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Radiation Oncology

Radiation Oncology


Radiation therapy is a crucial component of cancer treatment and here at the NCIS, the Radiation Therapy Centre (RTC) is committed to providing our patients with excellence in radiation therapy treatments. 

We aim to deliver the best care for our patients through the following:

Evidence-based, Guideline-led Practices

Our radiation treatments are tailored to individual patients' unique circumstances with reference to international guidelines such as those published by the National Comprehensive Cancer Network (NCCN). This emphasis on adhering to established international benchmarks is aligned with our commitment to achieve high-quality treatment across the board for our patients. 

Specialty-focused, Multi-disciplinary Teams

Our diverse team of radiation oncologists works within sub-specialty teams focusing on specific tumour groups. This enhances expertise development and allows for incorporation of the latest advancements into our treatment protocols. 

Our sub-specialty teams work closely with our surgical and medical oncology colleagues to deliver coordinated patient care. Discussions of complex oncological conditions led by the expertise of relevant specialists are facilitated by our multi-disciplinary tumour boards. 

Quality Care, Safe Practices

The Department of Radiation Oncology is committed to delivering quality treatments safely. Multiple layers of process checks are put in place by our team of dosimetrists, medical physicists and audit team to maximise safety. This includes peer-review of all our radiation treatment plans.

During radiation therapy treatment, image-guidance through cone beam CT imaging or electronic portal imaging is done to confirm accuracy of patient set-up before the radiation is delivered.

Comprehensive Radiation Therapy Services

We offer a comprehensive range of radiation therapy services tailored to each individual patient's needs, including both external beam and brachytherapy modalities.


Delivery of successful radiation therapy requires the coordinated efforts of a dedicated team of staff with different skill sets. 

Our Radiation Oncology Team comprises: 

  • Radiation Oncologists
  • Radiation Therapists
  • Medical Physicists
  • Radiation Oncology Nurses
  • Patient Care Associates and Patient Service Associates

Radiation Oncologists

Radiation oncologists are medical specialists who are qualified to give radiation therapy. The radiation oncologist’s role is to determine the suitability of radiation therapy for each patient, and to give the final approval for the radiation therapy plan. During the course of treatment, the radiation oncologist is also responsible for reviewing patients for side effects. After treatment is completed, the RO determines the frequency of follow-up and subsequent tests.

Our radiation oncologists are also actively engaged in undergraduate and post-graduate teaching, as well as clinical research.

Radiation Therapists


Radiation therapists are a group of allied health professionals who are trained to operate the various systems required in the delivery of radiation therapy to our patients. These systems include data acquisition systems like CT simulation, planning systems for designing radiation therapy plans, as well as treatment units like linear accelerators that ultimately carry out the treatment.

The specific duties of Radiation Therapists include: 

  • Fabricating immobilisation devices for accurate treatment delivery 
  • Simulation for tumour localisation and planning through the use of imaging modalities such as Computed Tomography 
  • Designing of treatment plans and dose calculations in collaboration with radiation oncologists and physicists 
  • Reviewing of prescriptions, images and approved treatment plans to ensure that the information is valid before treatment delivery 
  • Ensuring daily set-up reproducibility for safe and accurate treatment delivery 
  • Delivering of radiation treatment and monitoring of patient's condition during treatment delivery 
  • Advising patients on pre-treatment preparation, procedures and possible side effects of radiation treatment

Radiation Therapists also play an important role in clinical research and implementation of new techniques and protocols in cancer treatment to provide holistic care to our patients.

Medical Physicists

Medical physicists provide the scientific and technical support in a radiation oncology department. They assist in creating, implementing and monitoring the procedures which allow the best treatment using radiation, taking into account the protection and safety of patients and others involved in the treatment process.  

Medical physicists make sure that all equipment meet international and national standards. This can include machines such as linear accelerators, CT scanners, treatment computer systems and radioactive materials. They are also responsible for the design of new radiation oncology facilities and the commissioning of new equipment. 

