The Harley Street Heart and Cancer Centre (Singapore)

The Harley Street Heart and Cancer Centre is a one-stop specialist centre based in Singapore that provides the latest and most advanced treatments available for people with cardiovascular disease and cancer. Our internationally recognized specialists have trained in leading centres around the world, including the United Kingdom, United States, Canada and Australia to deliver a caring and professional service for our patients.

At the Harley Street Heart and Cancer Centre, we aim to maintain the medical excellence and qualities associated with the Harley Street name and believe in treating the individual and not just the disease. Collaborating with leading medical centres and specialists worldwide allows our international patients to enjoy a smooth continuity of care after returning home to their country.

Our dedicated specialists treat patients with a wide range of heart and vascular conditions and also offer screening packages for those who would like a general medical or cardiovascular check-up. Using the latest equipment and technology, our specialists will carefully assess your condition and determine the best management plan. We provide treatments such as coronary angiography and intervention, implantation of cardiac pacemakers and devices, catheter ablation of cardiac arrhythmias and peripheral vascular intervention. A key mission of our heart and vascular specialists is to provide the best possible care and service to optimize your cardiovascular health.

We have dedicated facilities for outpatient chemotherapy and associated treatments. Our cancer specialists will carefully assess your condition and provide a detailed explanation of the management plan, treatment options, complications and outcomes. Patients can receive chemotherapy in the calm and supportive environment of our clinic. Our team of specialist cancer nurses works closely with the pharmacists, dieticians and other health care professionals to provide the highest standard of care alongside our cancer specialists.

Early and rapid diagnosis is vital because more than 90% of breast cancer can be cured when detected and treated early. Typically this will involve a number of tests which can be arranged together to ensure treatment can be started as soon as possible once the diagnosis is confirmed.

These will include baseline blood tests to check your body function and fitness for therapy, mammogram with ultrasound guided biopsy, full body imaging to exclude disease spread to other parts of the body.

We offer all the up-to-date treatment options in keeping with the latest advances. We will discuss the best options available based on the staging of the cancer with every individual. No two cancers are the same and no two individuals are the same. Therefore, the treatment should also be highly personalized.

Treatments option may include one or more of the following modalities:  Surgery, chemotherapy, radiotherapy, targeted therapy and hormonal therapy.

Screening is important as it helps to detect cancer that is very small and is at an early stage, which does not tend to cause any symptoms. There is a near to 100% cure rate when some cancers are detected in the very early stage.

Certain cancer screening tests are recommended for the general population above a certain age, other screening tests are targeted at the group of populations who are at risk of developing certain types of cancers. Our team of highly specialised doctors will take a detailed history, do a thorough clinical examinations before recommending the most appropriate screening tests for each individual.

Cardiac Screening (heart screening) identifies people who have evidence of heart disease (blockages in the arteries supplying the blood to the heart) and help to estimate the risk of a future heart attack. The tests themselves take little time and the results will give you either peace of mind or the information needed to make changes to your lifestyle, before a serious heart problem occurs.

1)    General Medical Screen is recommended for individuals above 40 years of age. By undergoing this screening, we will be able to identify the presence of the risk factors, such as hypertension, diabetes or high cholesterol levels, which can lead to coronary artery disease and cancer.
2)    Healthy Heart Screen
3)    Pre-exercise Cardiac Screen is recommended for individuals planning to perform strenuous exercises such as a marathon or triathlon.

Cardiac investigations often need to be performed in patients with symptoms suggestive of heart disease. Cardiac investigations may also be appropriate for people with no symptoms but who have risk factors for heart disease. The most common cardiac investigation that is performed is the ECG or electrocardiogram. This is the most basic test and provides information on the general health of the heart and the conduction system and whether the patient has had a previous heart attack. Information on other specialized cardiac investigations, such as the exercise treadmill test, echocardiogram, coronary angiogram and electrophysiological (EP) study is provided below.

