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Supportive and Palliative Care Research

Our overall aim is to improve the quality of life of patients and their caregivers throughout the disease trajectory – from primary treatment to the survivorship phase or end-of-life care. In particular, our goal is to reduce symptoms and treatmentrelated toxicities to optimise health and well-being. Novel drug therapeutics are not delivered in isolation, but within health systems. As such, innovative and scalable models of care need to be developed to maximise the in vivo benefits of cancer treatment. To evaluate these novel models of care, we also aim to develop and validate culturally relevant instruments to rigorously measure health-related outcomes.

OUR SPECIFIC AIMS ARE TO DEVELOP:

  • EVIDENCE-BASED INTERVENTIONS TO RELIEVE PHYSICAL AND PSYCHOLOGICAL SYMPTOMS:
    - Evaluate determinants and develop effective interventions for physical and psychosocial symptoms in cancer patients and survivors.

  • SCALABLE MODELS OF CARE BASED ON HEALTH SERVICES RESEARCH:
    - Develop, test, and implement scalable models of care that deliver integrated care to cancer patients and survivors across different care settings.

  • CULTURALLY RELEVANT OUTCOME MEASURES FOR ONCOLOGY RESEARCH:
    - Develop and validate outcome measures that are psychometrically valid and reliable for cancer patients and their caregivers in the Asian context.

  • EDUCATION IN ONCOLOGY, SUPPORTIVE CARE, AND PALLIATIVE CARE:
    - Design and implement a holistic and mentored programme for the development of research and interest in oncology, supportive care, and palliative care amongst medical students and junior doctors.

SPECIFIC AIM 1: DEVELOP EVIDENCE-BASED INTERVENTIONS TO RELIEVE PHYSICAL AND PSYCHOLOGICAL SYMPTOMS

PHYSICAL SYMPTOMS
Cancer patients and cancer survivors are living longer with a greater burden of symptoms, which adversely affect quality of life. The rapidly increasing armamentarium of new cancer treatments has resulted in not only better control of cancer over a longer time, but also an expanding range of cancer-related symptoms and complications, as well as treatment-related toxicities over an extended period.

Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating symptom that is highly prevalent among patients receiving chemotherapy drugs such as taxanes and platinum agents. In addition, chemotherapy-associated cognitive
impairment (“chemobrain”) and cancer-related fatigue are common symptoms experienced by survivors of cancer. Unfortunately, the mechanisms underlying these conditions are poorly understood, and hence effective treatments are lacking for managing these long-term toxicities. Our group is currently running a clinical trial to evaluate the effectiveness of using regional cryotherapy to prevent the onset and severity of CIPN. Furthermore, we are currently conducting large cohort studies to investigate the biochemical, genetic, and clinical predictors of chemobrain and cancer-related fatigue in patients with breast cancer and in adolescent and young adult cancer survivors. We are also in the midst of developing clinical trials (pharmacological and non-pharmacological) to mitigate these symptoms.

PSYCHOLOGICAL SYMPTOMS
Psycho-oncological care aims to address patients’ mood and worries as they come to terms with their diagnosis, undergo treatment, transition into survivorship, or prepare for end of life. Although psychological care in supportive and palliative services is being increasingly recognised, it is still in its infancy in Singapore. We are testing several cognitive behavioural therapy (CBT)-based interventions for patients and their caregivers that aim to help them cope and find a sense of meaning in their life despite their cancer-related suffering. We recently assessed the feasibility and acceptability of such a pilot programme for advanced breast cancer patients that yielded promising results; we are now undertaking a similar programme with advanced colorectal cancer patients. We are also about to launch a programme to assist patients in the earlier stages of cancer and their spouses with issues in intimacy and marital relationships due to disease- and treatment-related sequelae. Our aim for the next 2 to 3 years is to test the efficacy of these types of interventions to understand how psychological care may impact patient outcomes and become a standard part of supportive and palliative services locally.

An essential aspect of holistic care is the effective management of patients as persons. Rooted in the ethical concepts of selfhood, the study of personhood through the “Ring Theory of Personhood” facilitates a more culturally sensitive understanding of patients, their families, and their choices. In addition, to ensure that effective care determinations are made for patients at the end of life, we are also studying how multidisciplinary teams can provide input into these care determinations, particularly when patients may lack such capacity. Studies pertaining to this Welfare Model and the Ring Theory of Personhood are ongoing and remain at the heart of the ethics research at the Centre.

SPECIFIC AIM 2: DEVELOP SCALABLE MODELS OF CARE BASED ON HEALTH SERVICES RESEARCH

Clinical care is currently fragmented across disciplines, specialties, and settings. In our local context, it is also heavily based in institutional and specialist care settings. Innovative and scalable models of healthcare service delivery need to be developed to meet the supportive and palliative care needs of cancer patients throughout the disease trajectory, during treatment, and into the survivorship phase or advanced cancer care. Cancer survivors usually consult their oncologists, who may be based at various cancer centres, for their supportive and survivorship care needs, with cancer surveillance being the primary focus of survivorship care. With the increasing cancer
incidence and survival rates, the existing infrastructure in Singapore cannot meet the increasing demand for cancer supportive and survivorship care services. Hence, our team is currently studying the feasibility of conducting a share-care model with community partners for cancer survivorship.

We are also developing new models of care for advanced cancer patients. For the inpatient hospital setting, we are conducting a stepped-wedge cluster randomised trial of an integrated palliative and medical oncology model of care for advanced cancer patients who have an unplanned admission to hospital. In the outpatient setting, we recently completed a pilot study on an outpatient palliative care nurse intervention for advanced lung cancer patients. We are now looking to further develop the intervention before evaluations are conducted using a larger scale trial.

SPECIFIC AIM 3: DEVELOP CULTURALLY RELEVANT OUTCOME MEASURES FOR ONCOLOGY RESEARCH

Patient- and caregiver-centred outcomes, such as health-related quality of life and family satisfaction with care, are important measurable outcomes in supportive and palliative care. We are translating into Chinese and validating two outcome measures: the Integrated Palliative care Outcome Scale (IPOS) and the Family Satisfaction with End-of-Life Care (FAMCARE) scale. These translated and validated outcome measures will be utilised in the evaluation of supportive and palliative care health service interventions.

SPECIFIC AIM 4: DEVELOP EDUCATION IN ONCOLOGY, SUPPORTIVE CARE, AND PALLIATIVE CARE

The Palliative Medicine Initiative is an ongoing mentored research project that sees medical students and junior doctors mentored through the research and publications in palliative care, ethics, medical education, and oncology topics. In this programme, up to 20 medical students and junior doctors are regularly mentored by senior oncologists and palliative medicine physicians in clinical and ethical case reports, reviews of education practices, and programmes and research topics in a variety of cancer-related topics.

CONCLUSION
Over the next 2 to 3 years, we plan to continue developing interventions and models of care to improve outcomes for both cancer survivors and advanced cancer patients, particularly in the community setting. This will ensure that the excellent supportive and palliative care that is initiated in the tertiary cancer care institution will be continued in the community.

Researchers:

​A/Prof Alexandre CHAN​A/Prof Lalit KRISHNA​Dr. Kiley LOH​Dr. Patricia NEO
​Dr. Shirlyn NEO​Nurse Clinician Yung Ying TAN​Dr. Irene TEO​Dr. Grace YANG
​Dr. Alethea YEE