In Singapore and around the world, the incidence of cancer is climbing – and fast. Among the three main ethnic groups here, the Chinese are the hardest hit. Can recent advances in cancer prevention, detection and treatment halt the march of the disease?

THE words seemed to toll a death sentence – cancer, malignancy, mastectomy – but Mrs Cynthia Fong had no patience for disease or dying.

Her thoughts were on life and living. There was, after all, so much to live for.

Her husband’s safety consultancy business, which she helps out in, was doing well. “Our two daughters were in their 20s and starting their careers,” adds Mrs Fong, 55.

“My husband and I were looking forward to spending more time with each other and doing volunteer work.”

The diagnosis, when it came, seemed especially cruel in the light of the more carefree life that was beckoning.

Mrs Fong can pinpoint all too vividly just when the harrowing process began.

Early last year, she and her husband Fong Kim Choy, 58, joined some friends from the Barker Road Methodist Church on a mission trip to Myanmar.

Photos from that trip show her healthy, energetic, smiling. But upon her return, she felt something in her right breast: “I was showering and suddenly I felt this lump I had never felt before.”

Surely it couldn’t be cancer. After all, a mammogram less than two years earlier had delivered a clean bill of health. But, not wanting to take any chances, she went for another mammogram. The X-ray showed a suspicious 3cm mass in her right breast.

Next came a biopsy. She hoped it would be a false alarm but the results indicated it was all too real – Stage II/III cancer, meaning it had spread to lymph nodes in her armpits.

Worse, the cancer tested positive for a protein called human epidermal growth factor receptor 2 (HER2).

Her oncologist, Dr Ang Peng Tiam, the medical director of Parkway Cancer Centre, told her that HER2-positive cancers tend to be more aggressive than other types of breast cancers. They spread faster and tend to recur.

Within the week, she underwent surgery to remove her right breast and some 27 lymph nodes from her right armpit.

She was then put on the drug trastuzumab, more commonly known as Herceptin, which specifically targets HER2. It kills the cancer cells and decreases the risk of recurrence by as much as half, but costs about $4,000 a shot. Her treatment includes going for a total of 17 of these shots, once every three weeks.

Now almost a year later – after eight rounds of chemotherapy and 11 shots of Herceptin – her cancer appears to be in remission. She has become a lot more philosophical about life, though she still wonders why the disease chose her.

“I am very lucky to have beaten cancer for now and to be able to afford the treatment, but every once in a while I wonder: Why me?”

It could happen to you
But looking at the cold, hard statistics and the sheer incidence of cancer in Singapore today, the more compelling question is: Why not her?

Every day, about two dozen people here are diagnosed with cancer.

About a dozen die of cancer every day.

Each year, close to 9,000 new cases of cancer are found. Half of the victims die of it.

Crunching the numbers further, epidemiologist Chia Kee Seng of the National University of Singapore (NUS) Yong Loo Lin School of Medicine says: “Going by the statistics now, one in four of us will die of cancer.”

The incidence of cancer as a proportion of the population is rising at an alarming rate. Prof Chia pulls out figures from the Singapore Cancer Registry report to compare five-year incidence rates.



Between 1968 and 1972, about 12,000 Singaporeans were diagnosed with cancer, an incidence rate of 135 per 100,000 males and 103 per 100,000 females.

Fast-forward to the five-year period between 1998 and 2002, and the number of new cases tripled to more than 38,000. And the incidence rate shot up 70 per cent for males to 231 per 100,000 and more than doubled for females to 240 per 100,000.

The sharp rise has been largely attributable to the dramatic increase in breast cancer in women and colorectal cancer in both sexes, he says.

He also raises a red flag – the significantly higher rate of the disease among the Chinese here.

The Cancer Registry’s interim report recorded 43,424 new cases of cancer between 2002 and 2006. About 85 per cent – or 37,125 – were Chinese, even though they form only 74 per cent of the population here.

Only 9 per cent – or 3,807 – of the recorded cases were Malays and 4 per cent – 1,843 – were Indians.

