good reflection of the overall situation of account of your roles as an undergraduate
South-east Asia. and post-graduate teacher, lecturer and
So, can we say that the incidences of blood mentor?
Currently, I teach the hematology specialist trainees; I
cancer are low? am part of the committee under the Ministry of Health
So let’s take Singapore as an example, if we look at oversee the residents (the hematology specialist
to
lymphoma, it is the fourth most common cancer. Lung cancer, trainees) and we also conduct the specialist exams. In
breast cancer, colon cancer and after that the most common terms of research interests, I am the chairman of one
is lymphoma cancer. of the boards of the SingHealth ethics committee.
We still run clinical trials in Parkway Cancer Center,
Give us an account of your work with but now we usually participate in trials that are
SingHealth-DUKE Blood Cancer Center. More initiated by the pharmaceutical companies
so, an account of your experience with that themselves.
Pharmaceutical- sponsored/ Investigator-
initiated Clinical Trials. What are the risk-factors associated with
I was the director for the lymphoma program at the conducting a hematopoietic stem cell
SingHealth-DUKE Blood Cancer Center. My main interest transplantation? At what stage of the
when I was working there was to bring new therapies at patient’s condition is this required and
early stages to patients. By early stage, I mean the drug what are the subsequent success rates?
hasn’t been commercialized yet. Hence, we try our best to When we do the stem cell transplantation, it’s not
bring these trials to Singapore. Now, companies that select only about injecting stem cells into the patient. You
centres for clinical trials feel that it may not be cost effective have to give them a very strong chemotherapy, just
to run these trials in Singapore because of the relatively
higher cost and smaller patient numbers. So we did not get before the stem cell infusion. Let’s say, a patient is
many of those trials but the way we got the drugs were to admitted today; first we will give them very strong
design our own trials where we can get the drug free, but we chemo for five or six days and let them rest for a day
or
have to apply for our own grants to fund it. That is the so. Then the stem cells will be given. The reason why
investigator-initiated trials and that’s how we got the drugs we give them strong chemotherapy for leukemia, is
to the patients. because the transplant is meant to be the last
Would you say that the costs are increasing because of tech? Do
see it increasing more in the future or do you see a radical
advancement in technology that will reduce the costs in the
future?
Yeah, I think the costs must get lower. It will become lower when there is
for a similar market share. Competition and regulation on how drugs are priced
competition from a few Pharma companies having the same kind of drug fighting
will hopefully ensure lower medical costs in the future.
What are the varied differences between leukemia and
Lymphoma? Which poses greater degree of risk? How can we
measure for any preventive steps?
Leukemia is a cancer that arises from the blood cells in the bone marrow (red
blood cells factory) and lymphoma is a cancer of the lymph nodes. Patients with
lymphoma can present with swelling of the lymph nodes under their arms, neck
and so on. Everyone has many, many lymph nodes but they are usually very tiny.
They are small houses for the immune cells to grow and mature, so they can
function normally. The lymph nodes can even filter
treatment that can cure the patient. That’s the purpose of the things, like cancer cells. That’s the reason why for
breast cancer, patients can have lymph nodes under
strong chemotherapy; to wipe out any remaining cancer cells. their arms due to the spread of breast cancer cells to
Another reason is to prepare the patient and bone marrow to the lymph nodes that drain the breast region.
Lymphoma, on the other hand is strictly different, the
receive the stem cells. These stem cells are the cells that will
go into the patient’s bone marrow and become a new immune cancer cells themselves are the lymph node cells. ..
I would say acute leukemia poses a great risk to
system. If the patient’s immune system is very active, they can
even reject those cells. That’s another reason for giving strong immediate health, because acute leukemia starts and
chemotherapy before the stem cells are infused. When I say grows very fast. The most dramatic one I have seen
was someone who two weeks before had a normal
‘prepare the body’ I mean, kill all the very active immune cells blood count, and two weeks later, the same test
in the patient, so to accept the stem cells. So, we are reducing showed the leukemia cells in the blood count – from
the patient’s immune system on purpose. And a new immune normal to haywire life threatening disease. That was
system is expected to grow within that period. During that the most dramatic. Of course it usually doesn’t
period, of course, there’s a risk of infection, risk of bleeding,
and another risk is the patient’s body rejects the donor’s cells. happen like that, but acute leukemia develops so
On the other hand, the donor cells that come in, they can also rapidly, it can immediately become life threatening.
attack the patient’s body. It is very complicated and the main There aren’t really preventive steps that can be taken.
risk of transplantation. In order to make sure a donor cell is There’s a loose association between smoking and
compatible with the patient we have to make sure that they acute leukemia, but then again smoking is related to
match. What we are matching is HLA type and not and not so many other health problems.
strictly the red cell groups (i.e. ABO blood groups) Not
everyone, even not all siblings will have matching HLA types. What’s one piece of advice you would give
Each sibling of the same parentage has about a 25% chance of to your patients?
matching. When I talk about acute leukemia and lymphoma, the
patient must understand when they are diagnosed
What is it like to treat cancer patients? How do with this. They need to have an exact diagnosis. Acute
you cope when a patient loses the battle against leukemia is a group of leukemia, it’s not only one
cancer? type; and lymphomas are a huge group of different
types, over 50 different kinds of lymphoma. So they
Treating cancer patients can be very rewarding and also very really need to know what type of lymphoma from the
sad; especially with acute leukemia. It’s because acute the 50 types is yours. Only then you can start treating.
leukemia is either very successful and is cured, but on the So once a patient is diagnosed, they really need a good
other hand, if you can’t control acute leukemia, the life diagnostic doctor, and the doctor must be able to tell
expectancy is very short. Sometimes it’s very difficult to cope you what type of leukemia is acting or what type of
with losses. Lymphoma they have. I will also say that hematology
According to you, what are the key healthcare has advanced so much with treatment in the last few
challenges of the 21st century? years. So when I treat patients with acute leukemia or
One of the key challenges is the rising costs of medical care. Lymphoma, of course we know that not every patient
Because if you look at the landscape of medical oncology and is a success, but the intention most of the time is the
hematology, you will see a lot of targeted therapy, cure. You know, there are certain very advanced types
immunotherapy and so on. These are very effective but they
come at a very, very high price. It’s an extremely high cost of of cancer where patients come in, the intention cannot
medication. So I think the cost and controlling the cost with be be to cure it any more because it’s too late. But for
a major challenge of the 21st century and moving ahead. blood cancer that’s not the case. The intention most of
the time is cure.