Tag Archives: LohGuanLye

Intraoperative Radiotherapy (IORT) A New Breast Cancer Treatment Innovation

November 10, 2017 EZ Malaysia Leave a comment

Dr. Teoh Mei Shi

Consultant Breast, Endocrine & General Surgeon

MBBS (India), MS (USM), Fellowship Breast Oncoplastic Surgery

Breast Cancer is the most common cancer amongst women in the world. Incidence of breast cancer is increasing and the lifetime risk of developing breast cancer in Malaysia is one in 15 women. In developed countries, the lifetime risk of developing breast cancer in women is as high as 1 in 8 women. With more awareness and screening for breast cancer, women are detecting breast cancers earlier, which are smaller and have better survival outcome.

Treatment for breast cancer has evolved significantly over the last few decades due to better understanding of the tumor biology and its behavior. This has led to better adjuvant therapy like systemic chemotherapy, radiation therapy, hormonal therapy and targeted therapy. For most of the earlier twentieth century, Halsted radical mastectomy was the standaradised operation for all stages of breast cancer resulting in poor cosmetic outcome. However, over the recent decades, breast conserving surgery (BCS) eg. Lumpectomy has become the popular alternative to mastectomy in the treatment of early breast cancer.

When detected early, the breast conserving surgery involves a lumpectomy followed by 4-6 weeks of external beam radiotherapy to the whole breast and boost to the tumor bed. This combined method has been proven to reduce local recurrence of breast cancer by 60-70%. However, the side effects of whole breast radiotherapy treatment can be detrimental eg. pain and oedema to the breast, skin fibrosis, fatigue and tiredness and in some cases, there can be associated radiation- induced lung injury and cardiac morbidity.

Over the last few years, a new innovative breast cancer therapy known as Intraoperative Radiation therapy (IORT) has become available using the Intrabeam technology. IORT delivers a single dose of radiation directly to the area where the tumor has been removed during surgery.The principle of this approach is to destroy the remaining cancer cells within the lumpectomy cavity where more than 90% of local recurrences usually occur close to the tumor bed.

The Intrabeam IORT is delivered using a miniaturized radiation applicator that is inserted and positioned into the lumpectomy cavity after removal of the tumor. A calculated low energy radiation dose is administered for 20-30mins after which the wound is closed surgically. The operation carries standard risks of bleeding and infection and slightly higher seroma collection comparable to normal breast surgery.

This technology is an excellent option for women having a lumpectomy or breast conserving surgery and is for individuals diagnosed with early-stage breast cancer. The IORT therapy may function as two options ie. as a boost therapy or as a single treatment. Patients are carefully selected and multidisciplinary discussion with breast surgeon and radiation oncologist is carried out to decide the best outcome for the patient.

IORT offers the following advantages:

Reduced radiation treatment time (single session vs 20-25 sessions) in candidates selected for surgery
Minimized radiation exposure to surrounding healthy breast tissue, underlying bones, lungs and heart.
Reduced daily trips to the radiotherapy centre and convenient for those staying very far away.
Same day radiotherapy treatment and no treatment delay for those going for chemotherapy after surgery
Provides additional radiotherapy “boost” for high-risk patients who need additional external beam radiation therapy.

The international TARGIT research group has been investigating this new method of delivery radiotherapy for breast cancer after lumpectomy since 1998. The trial compared Intrabeam IORT to standard external beam radiation therapy and found that both treatments were comparable and equally effective with an overall low breast cancer recurrence as well as better breast cancer survival rates. Women who had intraoperative radiotherapy had the advantage of fewer skin side-effects and better cosmetic outcome compared to women who had whole breast external beam radiotherapy.

Conclusion

Intrabeam IORT will be a technology of the future for breast cancer treatment. In properly selected cases, the patients can be offered an alternative option whereby they can receive a shorter dose treatment with lesser side-effects to the breast. It can also be time saving, cost-effective and offers the patient an overall better quality of life.

This treatment will be available at Loh Guan Lye Specialists Centre where a dedicated and trained team of Breast Surgeons and Radiation Oncologists can be consulted to see if you are eligible for the treatment.

Common Questions From Couples Desiring IVF Programme

June 30, 2017 EZ Malaysia Leave a comment

Mr. Sim Seng Keat

Obstetrician & Gynaecologist / Fertility Specialist

1. Do you really need IVF programme to get pregnant?

Though it is also equally important that IVF should not be attempted without good justification, it should not be delayed very long either. Unfortunately the public’s idea that IVF to be tried as the last resort has delayed the decision making of many couples and hence most of them have reached their late thirties and even late forties before trying for IVF- assisted pregnancy.

