A Detailed Guide To Radiotherapy Treatments In Singapore

Medically reviewed by Dr Johann Tang, Senior Consultant Radiation Oncologist

Part 1: The Importance Of Radiotherapy

1.1 Introducing Radiotherapy

Cancer is an increasingly common condition that affects people across the globe. In Singapore alone, cancer affects approximately 1 in 4 people in their lifetime, and comes in many forms such as breast, prostate, lung, cervical, and brain cancer, amongst others. With the lethality of cancer, it is always essential for early detection and diagnosis, which facilitates effective treatments such as radiotherapy, also known as radiation therapy.

Radiation therapy in Singapore is a key method in treating cancer, utilising various means to deliver high-energy particles such as X-rays, gamma rays, protons, or electrons into the body to destroy or damage cancer cells while minimising damage to nearby healthy tissue. Radiation damages the DNA of cancerous cells, preventing them from growing and dividing and causing them to break down. While healthy cells nearby may also be affected, they possess self-repair abilities which cancer cells lack, allowing them to grow and return to healthy functioning with time.

The radiotherapy treatment prescribed differs from patient to patient. For some patients in Singapore, radiation therapy is the only required cancer treatment in the form of curative radiotherapy, and delivers effective results for early stages of cancer such as nose and prostate cancer, as well as for brain tumours. In the majority of cases, it is also used in conjunction with other treatments such as chemotherapy and surgery to increase the likelihood of a successful treatment.

Radiotherapy is also utilised in preparation for surgery, such as neo-adjuvant radiotherapy where it is used to shrink the size of the tumour to make it easier for surgical removal; or adjuvant radiotherapy that follows up after surgery to kill any remaining cancer cells and reduce the likelihood of the tumour returning. For situations where the cancer has metastasied and spread through the body, radiotherapy may be used to ease symptoms, in the case of palliative treatments. It can help by shrinking tumours to reduce pain and other related symptoms, such as breathing issues or loss of bowel and bladder control, helping improve one’s quality of life.

There are four main types of radiation therapy used in Singapore. The most common is external beam radiotherapy (EBRT), where a machine is utilised to carefully direct and focus beams of radiation at the cancer. Another treatment option is utilising radiotherapy implants, also known as brachytherapy; where small pieces of radioactive material are temporarily or permanently placed inside one’s body near the cancer. The type of radiation therapy recommended for patients depends on various factors, such as the type of cancer being presented, tumour location, as well as potential side effects. Another form of brachytherapy is the use of high dose rate brachytherapy (HDR) often used in the treatment of cervix, endometrial, prostate, and breast cancer.

A novel alternative to EBRT treatments in Singapore, proton therapy utilises a stream of positively-charged protons instead to destroy cancer tumours. The main advantage of using proton particles is that they do not scatter radiation as they travel through the body, depositing their energy at the targeted tumour region. This allows for not only more effective focusing but also reduces damage to nearby healthy tissue, speeding up recovery and reducing side effects. Proton therapy is useful in treating tumours which have not spread and are near important parts of the body, such as the brain and spinal cord. It is also utilised in treating other cancers, such as CNS, head, neck, lung, and prostate cancer, amongst others.

1.2 Radiologists & Radiation Oncologists

Radiologists and radiation oncologists in Singapore play different roles in helping to treat patients. Radiologists specialise in utilising a variety of medical imaging techniques to diagnose and treat conditions, of which cancer is amongst them. All cancers require the input of radiologists to perform an imaging procedure for initial diagnosis, and they have various tools at their disposal such as computed tomography (CT) scans, X-rays, ultrasound, magnetic resonance imaging (MRI) scans, positron emission tomography (PET) scans, and mammograms, amongst others. After examining the medical images, radiologists interpret the results to provide their diagnosis, and work closely with other physicians to recommend an individualised treatment plan.

Radiation oncologists refer to physicians who specialise in treating cancer, and are in charge of determining the delivery method as well as dosage of radiation therapy to be delivered to a patient. With their speciality in various types of cancer, radiation oncologists oversee patients’ individualised radiation treatment plans, as well as effectively carrying out the treatment process and reviewing patients’ response and overall health across the entire duration.