•    Electrocardiogram (ECG) is a quick and painless way to assess the rate, rhythm and electrical activity of the heart and also provides some information on the general health of the heart. It is a simple procedure involving lying down on a bed for 2-5 minutes with 10 stickers (electrodes) attached to your chest. A print out of the electrocardiogram ECG is provided, which can be read by the cardiologist during the clinic visit.

•    Exercise Treadmill Test (ETT) provides the cardiologist with general information about how well the heart copes with exercise and may detect an underlying problem that is not present on the resting ECG. As the body works harder during exercise, the working muscles require more oxygen, so the heart must pump more blood. The test can show if there is a reduction in blood supply to the heart or if any abnormal heart rhythms develop with exercise. During an exercise test, the ECG electrodes are attached to the patient and the readings constantly displayed on the treadmill monitor. The blood pressure is also recorded every 2-3 minutes. The treadmill starts slowly and the speed and its slope are increased every three minutes according to a standard protocol. The exercise treadmill test (ETT) is stopped when the patient achieves a target heart rate or if the patient develops symptoms, such as chest discomfort, breathlessness or dizziness. The test may also be stopped if there are significant changes on the ECG or blood pressure falls significantly (this should normally increase with exercise)

•    Exercise Stress Echocardiography (ESE) is an exercise stress test that allows the cardiologist to study the capacity and reserve of heart muscle function under stressful condition.

•    Dobutamine Stress Echocardiography (DSE) is a non-exercise stress test that allows the cardiologist to study the capacity and reserve of heart muscle function under stressful condition.

•    Transthoracic Echocardiogram is a non-invasive and risk free test which uses standard ultrasound techniques to image 2-dimensional slices of the heart. Electrodes are attached to the patient’s chest to provide continuous ECG monitoring during the test. A transducer (or probe) is placed on the chest wall of the patient. An ultrasound beam passes out from the probe and reflects back from the structures within the heart. The probe is placed in various positions that allows the cardiologist to build up an accurate image of the heart.

Echocardiogram provides information on size and shape of the heart, pumping capacity and the location and extent of any heart muscle damage. It also allows evaluation of the heart valves. A Doppler analysis is done to look at blood flow from chamber to chamber and can detect abnormalities in the pattern of blood flow through the valves. The test takes about 30 minutes and is performed by a trained technician or cardiologist.

•    Carotid Intima-Media Thickness Test involves a special ultrasound scan of the carotid arteries in the neck to measure the thickness of the inner two layers – the intima and media. Several clinical studies have demonstrated a correlation between the Carotid Intima-Media Thickness (CIMT) and the future risk of cardiovascular disease. This test can therefore alert the doctor that the patient is at higher risk of a heart attack or stroke, even if the person has no symptoms. Early detection may indicate the need for a more aggressive approach to managing the risk factors associated with heart disease and stroke.

•    Cardiac Computed Tomography (CT) uses advanced CT technology along with intravenous radio-opaque dye (contrast) to obtain high resolution 3-dimensional images of the heart. Small electrode patches are placed on the patient’s chest which allows continuous ECG monitoring during the test. This test is performed with the patient going into a metal dome, with your arms raised over your head. The patient will be required to lie still and hold their breath for 10 seconds to allow the pictures to be taken. At the same time,the dye is injected via a fine tube (cannula) placed in a vein in the back of your hand. Under certain conditions, a drug may be needed to slow your heart rate down for the test. The table that the patient will be resting on will automatically move into place within a donut-shaped scanner for imaging. Within the scanner, X-ray tube will emit X-rays and circle the body for 5-8 seconds. The X-rays passes through the body and are picked up by detectors within the scanner, which are then used to generate real time images of the heart muscle, chambers, valves and coronary arteries. The radiation dose of the CT scan is equivalent to a coronary angiogram but is less invasive, with potentially less risk and less recovery time. Narrowings or blockages and the presence of calcium within the arteries can be detected and if significant may support the need for an invasive angiogram.