Attempting to try for IVF must be a timely decision by the couples. Incorporating fertility status into annual checkup early in your married life will give a perspective idea about your fertility status. Then it will be more realistic to decide on when to enlist for fertility assistance and /or when to have a timely attempt for IVF amidst your busy daily routine.

The following time proven approaches still stand true:

It is better to have the first child early
Couple should decide to go for a checkup with Fertility specialist when there is failure of pregnancy after actively attempting for one year in women less than 35 years old and half a year of active attempt in women more than 35 years old.
It is strongly recommended to have early fertility consultation in couple with preexisting gynecological or male fertility related disorders.

2. How long is the duration of IVF injections and is it easy to self-administer injections?

Though earlier IVF injection schedules were longer & lasted for 4-5 weeks, with the advent of recent methodologies, newer injection schedules are shorter lasting which is less than two weeks. It has been proven that the chance of having successful IVF pregnancy has been equally good even in couple adopting shorter injection schedule!

This has not only reduced the stress and time spent in keeping to the schedule but also the number of injections. Moreover, the shorter injection schedules tend to be equally flexible to plan for egg-retrieval procedures and better in reducing the risk of ovarian hyper stimulation.

With the development of newer user friendly injection pens, self-administration of injections deliver dosages precisely and are also easier to use reducing the likelihood of errors and mistakes.

3. Is it possible to plan / prefix earlier for all appointment dates for couples adopting to go for attempt of IVF pregnancy?

Yes, all the appointment dates from the first day of the injection to the end of IVF procedure including the dates of blood tests could be planned and fixed much in advance and can be made known to the couple even during their first day of consultation. This usually helps the couple to plan their leave or allocate time and be available for all appointments in the midst of their busy work commitments, holiday plans and family obligations.

Treatment plan includes 6 appointments, first three are for collection of medications after pelvic ultrasound examinations. Fourth appointment is for semen collection from husband and day case admission for wife for egg retrieval. Fifth appointment is for admission as day case for wife to have the embryo transfer and sixth appointment is for wife to have the blood test to detect pregnancy status.

Hence husband must be present for the fourth appointment unless he has already preserved frozen sperms to be used for IVF procedures. It is needless to say wife must be present for all appointments. It is highly recommended to have the presence of an accompanying adult with the wife for day-care admissions for fourth and fifth appointments since these admissions are for the wife to undergo minor procedures.

Schedule of appointments depend on the day of onset of menstruation and hence for women with regular menstrual cycles, appointment dates are very much predictable and easier to fix.

Women with irregular menstrual cycles require oral contraceptives or progesterone-only pills to induce menstruation to get the date of onset of menstruation to plan for all future appointments.

4. How is the egg retrieval procedure performed? How true are hear-says about pain during and after undergoing egg retrieval procedures?

From the feedback from many patients, egg retrieval procedures are relatively painless though very few of them might experience minor lower abdominal discomfort for a shorter duration after the procedure.

Most egg retrieval procedures are performed easily with minor sedation though some of them might need light general anaesthesia or spinal anaesthesia.

Newer well designed needle tips are very small in diameter with finer needles causing lesser trauma and as such these procedures are relatively painless. Hence most of them do not even require paracetamol for pain relief though very few patients require paracetamol for a day or two.

5. Are these dreadful stories of Ovarian Hyper Stimulation (OHSS) true?

5 to 20% of women undergoing IVF procedures with longer injection schedules develop OHSS while chances of developing OHSS is much lesser in women with shorter injection schedules. OHSS developing after egg retrieval in women produces a bloated abdomen, poor oral intake, shortness of breath, abdominal pain, reduced urine output, nausea and vomiting.

Occurrence of OHSS can be reduced to less than 1% by the introduction of deliberate efforts such as use of agonist medications as triggers and with the approach of new technique of freeze-all embryos.

With the advent of well researched methodologies the incidence of OHSS has reduced significantly while the success rate of IVF pregnancy has increased satisfactorily.

6. What are the factors to be considered before deciding the chances for getting successful pregnancy after IVF procedures?

Everyone would like to know the chances of getting pregnant through IVF procedures though there are many factors that decide the success after such procedures.

