The incidence of breast cancer has been increasing in Hong Kong. Multidisciplinary approach of breast cancer management is currently the gold standard in treatment of breast cancer. 
Breast surgery is more than removal of cancer; it combines the oncological principles with the aim of minimizing disfigurement and maintenance of quality of life. The Helsinki university hospital and the Memorial Sloath Kettering Cancer Center were one of the high volume institutions in Northern Europe and USA respectively. This 4-month overseas training program provided hands-on experience and exposure to surgical techniques such as breast reconstruction, oncoplastic surgery and fat grafting. 
Surgery was not the only mainstay treatments in breast cancer. The author not only gained insights in surgical techniques, but other areas of breast cancer management, such as clinical oncology, radiology, pathology and allied health adjuncts, which were equally essential elements in multidisciplinary management of breast cancer. 
 

Advances in novel therapies have revolutionised cancer care in recent years. They introduce new options and hopes, but also risks and challenges. Patient needs and treatment decisions have become more complex than ever, calling into play the full power of a multidisciplinary team.

At the Royal Marsden Hospital, a leading specialist cancer hospital based in London, pharmacists have a crucial role in the care continuum, from participating in individual clinical decisions to developing institutional guidelines, and from providing direct patient education to coordinating off-site chemotherapy. As part of a multidisciplinary team, pharmacist independent prescribers may also prescribe medications, including chemotherapy, within their clinical competence.

Back in Hong Kong, clinical pharmacy at Queen Elizabeth Hospital has grown rapidly in the last decade, most notably in cancer care. Services include clinical verification of prescriptions, inpatient medication review, patient counselling clinics, as well as protocol development. These responsibilities encompass a broad range of expertise and skills – a challenge for pharmacists to evolve from theory to practice, and an opportunity to establish a robust approach in training and credentialing. The model at the Royal Marsden Hospital has shown insights into a continuous service development process, not only the knowledge and skills, but also the standards of practice and a professional competency framework.
 

Ageing population and advancement of healthcare technology affect patient care. Telemedicine and telenursing has emerged as new modalities for 21st century to improve healthcare effectiveness and efficacy. Telenursing is regarded as a new modality of nursing care over distance.1 It continues to grow as a valuable method for providing nursing care to patients, especially in their homes.2 Clinical applications of telenursing has been widely adopted in western countries under different settings. Nurses use their nursing knowledge and skills to assess, plan, initiate, educate and evaluate nursing interventions for their distant patients through electronic means. Telecare nurses collect and interpret information on the phone from callers (patient or caregivers), seeking advice.
The feasibility of telenursing using mobile phones in supporting psychoeducational needs of colorectal cancer caregivers in Hong Kong was first investigated in 2013.3 The effectiveness and efficacy were further evaluated by a randomized controlled trial in 2014. Telephone intervention was found to improve psychological wellbeing and quality of life in the intervention group. 4 Apart from these, benefits of telenursing on colorectal cancer patients receiving the Enhanced Recovery After Surgery (ERAS) Program was investigated by a prospective four-week intervention study in four hospitals (QMH, UCH, CMC and QEH). A structured nurse telephone follow-up was given to ERAS patients after their discharge. Fifty patients with mean age of 67.94 (S.D. 11.1, 29-89) years were recruited. Telephone follow-up was found to be feasible with 147 out of 150 telephone calls (98.67%) successfully made. The mean duration of each telephone conversation was 10.03 (S.D.3.944; 3-20) minutes. Telephone call was well accepted by patients with 47 patients (94%) retained in the study. Patients reported different home care problems and nursing advice could be provided immediately. The mean scores for stress, anxiety and depression measured at baseline decreased over time after telephone intervention. Hence, telenursing was found to be both feasible and acceptable. 
Telenursing is not going to replace bedside or patient-centered nursing. However, it will be expected to benefit the model of future health care delivery in terms of timely health care advice.
 

The increase in the number of older adults in Hong Kong characterizes an increase in the number of people living with chronic and progressive diseases. There are evidence that palliative care can improve the quality of life to those patients. The challenge to provide high quality of palliative care service throughout patient’s disease journey is undoubtedly a burning issue. Through the corporate scholarship program, we have the opportunity to visit Royal Free Hospital in United Kingdom about the palliative care service.
The palliative care team (PCT) has specialist skills in pain relief and symptom management and provides emotional support and advice on terminal illness. It works closely with the occupational therapy and physiotherapy departments, as well as chaplaincy teams and community palliative care services, including local hospices and community providers. The PCT works closely with all health care professionals involved in a patient's end of life care. The seamless collaboration between GPs and palliative care team continues to provide support for patients in community. The consultative team in Royal Free hospital provided service to cancer and non-cancer patients in palliative care needs. 
Other than to give advice on symptom management to parent team, the role of nurses in PCT are very crucial that facilitates the family meeting for decision making, goal of care and understanding the expectation from patients and their families. They also showed competency on screening referral with categorisation of priority. Thus, the role and competency of PC nurse has room to enhance for better palliative care service in Hong Kong.
 

The objectives of this training program were to consolidate skills in evidence-based interventions and strategies to promote adjustment and reduce overall risk of psychopathology of patients in palliative care setting. It also aimed to help us delineating and enhancing the role of clinical psychologists in the multi-disciplinary collaborative practice through learning about different service delivery models in the training program.
The training took place at the University of Melbourne and on the clinical oncology department in St. Vincent’s Hospital in Melbourne, Australia. The training was divided into two parts – a four day training workshop and a 2-weeks clinical attachment.
Similar to the practice in Hong Kong, the palliative care team provides inpatient, outpatient, consultancy and day care service. The team also liaises closely with services in the community, e.g. the Melbourne City Mission team who offers home visit and home based support. After office hours telephone support service was often operated by senior palliative care nurses so as to support patients and carers living in the community.
At St. Vincent Hospital, there is a specialized team named the Psychosocial Cancer Care team to offer inpatient and outpatient psycho-oncology service to cancer and palliative care patients. The team is led by psychiatrists and includes clinical psychologists, music therapist and art therapist.
Through this training, we learned about the use of Biopsychosocial-spiritual (BPSS) Model in understanding patients’ psychosocial and spiritual needs and guiding psychological treatment. We also observed how the use of psychotropic drug for psychiatric problems or illness related symptoms could ease patients’ distress efficiently. Lastly, participation in staff support group had equipped us to offer spiritual support to our team in the future.
This overseas training offers a valuable opportunity for us to update our professional knowledge and clinical skills in assessment and management of psychiatric and psychological distress in palliative care setting. The combination of training workshop and clinical attachment is perfectly arranged for our learning, to apply what we have learnt in clinical practice.