With over 18 years of experience, Dr Tang is a highly experienced radiation oncologist based in Singapore. He underwent additional fellowships in both breast and prostate brachytherapy, as well as skin and paediatric care. Dr Tang was also a board member of various international oncology boards and societies, as well as a mentor to resident radiation doctors and authoring various publications. In addition to being frequently invited to give talks abroad, Dr Tang has also won several research prizes and held various research grants.

Dr Tang adopts an evidence-based and individualised approach to treating his patients at his clinic, which works in conjunction with advanced medical technology to minimise side effects and maximise treatment outcomes. Dr Tang and his team of experienced medical staff are fully committed to patient-centered care, reassuring patients by fully attending to their clinical needs and journeying with them from diagnosis to treatment completion.

Part 2: Various Radiotherapy Treatments

In this section, we will cover more about the various radiotherapy treatments that are carried out by radiation oncologists in Singapore, as well as their effectiveness in treating a wide range of cancers, such as prostate, cervical, breast, and lung, amongst others.

2.1 External Beam Radiation Therapy

External Beam Radiation Therapy (EBRT) is the most commonly used type of radiation therapy in Singapore, which focuses a beam of high-energy particles into the target region using a machine. There are many types of EBRT treatments available, such as 3D CRT, IMRT, VMAT, IGRT, stereotactic radiotherapy (SBRT), stereotactic radiosurgery (SRS), as well as proton therapy. Each of these treatments are designed to treat various types of cancers, and are pain-free as well as varying in treatment duration and dosage intensity.

3D Conformal External Beam Radiotherapy, also known as 3D CRT, is one of the most common forms of EBRT used by radiation oncologists in Singapore. As per its name, the radiation beams utilised in this treatment are generated by a linear accelerator, and customised to conform to the precise shape of the malignant tumour. The usage of imaging technologies such as MRI and PET scans helps to create a three-dimensional image of the tumour and nearby organs and tissues, allowing for a refined treatment plan and an effective dose of radiation to be administered. 3D CRT is routinely utilised in breast cancer treatment in Singapore, as well as treating lung cancer and brain tumours.

Intensity Modulated Radiation Therapy, or IMRT for short, utilises multiple smaller beams from different angles to deliver varying intensities of radiation to the affected region. Similarly to 3D CRT, IMRT utilises careful planning via imaging technologies to effectively determine the ideal dosage. The main goal of IMRT is to conform the radiation dosage strictly to the targeted tumour or area while reducing the exposure of radiation to healthy tissue. IMRT is frequently used in prostate cancer radiation treatment, as well as for head and neck cancers and pelvic tumours; and is useful in reducing treatment toxicity.

Volumetric Modulated Arc Therapy, or VMAT, builds upon IMRT by directing the high-energy beams in a series of arcs or angles via a rotating treatment machine. These arced beams allow radiation to precisely target tumours in difficult locations, such as those wrapped around organs. The main advantage of VMAT is its significantly shorter duration, with a treatment session being completed in less than two minutes on average. It is used in the treatment of prostate and lung cancers, along with head and neck cancers; and is also utilised for patients who may feel discomfort or pain when lying down for prolonged periods.

Image Guided Radiation Therapy (IGRT) utilises detailed scans using PET, MRI, or CT technology that are taken before and during the treatment session. It allows for the precise delivery of high-powered beams of radiation onto the tumour, maximising effectiveness and reducing damage to nearby healthy tissue. It is useful in treating cancers located close to sensitive structures or organs, or for tumours that move with respiration, such as head, neck, abdominal, pelvic, and lung cancers, amongst others. 

Stereotactic Body Radiation Therapy, or SBRT, delivers extremely precise and intense doses of radiation to treat both primary and metastatic tumours; utilising imaging technology to locate tumours accurately. It is often used as a radiation treatment for lung cancer, as well as smaller tumours located in the brain, spinal cord, and liver. An advantage of SBRT is the larger doses of radiation delivered during a single session, allowing for a greatly reduced overall treatment timeline, in addition to requiring no anesthesia as well as better treatment outcomes and fewer side effects.