Basically in sub fertile women of less than 35 years, transfer of two good quality embryos in fresh IVF attempt confers more than half the chance of getting pregnant. In established IVF centre with good “Freezing and Thawing Program”, transfer of 2 good quality thawed embryos also provides good outcome.

80% of fertile couple conceive naturally through active attempts within a period of 12 months.

Direct comparison of chances of getting pregnant of sub fertile and fertile couple might not be appropriate. It is very encouraging and overwhelming to note the uptrend in the increasing pregnancy rates after fertility techniques, with the advent of research proven technologies and procedures.

EZ 46 - Medicines & Sciences, EZ 61 (2), Medicines & Sciences

Statin, to use or not to use, That’s the question!

April 7, 2017 EZ Malaysia Leave a comment

Dr. Goh Eng Leong

Consultant Cardiologist & Physician

B.Sc. (Med.), M.D. (UKM), M. Med. (S’pore), MRCP (UK), FNHAM, AM

Since 1950s, high cholesterol (LDL – C : Low – Density Lipoprotein Cholesterol) has been identified as a major risk factor for the development of atherosclerotic diseases (ischemic heart disease, stroke and peripheral vessel disease).

Many epidemiological and interventional studies have provided robust evidence to the association between high cholesterol and atherosclerotic disease, which is the number one killer worldwide.

To combat this deadly disease, the quest for drugs that could reduce cholesterol has begun since 1960s. Of all the investigational drugs developed, Statin emerged to be the first established lipid lowering medication that is able to reduce cholesterol effectively.

In 1976, the Japanese biochemist Akira Endo isolated a factor from the fungus Penicillium citrinum which he developed into the first Statin. He named it Compactin or Mevastatin.

In 1978, Alfred Alberts at Merck Research Laboratories discovered a potent inhibitor of HMG – CoA reductase in a fermentation broth of Aspergillus terreus, which was named Lovastatin, Mevinolin or Monacolin K.

Since Lovastatin had been commercialized, six other statins – two semi – synthetic statins (simvastatin and pravastatin) and four synthetic statins (Fluvastatin, Rosuvastatin and Pitavastatin and Atorvastatin) – have been introduced to the market over the years.

As a practicing cardiologist, I think Statin is the most controversial medication in the history of medicine. While many mega – clinical trials have proven the benefits of Statins in term of reduction of cardiovascular mortality and morbidity, a lot of negative publicity on Statins have demonised these medications. Social medias are the major channel where the fallacies of Statins spread virally. The minor side effects of Statins are exaggerated and the therapeutic effect of Statins are covered. These type of negative and bias reports on Statins have caused confusion not only to general public but also to physicians.

I hope I can put the facts of Statins in its correct perspective by presenting the scientific evidence to dispel the confusion and misunderstanding. As Socrates’s famous saying : there is only one good – KNOWLEDGE ; and one evil – IGNORANCE.

LDL and Statin : The irrefutable truth – proven in many mega clinical trials

High LDL cholesterol causes cardiovascular disease. There is a strong and graded positive association between LDL cholesterol and the risk of cardiovascular disease. This association applies to men and women, and to those with or without established cardiovascular disease. A 1% increase in LDL cholesterol is associated with a > 2% increase in coronary artery disease over 6 years.
Reduction of LDL will reduce mortality and morbidity, the lower LDL better the clinical outcome. Meta – analysis of many Statin trials has showed a dose dependent relative reduction in cardiovascular disease with LDL reduction. Every 1 mol / L reduction in LDL cholesterol is translated into a 20 – 25% reduction in cardiovascular disease mortality.
Statin is the mainstay of treatment to reduce LDL and cardiovascular mortality and morbidity.
Statin causes atherosclerotic plaque regression.
Bad publicity on Statin has caused a reduction in the usage of Statin by patients and prescription of Statin by physicians. The decline in the use of Statin translated into increase in CV morbidity and even death. The benefit of cardiovascular protection of Statins really outweighs the small risk of side effects. Let us have a closer look on the side effects of Statins.