Prof Chia crunches the data further, pointing out that the numbers for Chinese translate to an age-standardised incidence rate of 250 per 100,000 for males and 209 per 100,000 for females.

For Malay males, the crude incidence rate is only 165 and for females it is 177. For Indians, it is 113 for males and 128 for females.

“This is significant. Compared with the Malays and Indians, the Chinese are 11/2 times to two times more likely to be hit by some form of cancer,” he says.

This raises the key question: What accounts for the increased incidence of cancer among the Chinese?

Are Chinese genes or modern lifestyles to blame? Cancer research seems to weigh in more on lifestyle than genetic predisposition.

“It is too short a time for any kind of genetic evolution. So it must be due to our modern lifestyle - the kind of food we eat and the more sedentary lifestyle we lead,” says Prof Chia.

That could partly explain why the rate of cancer is higher among the Chinese here, who tend to be socio-economically better off than other races.

But he does not totally rule out the role that genes play: “Our genetic makeup may determine the degree of harm caused by environmental factors.”

So while there are more smokers among the Malays than Chinese here (23.2 per cent of Malays smoke daily, while only 12.3 per cent of Chinese do so), the Chinese male is twice as likely to be hit by
lung cancer. Between 1998 and 2002, the age-adjusted incidence rate of lung cancer among Chinese males was 52 per 100,000, while for the Malays it was 35 per 100,000.

“This could be because smoking may have a greater effect in triggering genetic mutations in the Chinese,” says Prof Chia.

But whatever one’s ethnic group, Singaporeans of all races can take heart in the fact that death rates for several cancers are falling, thanks to earlier detection of tumours and advances in treatment.

As Prof Chia says: “When we see cancer early, we have a chance to fight it.” Over the past 30 years, cancer survival rates have been boosted by earlier and more sophisticated means of detection.

Since the Pap smear – a simple swab of the cervix for pre-cancerous and cancerous cells – became part of routine screening for many women here, incidence and deaths due to cervical cancer have fallen and will continue to fall, says Prof Chia.

Even though the incidence of breast cancer is rising, five-year survival rates for this condition have improved as the use of mammography ensures that the disease is detected earlier. Prof Chia notes that
five-year overall survival has improved from 46 per cent in the 1970s to 76 per cent currently.

But other body parts – the lungs and pancreas, for example – are less accessible and harder to monitor. So their malignancies are far more deadly.

But however advanced the detection methods, doctors note many Singaporeans just do not screen themselves for cancer. It could be due to the costs involved – colonoscopies can cost over $800 each
– or the fear of dreaded news, but many people are either ignorant of, or simply ignore, these life-saving actions, believing cancer will not happen to them.

Singapore Cancer Society chairman Koo Wen Hsin urges the authorities to make cancer screening more affordable and to allow people to use Medisave to cover the cost.

At present, Medisave cannot be used for health screenings, including cancer screening.

Health Minister Khaw Boon Wan recently wrote on his blog that his ministry will study the use of Medisave to pay for health screenings. He had expressed concern that unethical providers may encourage people to go for expensive health screenings of dubious value, which would deplete their Medisave accounts.

But Associate Professor Koo, who is also deputy director of the National Cancer Centre Singapore, argues: “For cancer patients, most of the medical expenses are incurred towards the end-stage of their lives. But if you can catch the disease early, that will not only reduce the pain and suffering but also save lives and the nation’s expenses on health care.”

Nipping cancer in the bud But is it possible to stop cancer in its tracks in the first place – even before cells mutate to embark on their malignant mission?

On this, research offers much hope, says NUS Associate Professor Koh Woon Puay. Prof Koh, who heads a large-scale study looking at causes of diseases including cancer among Chinese, says a number
of different types of environmental factors have been established as known causes of cancer.

“Some of these causes are well established. Smoking, for example, is the chief cause of lung cancer, and is also implicated in many other cancers. Heavy alcohol drinking has been linked to certain cancers such as that of the liver, oesophagus, and even breast and colon.

“Research has also linked specific viruses to certain cancers, leading to the development of vaccines to target these viruses.”

