Dr. Koh Poh Koon, Consultant Surgeon, Novena Colorectal Centre,
Medical Director and Consultant Surgeon, Capstone Colorectal Surgery Centre,
Adjunct Assistant Professor, Duke-NUS Graduate Medical School,
Adjunct Clinician Scientist, Institute of Bioengineering & Nanotechnology, A*STAR,
Visiting Consultant, Department of Colorectal Surgery, Singapore General Hospital,
Visiting Consultant, Department of General Surgery, Changi General Hospital,
Acting Director, Colorectal Cancer Molecular Genetics Research Laboratory, Singapore General Hospital,
Acting Director, Colorectal Cancer Genomic Health Service, Singapore General Hospital
18 February 2012
By Ai San Yip
Edited by Wan Qing Leow Rachel
Photo courtesy of Novena Colorectal Centre
Photo (Left to Right): Dr Koh Poh Koon, Dr Francis Seow-Choen, Dr Ho Kok Sun, Dr Lim Jit Fong
Novena Colorectal Centre (NCC) is a dedicated group practice formed by four prominent Singapore colorectal surgeons â€“ Dr Koh Poh Koon, Dr Francis Seow-Choen, Dr Ho Kok Sun and Dr Lim Jit Fong, in partnership with Fortis Healthcare Singapore offering comprehensive and integrated colorectal care. Some ofÂ the services include genetics screening for hereditary colorectal cancer, treatment of functional bowel disorders and advanced minimally invasive surgical (MIS) techniques in colorectal surgery. With an in-house Anorectal Physiology Measurement Laboratory, patients can receive comprehensive diagnostic and investigative services for dis-coordinated bowel movement and bowel incontinence.
1. What is your background?
I received advanced training in surgical treatment of Inflammatory Bowel Diseases in Edinburgh (UK) and Cleveland Clinic U.S through a HMDP Scholarship provided by the Ministry of Health Singapore. In 2010, I was awarded a second HMDP Scholarship to pursue further training on â€œClinical Gene Testing and Personalised Medicine in Colorectal Cancer Managementâ€ at the Genomic Medicine Institute at Cleveland Clinic, USA.
2. The motivation behind Novena Colorectal Centre is ... ?
Novena Colorectal Centre is set up as a new partnership between four colorectal surgeons with expertises in various aspects of colorectal disease management. We came together because we can synergise and pool our individual in-depth knowledge in specific domains to collectively manage the entire spectrum of colorectal diseases. In this way, the partnership as a whole is greater than just the sum of its parts. Together, we have the bandwidth and the necessary expertise to deliver excellent surgical care, induct cutting edge technologies, perform translational research and support surgical education. As a group, we now have the synergy to bring about a truly one-stop service to all patients with the entire spectrum of colorectal diseases.
For example, apart from general colorectal surgical and laparoscopic procedures, I specialise in the management of hereditary colon cancers such as Lynch Syndrome or Hereditary Non-polyposis Colorectal Cancer (HNPCC). My contribution is in the genetics of colon cancers and the management of patients and their families with hereditary colon diseases especially pertaining to genetic testing, clinical risk management and surgical strategies for cancer risk reduction in these high risk families.
One of my other colleagues, Dr Lim Jit Fong has specialised interest in dys-synergic defaecation. He diagnoses and treats patients with functional bowel problems such as chronic or obstructed constipation as well as faecal incontinence using sacral nerve neuromodulation. This utilises an implanted device capable of electrical stimulation of the sacral nerves to induce colorectal motility. These devices are available in U.S. and Europe but not locally. Why? Use of these devices require specialised skillsÂ and advanced investigation tools to measure and monitor key clinicalÂ parameters such as rectal pressure, anal muscle strength, tolerable volume of rectum etc. Thus we have set up the first and only private-operatedÂ Anorectal Physiology Measurement Laboratory in our Centre to provide anorectal physiological measurement in the Singapore in order to support this innovative technology of Sacral Nerve Neuromodulation.
Dr Francis Seow-Choen brings with him years of experience as a master-surgeon. His vast international network allow us to tap into the expertise of other academic centres of excellence to benchmark our level of care. Dr Ho Kok Sun who is also an accomplished laparoscopic surgeon and the current President of the Society of Colorectal Surgeons (Singapore), brings with him a keen business and financial sense that is crucial to us as we endeavour to bring cost effective and value-added services to our patients.