•    The Coronary Calcium Score may be used as a screening tool to evaluate the risk for future coronary artery disease. Essentially, more coronary calcium means more coronary artery plaque, suggesting a greater likelihood of significant narrowing in the coronary arteries and a higher risk of future cardiovascular events. The preparation for a calcium score is identical to that for a cardiac CT angiogram. The CT scan captures multiple images of the heart synchronized with the patient’s heartbeat. A computer program calculates the amount and distribution of calcium in the coronary arteries. The score will be evaluated alongside other risk factors and facilitate recommendations regarding your lifestyle, medications or additional cardiac testing from your cardiologist. The procedure only takes a few minutes and the radiation risk is comparable to that of a plain X-Ray.

•    Cardiopulmonary Exercise Test or CPET is an advanced, non-invasive clinical test that can be used for a variety of purposes:

1.     To assess maximum exercise capacity and the degree to which some patients are limited by their disease process
2.     To determine the cause of unexplained exercise limitation or breathlessness
3.     To determine a patient’s fitness to undergo a surgical procedure
4.     To follow disease progression over time or monitor the effects of therapy and make decisions about treatment plans
5.     To monitor the effects of training in highly conditioned athletes or guide decisions regarding training programs

CPET can evaluate the overall health of your heart, lung and circulatory system, and is the most accurate measure of your cardiorespiratory fitness.

•    Coronary Angiogram is a test which allows your cardiologist to visualize the coronary arteries. The coronary arteries supply the heart muscle with blood and oxygen. The procedure can be done from the wrist (radial artery) or the leg (femoral artery).

In the Catheterization Laboratory, the cardiologist places a local anaesthetic at the puncture site. When the artery is completely frozen and anaesthetised, a tiny plastic tube is inserted into the artery. The procedure is performed through this ‘gateway’. Specially shaped plastic pipes (catheters) allow the mouth of the coronary arteries to be engaged. A radio-opaque dye (usually iodine-based) is injected through the tube and X-ray pictures are taken. This allows the cardiologist to see any narrowings or blockages and can also give information about the blood pressure inside the heart and how well the heart is pumping. During an angiogram, patients are continually linked to a heart monitor (ECG) that shows the heart rate, rhythm and blood pressure. The procedure usually takes 10-20 minutes. An coronary angiogram requires you to be fasted for at least 6 hours and can be done as a daycase procedure.

For effective treatment and best outcome for any individual,  obtaining accurate initial diagnosis of the cancer type is of paramount importance. Blood tests are routinely done. The kind of imaging modality chosen will depend on the types of signs and symptoms that a person presents with. These may include a mammogram, a CT, an MRI, an ultrasound, a bone scan or a PET-CT scan.   Sometimes it may be a combination of these to determine the exact location of the cancer in the body for choosing the best location for a biopsy and for proper cancer staging.

As mentioned, a biopsy involves obtaining a piece of tissue from the tumour to be examined under the microscope. This will give us the most accurate information on the type of cancer that we are dealing with, thus enabling us to choose the most effective treatment.

Cancer treatment requires a multidisciplinary approach involving a team of doctors (surgeons, chemotherapy and radiotherapy doctors), nurses and other health care professionals. We believe the optimal treatment needs to be tailored to the requirements of each individual since each cancer patient is unique. Our approach to the best treatment option is carefully assessed by our team of specialists.

The Harley Street Clinic Heart and Cancer Centre has dedicated facilities for outpatient chemotherapy and associated treatments. Our senior consultant medical oncologist offers a thorough consultation, including providing detailed explanation of management plan, treatment options, treatment complications and treatment outcomes.

Patients can receive chemotherapy, symptom management and blood tests in a calm and supportive environment. Our team of specialist cancer nurses works closely with the pharmacists, dieticians and other health care professionals to provide the highest standard of care to patients under the care of the medical oncologist.

We care for the whole person, and ensure each individual receives optimum support, including pre-treatment visits, follow-up telephone advice or review on the day unit.