Stereotactic Radiosurgery (SRS), is similar to SBRT in its delivery of highly precise and intense doses of radiation to treat small and localised brain tumours, as well as tumours affecting the central nervous system (CNS). It concentrates many small radiation beams onto the region where the tumour is, having minimal effect on the tissue it passes through while delivering its effectiveness at the area where the beams intersect. As a non-surgical procedure, it avoids the complications that may arise from surgery, such as haemorrhage, bleeding, infection, and the need for anesthesia.

There are two main modalities of stereotactic radiosurgery: Framed and Frameless SRS. Framed SRS is a more traditional approach which involves a metal cranial headframe that is secured onto the patient’s skull. Frameless SRS is non-invasive and uses a thermoplastic mask to secure onto the patient’s head, which provides greater comfort to the patient while maintaining effective treatment outcomes.

2.2 Brachytherapy

In contrast to EBRT which delivers radiation therapy via an external source, brachytherapy does so by inserting radioactive sources inside the patient’s body. Brachytherapy allows a higher total dose of radiation over a shorter time, and it is often used in conjunction with EBRT to increase the likelihood of fully destroying cancerous cells. It also features a shorter treatment timeline and reduced side effects, as well as the option for outpatient treatment to allow patients to go about their daily lives.

Brachytherapy treatment in Singapore can be either permanent or temporary. Permanent brachytherapy is generally carried out using implants such as radioactive seeds, which utilise a radiation source from iodine, palladium, cesium, or iridium and enclosed in a metallic capsule. This prevents the radioactive material from moving to other parts of the body. Temporary brachytherapy places radioactive material inside a catheter, needle, or applicator, which is then inserted into the affected region for a specific amount of time during each treatment session before removal. 

Brachytherapy can be provided using low dose rate (LDR) or high dose rate (HDR) techniques. They differ by the length of time that the radioactive sources remain in place, with HDR treatments delivering radiation over 10-20 minutes while LDR treatments delivering it over an extended period which can range from several days to permanently. HDR brachytherapy is used in treating prostate, cervical, head, and neck cancers, while LDR brachytherapy is more suited for brain cancers and prostate cancers as well.

One of the main uses of brachytherapy treatment in Singapore is in prostate brachytherapy, which can be utilised either as a sole treatment modality for early-stage prostate cancer or alongside EBRT for larger cancers with greater risk of spreading. It involves the placing of radioactive sources in the prostate gland, and can be either LDR or HDR in procedure.

Brachytherapy also plays a key role in cervical cancer treatment in Singapore. Cervical cancer is the 2nd most common cancer affecting women across the globe, and brachytherapy works alongside EBRT and chemotherapy for effective treatment. Intracavitary brachytherapy is most often utilised, whereby a radioactive device is inserted into the vagina, cervix, or surrounding tissues for either a few minutes or an extended duration, depending on whether HDR or LDR techniques are utilised.

Brachytherapy also helps to treat breast and endometrial cancer, also known as uterine cancer. Brachytherapy plays an important role for patients who have undergone a hysterectomy surgery to remove the uterus, with both LDR and HDR treatment procedures being used alongside EBRT. Vaginal Vault brachytherapy is a commonly used HDR procedure, with an applicator being inserted into the uterus near to the tumour for approximately 20 minutes per treatment session.

Arrange a consultation with us today to find out more about our brachytherapy treatments in Singapore, and how we can best help you.

Part 3: Visiting A Radiation Oncologist

The treatment process is naturally daunting for cancer patients. Read on to learn more on preparing for a visit to a radiation oncologist in Singapore, as well as what to expect for subsequent treatment sessions.