In NCC, our tag line is â€œPushing Frontiers, Saving Livesâ€. â€œPushing Frontiersâ€ embodies our desire to expand the technological envelope to ensure that no patient is denied the state-of-the-art when it comes to their care. It also articulates our philosophy that we will spare no effort to explore all options for the benefits of our patients. â€œSaving Livesâ€ clarifies that our focus is always on the patients and their well-being, so that all our endeavours are patient-centric. Advanced surgical techniques such as key-hole (laparoscopic) surgery and robotics-assisted surgeries require a team approach which would be extremely difficult for a single surgeon to champion. Having a strong team like ours with individual competency in advanced laparoscopic and robotic surgical techniques will also allow us to rapidly adopt innovative, new techniques and technologies for the benefit of our patients. With a large collective patient pool, we can more effectively analyse outcome measurements to ensure that our practice is evidence-based even as we push the technological frontier to save lives.
3. We saw you on Straits Times interview several weeks ago. What is Fortis Healthcare Singaporeâ€™s (FHS) involvement (strategic role) in the partnership? How can this involvement add value for patients?
Fortis Healthcare Singapore is our facilities provider and management partner. Fortis Healthcare Singapore through the anticipated launch of the Fortis Hospital for Colorectal Diseases (FHCD) at Adam Road this June 2012 is committed to bringing integrated, patient-centric healthcare. Novena Colorectal Centre (NCC), a partnership with theÂ four of us as founding partners, will provide the clinical and surgical expertise. This new hospital, dedicated to the treatment of colorectal diseases, is designed with the needs of the colorectal patient in mind. Sparing no details to make the convalescent period of the patient a soothing and pleasant experience, we believe that both NCC and FHCD are aligned in ourÂ vision to be a global leader in the integrated and comprehensive colorectal diseases management healthcare space and to continually push the technological frontiers to save lives while remaining patient-centric at all times.
From this viewpoint, we would expect to fine-tune our engagement model with Fortis Healthcare Singapore as we learn and evolve together. Our model is not the typical employee-employer model, but a partnership model where each of us has an identity, domain interest and collective competence while at the same time, remaining driven by our vision.
We believe that this unique partnership between a group practice and a dedicated healthcare management provider will generate a critical mass to drive the twin arms of clinical research and translational application. We hope to be the first adopter of new technologies (first-to-use and first-to-try). To adopt new technologies or techniques in surgical treatment, a framework that supports exploratory research and teaching pedagogies is crucial.Â The close partnership between FHCD and NCC allows for the creation of a governance framework focusing on patient safety and a conducive environment for peer appraisal and group-learning to shorten the learning curve. This is a unique model in the private healthcare space in Singapore.
Editorâ€™s note: The Straits Times article, dated 04 February 2012, revealed that Fortis Healthcare invests SGD 70 Million in two colorectal centres in Singapore.
4. What are some of the challenges you face?
The biggest challenge is finding the right group of surgeons with the correct alignment and vision, yet possessing the necessary complementary skill sets in the realm of colorectal disease management. The next challenge is creating an engagement framework and core values that can align the individualism (yes, most surgeons have big egos!) to create the right team dynamics and propel the group towards the common vision.
Add on a healthcare partner like Fortis Healthcare Singapore (FHS) who is part of a huge global healthcare conglomerate with diverse interests globally, and one begins to see the challenges of integrating NCC with FHS. Fortunately, the four of us have had prior experience working together in Singapore General Hospital so the first challenge is easily surmounted. We are still evolving as we go along in terms of finding the ideal engagement model. With the key principles of engagement nailed down, I believe the minor adjustments that are necessary along the way will not be a show-stopper. Having been engaged with Fortis Healthcare Singaporeâ€™s senior management team in the early stages of our mutual development has allowed us to evolve a common set of core values and strategic vision. I am optimistic that with this common set of core values and alignment in our strategic vision, we will be able to navigate the grey areas as we embark on creating a unique game-changing private practice healthcare model in Singapore and beyond.
Moving forward, one of the issues close to my heart when it comes to public engagement and healthcare delivery is in the management of patients and their families diagnosed with hereditary colon cancers. Colorectal cancer is the most common cancer in Singapore and adopting a cancer screening program as a cancer prevention strategy should clearly target high risk groups. These programs are currently focused on the screening of individuals who are older than 50 years old and selected at risk individuals via endoscopy or fecal occult blood testing.