Medical  physicists train other professional groups on topics such as radiation physics and radiation safety. They also have both a primary and supporting role in research activities in a radiation oncology department. 

Radiation Oncology Nurses

Radiation Oncology Nurses are licensed registered nurses who work collaboratively with radiation oncologists and radiation therapists to care for patients at the time of initial consultation, during radiation treatment, and at follow-up appointments. 

Our nurses provide the following important functions leading up to a patient's successful treatment:

  • Symptom Management and Patient Education

    Prior to the initiation of radiation therapy, radiation oncology nurses provide counseling for patients and their caregivers on the possible side effects of treatment they may experience. During radiation therapy, they will assess patients for ongoing toxicity and advise them on appropriate nursing care. Where necessary, they may also actively manage the symptoms, for instance, applying necessary dressing to skin affected by radiation therapy. 

  • Assistance in Medical Procedures

    Sometimes, radiation therapy may involve specialised procedures requiring placement of applicators, sedation or clinical monitoring. In these instances, our nurses are often called upon to assist the radiation Oncologist to ensure the procedures are done effectively and safely.

  • Emotional Support

    Recognising that the period of radiation therapy can be a difficult time for patients and their loved ones, our nurses are available to provide support and counseling. They can help patients access various community resources and support groups, as well as assist with issues such as home care, hospice or medical equipment.

Patient Care Associates and Patient Service Associates


Patient Care Associates (PCAs) and Patient Service Associates (PSAs) are ancillary staff who play key roles in the coordination of patient care and general administration. 

They are responsible for the registration of patients upon arrival, handling of appointments and assisting the doctor during consultation. When a decision is made for radiation therapy, they will provide the necessary financial counseling before treatment is initiated. Our PCAs and PSAs work closely with the different teams in the Radiation Therapy Centre to help create a better experience for our patients. 



IMRT allows for (red cloud) to be effectively delivered to the tumour (green line) while sparing the adjacent kidney.

Intensity Modulated Radiation Therapy (IMRT) / Volumetric Modulated Arc Therapy (VMAT) 

Intensity Modulated Radiation Therapy (IMRT) and Volumetric Modulated Arc Therapy (VMAT) use sophisticated computer algorithms paired with dynamic multi-leaf collimators (MLCs) to deliver high doses of radiation to tumours while sparing nearby critical organs. Volumetric Modulated Arc Therapy (VMAT) offers potentially shortened treatment times by integrating movements of the treatment gantry with movements of the dynamic MLCs. Currently, these techniques are utilised in head & neck cancers, prostate cancer, and other tumour sites where radiation therapy needs to be delivered to relatively large areas, yet require sparing of nearby organs.

Immobilisation via a whole body vacuum bag to achieve positioning required for stereotactic radiotherapy.

Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) 

These specialised treatment techniques make use of precise positioning, immobilisation devices and multiple treatment beams to achieve highly focused radiation therapy targeting suitable tumours. This allows larger radiation doses to be delivered during each treatment, thereby shortening the treatment duration without compromising safety. SRS is typically used for tumours in the brain. SBRT (also known as stereotactic ablative radiotherapy) can be used to treat small tumours in the lung, liver, spine or other organs. In certain tumour sites like the lung and liver, respiratory motion may compromise the therapeutic efficacy of stereotactic techniques. For such cases, respiration control capabilities are available including Active Breath Control (ABC) which limits such motion, as well as 4D CT simulation that can account for tumour motion at the planning stage.


3D reconstruction and planning for breast brachytherapy


High Dose Rate (HDR) Brachytherapy 

High Dose Rate (HDR) Brachytherapy is able to deliver extremely high doses of radiation therapy to tumours with minimal normal tissue effects through the use of Iridium-192 sources placed directly at the tumour site through the use of specialised applicators. HDR Brachytherapy is used in gynaecological tumours such as cervical and uterine cancers, as well as prostate and breast cancer treatments. 