3.1 Preparing For Your First Visit

The radiation therapy treatment process begins with an initial consultation with a radiation oncologist in Singapore, who will review the patient’s medical reports, pathology reports, and radiology images before conducting a physical examination. Some factors that radiation oncologist consider for the appropriate treatment to use include:

• Type of cancer
• Size of tumour and location in body
• Proximity of tumour to healthy tissues
• Patient’s general health and medical history
• Patient undergoing other cancer treatments
• Age and existing medical conditions

From there, the radiation oncologist will arrange for a simulation process which involves the taking of X-rays or diagnostic imaging scans, and allows them to define the exact location and configuration of treatment for the cancer or tumour. The treatment setup will also be simulated, with patients being positioned and immobilised to reproduce the treatment process as thoroughly and accurately as possible.

Once the radiation oncologist has discussed with other staff such as therapists, nurses, medical physicists, and dosimetrists, they will design a tailor-made treatment plan that aims to deliver maximum radiation to the tumour within safe limits while limiting the dosage to nearby tissue, as well as reducing side effects. Once planning is complete, radiation therapy treatment can commence.

Your radiation oncologist will require you to sign a consent form informing on the benefits of treatment, possible risks, type of radiation therapy to be utilised, as well as other treatment options. Do take this opportunity to ask all relevant questions that you may be concerned about, such as your ability to handle work or leisure while undergoing treatment, expected side effects, as well as any possible long-term effects that may affect your overall wellbeing.

Here are some tips to best prepare for your first radiation therapy session:

• Find ways to relax and reduce stress
• Seek family or friends’ help to handle errands
• Arrange for transport to and from the clinic
• Share your concerns with staff and friends
• Consider your future fertility plans

The actual treatment session generally does not last long, with patients often spending no more than 20 minutes in the treatment room. Once done, patients will be brought to an examination room, where they can discuss issues regarding radiation, skin care, and nutrition.

Radiation therapy is usually accompanied by various side effects that are dependent on the area of the body being treated, each patient’s individual genetics, and factors such as smoking. They often occur during or shortly after treatment, and tend to be short-term, mild, and treatable; with the majority of them going away within 1-2 months after finishing radiation therapy. Some of these symptoms include fatigue, hair loss, nausea and vomiting, loss of appetite, and skin/urinary/throat changes, amongst others. Do consult your radiation oncologist in Singapore on how best to cope with these side effects.

3.2 Subsequent Treatment Sessions

Across the treatment schedule, the radiation oncologist and assigned nurses at your Singapore clinic will follow up weekly with you to check on your progress, degree of side effects and recommend treatments for them if necessary, as well as addressing any concerns you may have. 

With patients each responding differently to radiation therapy, radiation oncologists will plan out individualised treatment timelines that vary based on the type of treatment used as well as which can be changed during these review sessions. For example, a radiation oncologist may decide to extend the overall duration of treatment if a patient is experiencing more intense side effects as a result of higher doses of radiation per session, choosing to lower the intensity of radiation exposure during each individual session.Radiotherapy can range from approximately 2 to 10 weeks, depending on the type of cancer and treatment goals. During this period, it is important to get plenty of rest, consume a balanced and nutritious diet, stay hydrated, avoid exposing affected skin to sunlight, as well as seek emotional support from loved ones. Once treatment is fully completed, your radiation oncologist will also schedule follow-up appointments to ensure your recovery proceeds normally, as well as to monitor the tumour response. They may also order additional diagnostic tests if necessary to check if the tumour has fully disappeared.

At our radiotherapy clinic in Singapore, we believe that health should not come at the expense of being unable to afford radiation therapy sessions. In addition to providing affordable treatments, we also accept insurance grants for partial or full payment, depending on patients’ medical insurance and Medisave. Visit this link to find out more, or get in touch with our helpful staff for assistance.

Part 4: Conclusion

Radiation therapy is invaluable in treating Singaporeans with cancer, and with early detection and expert treatment and care, radiotherapy clinics provide patients a fighting chance to experience a full recovery from cancer and enjoy a new lease on life. Dr Tang and his experienced team of staff are committed to providing the utmost in patient-centered care, supporting them and their families from start to end.

Looking for quality radiation therapy in Singapore? Get in touch with us to find out more about our services and arrange for a consultation today.