She is referring to vaccines against hepatitis B, especially in Asia, which could soon cut deaths from liver cancer. Doctors also expect fewer cases of cervical cancers with the introduction of a vaccine
against the human papillomavirus (HPV).

Prof Koh adds that as more of these causes are researched and identified, more can be done to warn people to avoid harmful substances or change habits.

But what gets her excited is the mountain of evidence that is accumulating that suggests that food and nutrition and physical activity can hinder the cancer process.

“There is increased evidence that specific diets, foods and exercise can and do protect against cancer, not only before the process starts, but also afterwards,” she says, pointing to the strong links that several studies including hers have established between specific foods and cancer.

“For example, a diet with high intake of soya, vegetables and fruits has been linked to lesser incidence of breast cancer among post-menopausal Chinese women in the Singapore Chinese Health Study.

In contrast, what has been considered ‘a Westernised diet’ with high content of meat and refined grain has been linked to higher rates of colorectal cancer in United States-based studies.

“Of course, researchers have yet to understand it fully – like how exactly they offer protection against cancer or how they interact with other foods or genes; why the same food taken may offer more protection for one person but not another. But research is ongoing and every day we are a little closer to understanding how different foods protect a person from cancer or cause it.”

Mrs Fong’s doctor, Dr Ang, who has been treating cancer patients for 23 years, says that genetic research into cancer has also enabled doctors to save more lives.

He explains that research has helped doctors understand more clearly what happens when cells turn cancerous, right down to identifying the gene mutations that lead to cancer cells dividing unchecked.

“The latest generation of treatment exploits our knowledge of what happens within cancerous cells,” he says.

Chemotherapy, where doctors use toxic drugs to poison tumours, and radiotherapy, where tumours are burned away with radiation, remain the main weapons against cancer today.

But newer, more sophisticated treatments for cancer are being used and they are making an impact. These include “small-molecule” drugs that interfere with the signals inside cancer cells.

“There are drugs that tell cancer cells to commit suicide or apoptose, drugs that block the growth of new blood vessels around a tumour so that the tumour starves,” says Dr Ang.

Avastin, or bevacizumab, is one such drug that has prolonged life for people with bowel cancer.

Herceptin or trastuzumab, used by Mrs Fong, is another drug which has given much better survival prospects to women with breast cancer.

“Once cancer was so feared, it was equated to dying. Now the disease is no longer an inevitable death sentence.

“We can treat it, control it and it can become a chronic condition that you have to manage like diabetes.”

Bleeding cash
But with so-called miracle drugs like Herceptin costing as much as $4,000 a shot, there is the question of affordability.

Cancer survivors say cancer treatment, which can amount to tens of thousands of dollars, can easily drain their Medisave savings as well as the accounts of their spouses and family members. MediShield insurance can also be used, but there are limits on how much will be paid out.

That is why several welcomed the Health Ministry’s recent  announcement that it was looking into using Medifund to help middle-income patients pay for very expensive drugs – a major shift from its current stand of helping only the very poor. Medifund was set up in April 1993 to help needy Singaporeans who could not afford to pay medical bills.

The Singapore Cancer Society, which has its own programme to help needy patients, says it gets about 40 requests a month from patients who need help paying for their treatment.

Its chairman, Prof Koo, says he welcomes the proposal to extend Medifund help, as long as proper guidelines and frequent reviews are in place to “prevent wastage of precious public funds on treatment
that is futile”.

He says some cost-benefit analysis would have to be done: “For example, $100,000 to cure a child’s leukaemia is better value for money, than $10,000 to prolong a 70-year-old lung cancer patient’s life for two months.”

Doctors including Dr Ang advise Singaporeans to buy insurance coverage while they are healthy and to ensure that they have good coverage for critical illnesses such as cancer.

Mrs Fong, who wiped out the bulk of her own and her husband’s Medisave, health insurance schemes and family’s savings, now urges her friends to insure themselves while they are healthy. The price tag for her new lease on life so far: about $100,000. And she still has to fork out at least $30,000 more for her shots.

But her prognosis is good. Dr Ang says: “Thanks to Herceptin, her cancer is beaten back. I am optimistic that she will be completely cured.”