For cervical cancer, HDR brachytherapy is a critical component of successful treatment by allowing the safe delivery of curative doses of radiotherapy to the tumour. For prostate cancer, HDR brachytherapy can be used either as a standalone treatment or in conjunction with external beam radiation therapy, and hence can shorten the overall treatment duration. Selected breast cancer cases can also be treated with HDR brachytherapy, which will allow radiation treatment to be shortened to just one week instead of three to six weeks. 

At NCIS, each brachytherapy treatment is planned with the benefit of full 3D imaging through CT simulation, allowing us to know the exact dose delivered to the tumour and the nearby normal organs.


Patient being prepared before radiation therapy treatment


3D Conformal Radiation Therapy 

3D Conformal Radiation Therapy makes use of 3-dimensional imaging and computer-based planning to deliver radiation therapy to targeted areas while sparing normal organs. Its versatility and proven track record makes it a suitable and reliable radiation therapy technique for almost all tumour sites.


Radiation therapists using laser lights and light fields to verify setup before delivering electron therapy

Electron Therapy 

Electron Therapy allows for the radiation dose to be deposited at the skin surface while sparing deep, normal tissues. This property of electrons makes it suitable for the treatment of skin and other superficial tumours. We can tailor the electron energies to target tumours of varying depths.


Cone beam CT evaluation for positional accuracy immediately prior to radiation therapy treatment

Image-Guided Radiation Therapy (IGRT) 

Image guidance can be used with any external beam technique to optimise patient positioning immediately prior to initiating radiation therapy. We often use cone beam computed tomography (CT) to visualise the body’s internal structures in three dimensions. These near real-time images enable us to make fine positional adjustments, ensuring that radiation therapy is delivered to the intended tumour location precisely, while sparing normal organs. Cone beam CT imaging is a marked improvement over traditional imaging methods which are limited by their two-dimensional nature and lower resolution images.


First-timer? Not to fret, let us walk you through the process of what to expect during your visit at our Radiation Therapy Centre.


During consultation, your radiation oncologist will explain the need for radiation therapy and the potential side effects.

Step 1 - Consultation 

When you are first referred for a radiation oncology review, you will be seen by a radiation oncologist who will discuss with you the need for radiation therapy for your condition, and the potential side effects that you may encounter. Sometimes, further tests may be required before a decision to embark on radiation therapy can be made. 

Do not hesitate to ask your oncologist if you have queries about how the treatments are administered, the duration of the treatments, potential side effects and how these will be minimised and managed, as well as alternatives to radiation therapy treatments. 

If a decision to administer radiation therapy is reached, you will be given financial counselling on treatment charges, subsidies and the quantum of eligible Medisave and Medishield deductions. 

Before you leave, you will also be given appointment dates for CT simulation as well as the commencement date of your radiation therapy.


CT simulation staff guiding patient on optimal position

Step 2 - CT Simulation 

During CT Simulation, a CT scan will be done on the area that requires treatment. This scan is done in the treatment position, and may require the use of immobilisation devices. In addition, small permanent reference marks may be placed on the body. The immobilisation devices and reference marks enable us to reproduce the position accurately during treatment, which is crucial for successful treatment. As far as possible, your therapists will ensure that the scan and treatment position is comfortable for you. Do let them know if you face any discomfort or are unable to maintain the required position. 

For certain treatments, you may be required to have a full bladder or empty stomach. If contrast is needed for the scan, an intravenous plug will be placed for administration of contrast. Please inform us if you have any kidney problems, asthma or previous allergies to contrast. 

Typically, a CT Simulation will require between 30 to 60 minutes. It may take slightly longer if the treatment is expected to be complex, requiring specialised equipment or preparatory work beforehand.


Radiation oncologist and therapist reviewing the plan before final approval.

Step 3 - Planning 

After the CT simulation is done, the images are exported to a treatment planning system software. Thereafter, the radiation oncologist will identify the tumour and the areas at risk that require radiation therapy, as well as the critical organs that should be avoided. 