Chemotherapy is given for the purpose of reducing cancer recurrence after initial surgery is done to remove it. Despite the best surgeries, cancer can still recur as the cells may have already gone to other parts of the body and escaped detection from initial scans. Secondly, chemotherapy forms the main modality of treatment for cancers that have already spread, where surgery is generally not indicated. Lastly, chemotherapy may also be given as the first treatment for certain breast and rectal cancers to shrink the cancer before surgery for better outcomes for the patients.
Chemotherapy can be administered through a vein as an infusion, given orally in the form of pills.  This will be delivered throughout the body in the blood stream and kill cancer cells  both in the original tumour and also in the tumours that had spread. Sometimes chemotherapy may be injected into specific body compartments for more targeted delivery of the drug for specific cancers.

The choice of therapy will depend on the cancer type and also the general health condition of the individual. This will then determine the duration and the timing of intervals for each administration either through the vein or by mouth. The design of more recent drugs has been targeting the cancer cells more specifically thereby reducing the chances of side effects. Side effects of chemotherapy can generally be effectively managed with modern supportive therapies.

Hormone Therapy
Despite its name, hormone therapy is actually anti-hormonal. Their  main action is to block the action of natural hormones in the body from stimulating the growth of cancer cells in breast and prostate cancers. Our bodies make the hormones estrogen and testosterone naturally. There help regulate our normal bodily functions. However, in someone with breast or prostate cancer, these hormones actually accelerate the growth of the cancer, thus blocking them makes an effective anti-cancer strategy.

For hormone-sensitive breast cancer, hormone therapy is usually given for 5 or 10 years following curative surgery and chemotherapy to further reduce the chance of relapse. Hormone therapy is also effective in controlling breast and prostate cancers that have already spread to other parts of the body. They do not have the same side effects as chemotherapy. With good patient education and counselling, their side effects can be minimized and managed.

Immunotherapy
Immunotherapy, or biologic therapy, is the latest treatment available in the field of cancer care. Instead of killing cancer cells directly like chemotherapy does, immunotherapy works by boosting the immune system so that the patient’s body can reject and destroy the cancer by itself.

Patients whose cancer cells no longer respond to the original line of treatment given are usually moved on to different types of chemotherapy. Immunotherapy now offers another option when this change in treatment is needed. Furthermore, it has been shown to do better than standard chemotherapy drugs in extending survival in phase three trials.

Targeted Therapy
Targeted therapies has always been part of any anti-cancer strategy but only in recent years, have these really took off due to rapid advances in research and approval by health bodies for the use of these drugs. They target specific genes or cell receptors that control growth and spread of the cancer cells. By blocking these actions, the cells effectively stop growing and eventually get destroyed in the body. They have been proven to prolong life in more and more types of cancers such as lung, liver, breast, colon, kidney and skin (melanoma).

They usually come in the form of oral therapy such as tablets or capsules. Certain formulations are designed to be administered as injections or infusions along with chemotherapy to increase effectiveness. They have very few side effects and these usually come in the form of rash or diarrhoea which are very manageable.

Certain cancers are associated with gene abnormalities. Both breast cancer and ovarian cancers are associated with BRCA gene. Oncologists will assess the risk factors and recommend genetic testing accordingly. There are also tests available to assess the risk of early breast and bowel cancer recurrence. These tests help the oncologists to decide if chemotherapy is beneficial to patients who have very early stage cancer.

This is a small electronic device, about the size of a match box, that is inserted beneath the skin (usually below the left or right collar bone) and connects to the heart via one or more electrical wires (pacemaker leads) passed inside blood vessels. The Permanent Pacemaker (PPM) Insertion procedure is usually performed by the cardiologist using a local anaesthetic and light sedation and takes about one to two hours. Pacemakers send electrical impulses to the heart muscle to speed up the heart rate if it is too slow. Some patients with heart failure may benefit from a special type of pacemaker which can re-coordinate the left and right sides of the heart and improve heart function and decrease breathlessness. This is called cardiac resynchronization therapy (CRT). The procedure is more complicated than that involved for a standard pacemaker and can take a few hours to perform.