However, the approach of offering genetic testing and genetic screening in individuals or families with significant family history of colorectal cancer that may have hereditary colorectal cancer has not been emphasized enough. Up to 30% of all colorectal cancers have a familial clustering and indeed, our local data suggested that up to 23% of all colorectal cancers occurring under the age of 50 may have a hereditary basis. This means that a significant number of family members of these patients could be at risk of developing colon cancers themselves even before they reach the age of 50. Without a clear management strategy that must include genetic testing, many of these families are â€œcursedâ€ with the development of multiple cancers that are preventable to a large extent.Â We need to raise public knowledge and awareness about hereditary colon cancer and the options available to detect and risk stratify them.
To this end, NCC and FHCD offers a one-stop integrated high-risk family consultation clinic with ability for genetic testing and supported by a laboratory for genetic research. We will also be embarking on public outreach programs to engage and educate the public on the management options for those at high risk of hereditary colorectal cancers.Â
5. What do you think of the direct-to-consumer (DTC) genetic testing or the next trend in research?
Direct-to-consumer (DTC) genetic testing that allows the consumer access to their genetic make-up through a buccal swab or simple blood sampling done at the local pharmacy is controversial. This is a situation where the science has not caught up with the technology. Today, we can sequence the entire human genome at a fraction of the cost and within a matter of days or weeks compared to the time when the first human genome was sequenced. However, we do not yet know the risks and significance conferred by certain polymorphisms in the genome. Many diseases are also likely to be polygenic in nature and their causation multifactorial, reflecting a complex interplay of genetic factors and environmental influences. Hence, DTC gene testing is largely industry driven without clear clinical benefits or application at the moment. However, the tidal waves of DTC gene testing in U.S. and Europe may hit our shores in Asia, especially the affluent and internet-savvy Singapore sooner than we can imagine. With the internet, many services offered at any part in the world are now readily available. It is not uncommon to have a patient walking into my consultation room with information gathered from the internet and asking about the utility of these DTC testing services. Where there is demand, there will be supply and we may soon face the prospect of having to legislate this segment of the healthcare space ...
In Singapore, we do not currently have legislation pertaining to genetic testing, especially in the realm of germline genetic testing for hereditary disease. While â€˜gene testingâ€™ takes place in the prenatal diagnosis such as Downâ€™s Syndrome, much of the gene testing currently pertains to cancer genomics (e.g. KRAS, EGFR testing etc.) that has no clear hereditary basis. However, BRCA (BreastÂ Cancer Susceptibility) gene testing for hereditary breast cancer and APC testing for Familial Adenomatous Polyposis Coli (APC) can have potential knock-on effects pertaining to the insurability of the affectedâ€™ s children. Presently, there is no legislation in Singapore that protects the rights of an individual with regard to insurability or employability.Â This is unlike in the U.S. which has the federal Genetic Information Nondiscrimination Act [GINA 2008] passed by the Congress. This protects against discrimination (for health insurance coverage and employment etc.) based on genetic information. Clinicians, in advising patients the pros and cons of genetic testing, have to help their patients to rationalise the potential downsides to life-saving information needed for their care. Sadly, many patients are deterred by the lack of clarity in the law that safeguards their rights and often chose to forego genetic testing, to both their own and their familiesâ€™ detriment. Even in the realm of biomedical research, the widespread availability of deep sequencing technologies have allowed a huge amount of genomic data to be easily available. What happens when the equivalent of a â€œWikilLeakâ€ in genomic research happens? Imagine information about the finding of a â€œSchizophrenia pre-disposing geneâ€ in a supposedly healthy volunteers being released inadvertently.
In the absence of a law that can protect an individualâ€™s private and confidential genetic information without disadvantaging him from employability and insurability, biomedical research may face a stumbling block when that happens. Who will be the healthy volunteer for your clinical trial that investigates the genetic biomarker for Schizophrenia? Are his personal rights being protected?Â Are all these things being spelt out in the Informed Consent? Is that alone a sufficient safeguard?
6. If there is one word of advice you can give to aspiring technopreneur or fellow clinician-scientist who are looking to start their business in the industry, what would that be?
To have a good chance of success, one must understand the market situation and use oneâ€™s strengths to the maximum advantage. Stay within your core competencies which are your strength but constantly find innovation and novel applications to create a unique value proposition to your potential customers.
I think it is also important to be driven by a vision. While the strategy may change with the situation, the vision should allow one to remain focused.
Lastly, to succeed, one must not be afraid to take some calculated risks!