Side effects of Statin

Muscle pain :
- Myalgia : 5%, reversible. The problem of muscle pain can be reduced by monitoring of certain risk factors (old age, kidney impairment and concomitant administration of some medications which may cause drug – drug interaction)
- Rhabdomyolysis – severe form of muscle breakdown with acute kidney injury is very rare : 1 in 100,000
Hepatotoxicity : Side effects on liver
- Asymptomatic raise in liver enzyme ALT occurs in 3% of patients.
- Severe acute liver failure is also very rare – 1 in 100,000
Cancer : no increase in risk. In fact Statin may confer protection from cancer mortality
Dementia and cognition function loss : no increase in risk. In fact Statin may reduce dementia risk.
Hemorrhagic stroke : small risk. But Statin reduces overall stroke risk.
Diabetes :
- 5 – 10% risk
- But the cardiovascular protection is much more than this small diabetic risk.
- Even if patients develop diabetes they still live longer and healthier compared with those who have high LDL not taking Statin and no Stain induced diabetes.
- High risk factors of Statin induced diabetes are high baseline blood sugar and metabolic syndrome.
- Patients who are talking Statins are encouraged to live a healthy lifestyle to reduce the risk of diabetes

Understand these facts of Statins will help us to dispel Statin – phobia. Statins should definitely not be prescribed for all. But the high risk patients should take Statin to reduce the cardiovascular risk. The benefit of Statins should not be denied in these group of high risk patients just because of fear of side effects.

I encourage readers to discuss any issues on Statin use with respective physicians if there is any further doubt.

Cover Story, EZ 44

Loh Guan Lye Specialists Centre 41 Years of Caring & Healing the Story Goes On…

October 19, 2016 EZ Malaysia Leave a comment

Dr Mary Quah

CEO of LohGuanLye Specialists Centre.

“from Aspiration to Reality & Excellence”

Like many successful stories, it all started with a dream. The dream of the Late Datuk Dr Loh Guan Lye was to set up a private hospital ‘to reciprocate the support given to him by his patients and well-wishers over the years, and to also complement the increasingly overcrowded facilities of government hospitals. The hospital is a place where the public can seek specialist care and where specialists can practise good medicine’. The hospital then was named ‘The Specialists Centre’ which was later renamed LohGuanLye Specialists Centre (LSC) in1996, in honour of the late Datuk Dr Loh Guan Lye. The dream started in 1975 and the Centre is now 41 years old. Till today it is still family-owned and has been caring for more than three generations of patients.

The son, Mr Kelvin H Y Loh, Chairman and Managing Director, and the grandson, Mr Nicholas S W Loh, Executive Director, are also both successful Consultant Obstetrician and Gynaecologists practising in the hospital.

The unique story then continues with Dr Mary Quah, Chief Executive Officer, the driving force behind LSC, a non-family member, managing a family business in a One Big LSC Family way. She joined LSC in 1982 and has worked with three generations of the Loh family.

A visionary leader who leads with passion, Dr Mary Quah then made the dream into a vision and it became a reality with a lot of hard work and effort, dedication and commitment from everyone in LSC, making LSC to what it is today, one of the leading healthcare in the region, leading into the future.

In response to the earnest requests of patients for additional facilities and services, especially for cancer treatment, Dr Mary Quah was instrumental in the planning and development of the new wing in Macalister Road, from the architectural design and layout to the interior design and even the colour scheme with patient’s comfort in mind. With this new wing, which was completed in 2009, LSC now has three wings, namely the Main Wing, Women and Children’s Wing and the Diagnostic Wing, offering a very comprehensive range of facilities and services including the treatment of cancer and heart diseases.

With her leadership, LSC has overcome many challenges and has come out stronger than ever. LSC has also achieved many milestones, accreditations, various awards and accolades internationally and locally.

According to Dr Mary Quah, the culture of LSC is one of putting our heart and soul into everything we do, be proud of what we are doing and do our best. We strive to be the best and care for our patients with the best in human resource and technology to ensure good outcome.

Dr Mary Quah always believes in putting people first as ‘it’s the people who move an organisation’. When a leader leads an organisation with passion, and always does the right thing for the organisation and its people……that is the key success factor. Some of her inspiring phrases to the team include….’the business belongs to you, you take care of the business, we take care of you, the organisation grows, you grow’, ‘everybody in this organisation is important, we do not employ unimportant people’, ‘customise your handling of people’. She takes pride in her team and is thankful to have such a caring team of dedicated and committed Management, Doctors and Staff in the organisation, as well as Mr Kelvin Loh and Mr Nicholas Loh for believing in the team and their support.

Most of all she is very thankful to all LSC patients for their trust and continuing support and for making LSC their ‘Hospital of Choice’.