An implantable cardioverter defibrillator (ICD) is a sophisticated device that is inserted by cardiologists in patients with life-threatening heart rhythm disorders (usually ventricular tachycardia or ventricular fibrillation) to lower the risk of sudden death. Several large studies have conclusively shown that some patients with severe heart failure who have not yet experienced a life-threatening ventricular arrhythmia may also benefit from insertion of an implantable cardioverter defibrillator (ICD) to lower the chance of dying suddenly. The device continually monitors the patient’s heart rhythm and, if it detects a dangerous one, can either deliver a small series of electrical impulses (called anti-tachycardia pacing) or an internal electrical shock to restore normal rhythm. ICDs are inserted in a similar way to pacemakers and can also provide back-up pacing to the heart if the heart rate is too slow.

Implantable Loop Recorder (ILR) Insertion
This is a small electronic device, about the size of a USB memory stick, which is implanted just below the skin of the chest to record the heart rhythm continuously. The implantable loop recorder (ILR) is a diagnostic tool that is inserted in patients who have episodes of black-outs, seizures or recurrent palpitations which are not frequent enough to be detected with a 24-hour Holter monitor or 30-day cardiac event recorder. The device is implanted by the cardiac electrophysiologist using local anaesthesia through a small 3-4cm incision in the chest wall. Because of the ILR’s long battery life of 2-3 years, the heart can be monitored for an extended period of time allowing a diagnosis to be made when symptoms occur.

PPM, ICD and ILR Checks & Follow-up

Implanted cardiac devices need to be checked and followed-up closely by the cardiologist. This is to ensure that the device is still functioning well, the settings are optimized and to detect any abnormalities early to allow corrective measures to be taken. The frequency of the follow-up checks depends on the underlying heart problem for which the device was inserted and on the patients underlying medical condition. In general, pacemaker follow-up visits may take place every 3-6 months, whereas ICD checks tend to occur more frequently, every 3-4 months. ILRs may be checked every 3-4 months or can be interrogated in-between scheduled visits whenever the patient experiences any symptoms. The implanted cardiac device can be analysed at the follow-up visit in the outpatient clinic by placing an electronic reader over the device and downloading the information. Some wireless devices can be checked without the need to place a header directly over the device as long as the patient is within the vicinity of the device programmer.

Remote Home Monitoring of Implantable Cardiac Devices
Remote home monitoring connects patients with newer generation implanted cardiac devices when they are at home or overseas to their doctors without the need to physically go to their doctors’ clinic. Data from the device is downloaded by a home monitoring kit supplied to the patient and transmitted via a transtelephonic or web-based system to a secure, central server, which the doctor can access. The doctor can check the device parameters are correct and detect any problems earlier than the next scheduled clinic visit. Automatic alerts are also usually set-up which notify the doctor if any serious problems with the device or lead are detected. This gives the patient an extra level of reassurance that their cardiac device is being checked more frequently than traditional follow-up visits and allows corrective measures to be taken sooner if required. However, patients still need to see their doctors at regularly intervals as remote home monitoring is not a substitute for careful clinical follow-up and any programming changes that are required need to be performed in the clinic.

Coronary Artery Bypass Graft (CABG) Surgery
Patients with a narrowing or blockage in the coronary arteries diagnosed by a coronary angiogram may be considered for coronary artery bypass grafting (CABG). This is usually recommended when the narrowings are too severe, complex or widespread to be treated by medication and / or coronary angioplasty and surgery provides both symptom relief and the best long term outcome. Although routine, this is a major operation and will require at least 1 week’s stay in hospital and 6-8 weeks to fully recover.