Next, our radiation therapists with specialised skills in planning will work closely with the radiation oncologists to design a radiation therapy plan that best delivers radiation to the tumour while minimising the dose to normal tissues and organs. This process is important in achieving the best possible outcome for our patients and requires adequate time. Often, a few rounds of optimisation are required before the best plan is selected. 

After the plan is finalised, it undergoes several layers of checks to ensure optimal treatment, safety and accuracy of the delivered plan.


A significant portion of daily treatment time is spent to place the patient in the exact treatment position required

​Step 4 - Treatment and Review 

When the radiation therapy sessions commence, you will be required to attend treatment daily. A radiation therapy schedule will be provided to you to inform you of your treatment times. 

During treatment, radiation therapists will position you exactly as you were during the CT Simulation. You will undergo radiation therapy in a treatment room with radiation therapists monitoring your progress via a CCTV during the process. 

Some days, treatments may seem to last longer due to additional imaging being done to ensure accuracy of the treatment. During the course of treatment, you will be scheduled for weekly appointments to see your radiation oncologist where you will be monitored for any side effects developed during the treatment process, as well as tumour response, if applicable. You may also be given medication to relieve some of the side effects. 

In addition, weekly consultations with our in-house dietitian may be arranged for patients whose nutritional status warrant review.


A follow-up session will be conducted to monitor any potential side effects as well as track tumour response to treatment.

Step 5 - Follow-Up 

Upon completing the course of radiation therapy, you will be given a follow-up appointment. The purpose of a follow-up session is to monitor the side effects as well as tumour response. This may sometimes involve additional imaging like diagnostic CT scans, MRI scans or blood tests.


Below are summaries of some recent scientific publications by our staff members. 

RE-IRRADIATION FOR RECURRENT GLIOBLASTOMA (GBM) : A SYSTEMATIC REVIEW AND META-ANALYSIS 

Can we use re-irradiation safely and effectively for patients with recurrent glioblastoma?

Glioblastoma (GBM) invariably recur after first line treatment. Treatment options are often limited at time of recurrence, and re-irradiation has not been routinely offered due to fear of complications and lack of effectiveness. We chose to address this clinical question by conducting a systematic review and meta-analysis spanning the last 20 years. Through our efforts, we included 50 studies consisting of 2095 patients. We found the re-irradiation had a modest benefit, in terms of disease control and overall survival. (6-month progression free survival of 43%, and 6-month overall survival of 73%). This was better compared to historical controls consisting of chemotherapy alone.  Serious side effects were low,  ranging between 4 and 10%. Although our study gives us encouraging results, we await further level 1 evidence to best direct us on how to manage this challenging disease. 

PALLIATIVE RADIOTHERAPY IN SYMPTOMATIC LOCALLY ADVANCED GASTRIC CANCER: A PHASE II TRIAL.

Can radiotherapy help reduce symptom in patients with locally advanced gastric cancer?

Patients with inoperable stomach cancer often have symptoms such as bleeding from the stomach, blockage or pain. We treated 50 such patients with a course of radiotherapy in a prospective study and found that >80% of the patients had an improvement in symptoms. Many also had an improved quality of life. 5% of patients had significant side effects, namely loss of appetite and inflammation of the stomach.

Overall, we concluded that radiotherapy to the stomach was generally well tolerated and resulted in improvement in fatigue, difficulty swallowing and pain in a significant proportion of patients.

THE EVOLUTION AND RISE OF STEREOTACTIC BODY RADIOTHERAPY (SBRT) FOR SPINAL METASTASES

How have scientific progress in stereotactic body radiotherapy (SBRT) led to treatment advances for spinal metastases?

