Posted by Doris 

Hi Dr,

Will breast cancer cells spread to the other breast or other parts of body after one of the breast had been removed and confirmed it is a localised case. Why was breast cancer not detected even when a mammogram was done every 2 years? Will it be good to wear bra the whole day or without after surgery? What are the types of food to take after surgery? Will a benign cyst turn to cancerous and how to monitor from benign to cancerous? Thank you very much in advance.

Answered by Asst Prof Sabrina Ngaserin, Breast Surgical Oncologist and Consultant, from Sengkang General Hospital (SKH) Breast Service

Dear Doris,

Thank you for your questions! Perhaps I can break them down into individual responses so that I may address each one in more detail.

1. "Why was breast cancer not detected even when a mammogram was done every 2 years?"

The speed of breast cancer cell to mass development can vary. Like all cancer cells, breast cancers start from a single cancerous cell, which divides and replicates into an evolving and enlarging cluster, until it gains enough mass to finally reveal itself. Breast cancer can be diagnosed from palpable lump, more subtle signs such as skin and nipple areolar changes, or be completely asymptomatic and detected only on imaging modalities. The Ministry of Health Singapore, Health Promotion Board ‘Screen for Life’, and Singapore Cancer Society recommend mammograms as the most reliable screening tool for breast cancer, as they can detect the presence of pre-cancerous lesions or early breast cancer even before they can be felt by hand. It is suggested that women of average risk for breast cancer who are 50 years of age and above get their screening mammograms once every two years, and women aged 40 to 49 years of age should consider doing screening mammograms every year.

The suggested age of commencement and frequency of screening was carefully derived based on evidence, with the aim of striking a balance between actual cancer detection and "over screening" across our population. While logic dictates that more frequent screening tests will allow more cancers to get picked up the moment they occur, for most ladies who may never be diagnosed with breast cancer in their lifetime, this may actually result in over-detection of other benign lesions, additional investigations, with the associated increased overall costs in order to achieve this. While this may allay fears for the affected individuals, such benign lesions would not have otherwise had significant impact to their survival. Therefore, although regular screening mammograms remain important for early detection of asymptomatic cancers, like you rightly mentioned, breast cancers may still develop in between the intervals of planned screening X-rays. This is why we also emphasize the importance of regular monthly breast self-examination as a crucial part of breast awareness so that any ‘surprise lumps’ that manifest in between can be detected as early as possible.

2. "Will breast cancer cells spread to the other breast or other parts of body after one of the breast had been removed and confirmed it is a localised case?"

I understand from your statement that you probably have experienced early breast cancer which was localized to the breast, no axillary lymph node spread, and that you have undergone breast conserving surgery.

Generally speaking, when completely treated based on best practice recommendations, early breast cancer can be successfully "cured" and the change of survival is said to be reasonably good. Below I’ve included the Age-standardized Relative Survival (ASRS) with treatment published by our Singapore Cancer Registry (2013-2017).

That said, breast cancer recurrence risk can still linger years after treatment ends. This may occur "locoregionally" in the breast or lymph node regions or as "metastases" (spread to other organs). This is why your breast surgeons and oncologists are likely to recommend lifetime surveillance, which will include regular clinical evaluation and mammography that assesses any remaining breast tissue you may have. Any unusual symptoms may prompt further testing.

For each case of breast cancer, patient, tumor, and treatment factors can cause the risk of recurrence to vary. To answer your question in a more individualized and detailed fashion, I will require more clinical details, including your personal profile (age and menopausal status), risk profile, tumor biology, cancer stage, if you were a candidate for genomic testing, and any other recommended/completed accompanying treatments (such as chemotherapy, radiotherapy, targeted therapy, hormonal therapy, or others).

In particular, ladies with early breast cancer that are hormone positive and HER2 negative may be a candidate for genomic testing. Genomic testing of your cancer allows computation of a "recurrence score" that can predict how likely it is that your breast cancer may return. You are presented with a relatively more tangible percentage figure. These results may have also influenced your treatment options.

All this said and done, I do emphasise that the most important part of being a cancer survivor is overall self-care (physical and mental) and maintaining a positive outlook. Do empower yourself to go on living your best life!

3. "Will it be good to wear bra the whole day or without after surgery?"

Post-surgical bra advice will depend on the nature of your operation. For most breast conserving oncoplastic surgeries that involve reshaping of the breasts, your breast surgeon may have advised you to fit for a bra with full cups, soft seams, and comfortable underband, and avoid compression that may result in distortion, as your newly remodeled breast shape is being set. I generally advise my patients to wear these around the clock (except when they are in the shower), at least for a couple of weeks for maximal benefit.

4. "What are the types of food to take after surgery?"

There is no evidence to say that one has to deliberately restrict any part of their diet after their surgery. We do advice avoidance of particular medications and herbs prior to and around any invasive procedure, as some have known or unexpected blood thinning effects that may increase risk of bleeding. The most important consideration here is a healthy balanced diet that keeps you strong and positive during this period of recovery. Consider an increase proportion of healthy foods such as brown rice, wholemeal bread, fruits, vegetables, fish, lean chicken, tofu, dairy, and water during this period of recovery. You should try and remain physically active (within reason) as long as your surgeon hasn’t highlighted any concerns pertaining to recovery.

5. "Will a benign cyst turn to cancerous and how to monitor from benign to cancerous?"

A simple breast cyst is essentially a fluid-filled sac. Its size is dependent on the amount of fluid entrapped within. In the absence of suspicious features and/or solid components on complete clinical and radiological evaluation, a simple breast cyst has negligible risk of malignancy. Treatment is necessary only when you have specific symptoms of concern, for example pain from cyst wall distension, infection, or if they are very large and unsightly. For these cases, we can perform "needle aspiration" to extract the cyst contents, usually under image guidance. You should not require any further surveillance in straightforward cases. Surveillance for a limited duration or further investigations may be required should you develop any unusual features.