Patients receive a general anaesthetic and are completely asleep. The breast bone is separated, which allows visible and physical access to the heart. In most cases, blood circulation and breathing functions will be taken over by a heart-lung machine (cardio-pulmonary bypass) although in some instances CABG can be performed on a beating heart (off-pump technique). The surgeon uses a segment of vein (taken from the leg) or artery (taken from within the chest or arm) to bypass or ‘get around’ the blockage. It is usual to have more than one and usually three or four arteries bypassed, which will improve the blood and oxygen supply to the heart muscle. The operation lasts between 2 and 6 hours. After your operation you will be moved to intensive care for close monitoring until you wake up. Once your condition is stable, you will be moved to the high dependency unit or the cardiac ward. Like all types of surgery, CABG carries a risk of complications, some of which are fatal, such as a stroke or heart attack. The risks of serious complications can vary, depending your age, whether you have other serious health conditions, such as kidney or lung disease, whether the surgery is performed as an emergency and the general state of your heart. Several pre-operative tests will allow your cardiologist to determine the overall risk benefit balance of having surgery. The outcome after CABG is dependent upon several factors, including compliance to medication and lifestyle modification, but successful grafts typically last 8-15 years.

Heart valves are structures within the heart that facilitate the flow of blood in one direction and prevent blood from leaking back in the opposite direction. Valve problems may occur if the valve is too narrow (stenotic) or incompetent (leaky). If severe, the valve may need to be replaced with a new valve (valve replacement surgery) or in some cases, the existing valve may be operated on and corrected without the need for a new valve (valve repair). If valve replacement surgery is required, the existing valve is changed to an artificial valve which can be made of metal, plastic, or a biologic material made from animal or cadaveric tissue. Heart valve surgery is a major operation requiring at least 1 week’s stay in hospital and 6-8 weeks to fully recover.

A small proportion of patients with severe aortic stenosis who are not suitable for conventional surgery or in whom the risk of surgery is considered to be too high, may benefit from a minimally-invasive, percutaneous procedure known as Transcatheter Aortic Valve Implantation (TAVI). This procedure involves the insertion of a pre-mounted tissue valve attached to a balloon catheter through a small incision of 4-6cm in the groin or chest. The doctor uses echocardiographic and fluoroscopic guidance for visualisation during the valve delivery. Once at the diseased site, the new valve is placed across the stenotic valve by balloon expansion. This method reduces the trauma to patients as the heart does not need be opened up, unlike the conventional surgical approach, and could result in a faster recovery and shorter hospital stay. However, this technique is relatively new and there is currently little long term outcome data available.

An aneurysm is a localized abnormal widening of the blood vessel due to a weakening of the wall. They can be clinically silent and not cause any symptoms but nonetheless be potentially dangerous and rupture if they increase to a certain size. Thoracic aortic aneurysms can be treated by the cardiothoracic surgeon through an open chest operation or endovascular approach. The operation involves the insertion of an artificial graft into the abnormal blood vessel to cover the diseased section either directly (open operation) or percutaneously with a balloon and stent through a blood vessel in the leg (endovascular approach).

Some patients may require surgical procedures to structure within their thorax (the cavity between the neck and diaphragm) other than their heart. These include operations on the lungs, lung lining (pleura), mediastinal lymph nodes, oesophagus, trachea and chest wall. Thoracic surgery may involve an open surgical operation or video-assisted thoracic surgery (VATS). VATS is a minimally invasive surgical technique that uses a thoracic endoscope to view the chest cavity on a video monitor after the lung has been collapsed using special surgical instruments inserted through 3-4 small skin incisions.

In the past, many patients could not tolerate chemotherapy as the side effects of chemotherapy limit the dosage that could be delivered to the patients. Now, there are good anti-sickness drugs available and medicine that helps the body to recover from the low immunity state at a faster rate, so chemotherapy can usually be given at the right dose without delay.

Our specialists recognise that supportive medicines such as pain killers, sleeping pills, nutritional supports is an important integral part of the treatment for cancer patients, they are highly skilled to offer this aspect of the support.

Cancer is an illness that affects the patients physically, psychologically and socially. We have a team of professional experts who are trained to look after these aspects during patients cancer journey.