Medical advances in diagnosis and treatment have resulted in patients with stage IV disease living longer and having a better quality of life. Technological progress in radiation oncology has enabled us to treat patients with greater accuracy, resulting in improved cancer outcomes with potentially fewer side effects. This review summarises the scientific evidence and expert opinions of SBRT for spinal metastatic disease, highlighting how this technique can be applied to benefit patients whilst avoiding any potential pitfalls.

RADICAL RADIOTHERAPY IN OLDER PATIENTS WITH MUSCLE INVASIVE BLADDER CANCER

Can elderly patients with invasive bladder cancer be cured with radiotherapy (with or without chemotherapy)?

We looked at 45 patients with a median age of 77 years old who had muscle invasive bladder cancer (MIBC) and were treated with radiotherapy (with or without chemotherapy). All patients received maximal transurethral resection of the bladder tumour prior to RT, and about half of the patients also received chemotherapy. The 2- and 5-year overall survival was 64% and 44%, respectively. One patient (2%) had moderately severe bladder inflammation due to the treatment. We conclude that older patients can be considered for potentially curative treatment despite their age. However, careful selection is warranted as frail patients may benefit less.

ASSOCIATION BETWEEN RADIATION HEART DOSIMETRIC PARAMETERS, MYOCARDIAL INFARCT AND OVERALL SURVIVAL IN STAGE 3 NON-SMALL CELL LUNG CANCER TREATED WITH DEFINITIVE THORACIC RADIOTHERAPY.

Is radiotherapy to the chest associated with an increased rate of acute myocardial infarct in patients with locally advanced lung cancer?

We reviewed 120 patients with stage III non-small cell lung cancer who were treated with radiotherapy between 2007 and 2014, with or without chemotherapy. Because some lung tumours can grow near the heart, there was a concern that radiotherapy could also cause cardiac side effects, such as acute myocardial infarction (AMI). After a median follow-up period of about 1½ years, we found that the incidence of AMI is low in our treated population, and concluded that there was insufficient evidence that radiation doses as used in our treatment were associated with increased rate of AMI decreased survival rates. 

MEASURING RADIOTHERAPY SETUP ERRORS AT MULTIPLE NECK LEVELS IN NASOPHARYNGEAL CANCER (NPC): A CASE FOR DIFFERENTIAL PTV EXPANSION

What is the setup uncertainty in nasopharyngeal cancer treatments and can modern imaging technology reduce it? 

We looked at cone beam CT (CBCT) data of patients undergoing nasopharyngeal carcinoma to determine setup uncertainty in the head and neck. The average uncertainty ranged from 1.88 to 3.35mm, and tended to be higher in the lower neck because of weight loss during radiotherapy. The uncertainty could be reduced with the use of CBCT to as low as 0.30mm. This will allow safer treatment to areas of tumor that almost touch critical organs like the brainstem.

 

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SURGERY OR RADIOSURGERY PLUS WHOLE BRAIN RADIOTHERAPY VERSUS SURGERY OR RADIOSURGERY ALONE FOR BRAIN METASTASES 

Does whole brain radiotherapy after brain surgery or radiosurgery help patients who have cancer spread to brain?

Previous studies done on patients who have cancer spread to brain were reviewed and summarised. There was some evidence that adding whole brain radiotherapy (WBRT) did not improve survival, but did lower the risk of recurrence in the brain one year after treatment. The impact of WBRT on neurocognitive function, neurological adverse events or quality of life was not clear, as results were inconsistent. 

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POSTOPERATIVE CHEMO-RADIOTHERAPY VERSUS CHEMOTHERAPY FOR RESECTED GASTRIC CANCER: A SYSTEMATIC REVIEW AND META-ANALYSIS 

Should patients receive chemo-radiotherapy or chemotherapy after surgery for gastric cancer?  

We summarised previous studies on patients with gastric cancer who had been treated with surgery. There was some evidence that chemo-radiotherapy improved survival compared to chemotherapy alone, though the chemotherapy used in most of these studies were older regimens. The degree of chemo-radiotherapy and radiotherapy side effects were similar. 

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EFFICACY OF PALLIATIVE RADIATION THERAPY FOR SYMPTOMATIC RECTAL CANCER

How effective is radiotherapy to rectum in controlling symptoms of advanced rectal cancer? 

This study showed that radiation is effective in the treatment of advanced rectal cancer, particularly for controlling symptoms such as pain, bleeding or obstruction. At the time of publication, this was the largest series of patients studied for this specific indication.  

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STRATEGIES FOR BILATERAL BREAST AND COMPREHENSIVE NODAL IRRADIATION IN BREAST CANCER - A COMPARISON OF IMRT AND 3D CONFORMAL RADIATION THERAPY

What is the best radiotherapy technique for patients requiring treatment to both breasts? 

This study was the first to explore the feasibility of bilateral breast and regional lymph node irradiation. Radiation to bilateral breasts and regional lymphatics is particularly challenging due to the large radiation areas involved. This study demonstrated that Intensity Modulated Radiation Therapy (IMRT) to bilateral breasts and regional lymph nodes can potentially be used to significantly reduce the risk of toxicity and side effects. 

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CLINICAL OUTCOMES OF FUNGATING BREAST CANCER TREATED WITH PALLIATIVE RADIOTHERAPY 

Is radiotherapy effective for controlling symptoms caused by advanced breast cancers that have eroded through the skin? 

This study showed that radiation is effective in the treatment of advanced breast cancer, particularly for the control of pain and bleeding. We also showed that short courses of radiation can be just as effective as longer courses.  

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GLIOBLASTOMA MULTIFORME OUTCOMES OF 107 PATIENTS TREATED IN TWO SINGAPORE INSTITUTIONS 

How is Glioblastoma Multiforme (GBM) treated locally and what are the outcomes? 

We looked at patients who underwent GBM treatment in 2 hospitals in Singapore. Patients usually receive various combinations of surgery, radiotherapy and chemotherapy. Those who receive radiotherapy and chemotherapy after surgery do better. Our outcomes are similar to other international institutions. Nonetheless, GBM remains challenging to treat because of its tendency to recur. 

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ACCURACY OF (18)F-FLURODEOXYGLUCOSE-POSITRON EMISSION TOMOGRAPHY/COMPUTED TOMOGRAPHY IN THE STAGING OF NEWLY DIAGNOSED NASOPHARYNGEAL CARCINOMA: A SYSTEMATIC REVIEW AND META-ANALYSIS

What is the accuracy of FDG-PET/CT in the staging of nasopharyngeal carcinoma, compared to conventional modalities?

We summarised previous studies which used FDG-PET/CT for the staging of NPC. We showed that PET/CT is more accurate than normal CT and MRI for spread to the lymph glands and other organs. MRI was still more superior than PET/CT in determing the local extension of the nose cancer.  

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FEASIBILITY STUDY OF TOXICITY OUTCOMES USING GEC-ESTRO CONTOURING GUIDELINES ON CT BASED INSTEAD OF MRI-BASED PLANNING IN LOCALLY ADVANCED CERVICAL CANCER PATIENTS 

How accurate is CT planning in cervical cancer? 

Internal radiation allows high doses to be delivered to a cervical tumour. The planning of these doses is essential. In this study, we used a CT scan to plan the patient's treatment. CT scans are easily obtainable and cheaper than MRI. This study shows they can be used effectively in planning treatment.  

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ACCELERATED PARTIAL BREAST IRRADIATION IN AN ASIAN POPULATION: DOSIMETRIC FINDINGS AND PRELIMINARY RESULTS OF A MULTICATHETER INTERSTITIAL PROGRAM 

How effective is Accelerated partial breast irradiation (APBI) for treatment of early breast cancer? 

Accelerated partial breast irradiation (APBI) is a procedure that allows breast radiation to be delivered to over 1 week instead of over a few weeks. Current studies of this procedure have been conducted only in Western populations. This study looks at the effectiveness of this therapy in our population. 

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