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Did you know, breast cancer is the #1 cancer amongst women in Singapore?
In fact, 1 in 13 women will get breast cancer by the time they are 75 years of age, and 1 in 6 women diagnosed are younger than 45 years old. Early detection is key, as it can often allow your breast specialist to execute preventative measures, prompt and often more simplified treatment options. Every woman with breast cancer deserves quality care to continue living their best life. This means an individualised multimodal treatment journey that optimises survival, and a supportive environment that priorities emotional wellbeing and each patient's quality of life.
Modern breast cancer surgery should include advanced state-or-the-art treatment options, including the latest minimally-invasive, oncoplastic, reconstructive, and symmetrising surgical techniques when preferred and possible. We aim to surgically save as much healthy breast tissue when desired with oncologic safety, restore femininity and preserve quality of life.
For February's 'Ask the Specialist' forum, Assistant Professor Sabrina Ngaserin, Breast Surgical Oncologist and Consultant from the Sengkang General Hospital (SKH) Breast Service, a member of the SingHealth Duke-NUS Breast Centre and SingHealth group, answers your questions about early detection, modern breast cancer therapy and advanced surgical techniques.
This forum is open from 1 Feb to 26 Feb 2021.
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is it all cases of breast cancer can save most of the tissue and could spare the nipple? or it depends on how big the affected areas and location of it?
Answered by Asst Prof Sabrina Ngaserin, Breast Surgical Oncologist and Consultant, from Sengkang General Hospital (SKH) Breast Service
Dear Li,
Thank you for your questions!
Breast conserving surgery (BCS) is a safe and often desired surgical approach for patients who have been diagnosed with early breast cancer. As you are probably aware, BCS can provide a better cosmetic effect compared to other radical treatments, improve patient satisfaction and quality of life.
While planning your surgical options, your breast surgeon takes into consideration several factors:
Simply put, we can conserve healthy breast tissue as long as we can safely resect all cancerous tissue with good cancer-free margins, while maintaining an acceptable cosmetic outcome in a patient that can also undergo radiation therapy. In patients with non-palpable tumors, several methods of pre-operative tumor localization exist, including wire-, radar-, radio-guided etc. Some patients may benefit from neoadjuvant (pre-operative) systemic therapy that may reduce the size of the cancer and enable the surgeon to minimize the area of resection required, such that they may improve your cosmetic outcome. Here, the tumor biology (subtype) is often taken into consideration.
Modern oncoplastic breast conserving surgery techniques also include individualized approaches with possibilities including periareolar, inframammary, axillary incisions, Mastopexy and Mammoplasty, Intercostal perforator artery flap reconstruction and breast symmetrization procedures.
The ultimate goal of BCS and RT is to minimise your local recurrence rate, described ideally to be less than 1% risk of 10-year local recurrence, and maximize your quality of life through your survivorship.
hello,
any maintenance suggestions for tnbc, post mastectomy & chemotherapy?
tnx.
Dear Moty1234,
Thank you for your question!
Triple negative breast cancer (TNBC) i.e. breast cancers that are not fueled by the hormones estrogen and progesterone, nor the HER2 protein, occur in only about 10-20% of breast cancers. TNBCs do tend to raise concerns as they are considered to be more aggressive and may confer a poorer prognosis than other types of breast cancer. This is related to factors such as their tendency to be of higher grade (they less resemble normal healthy cells in appearance and growth patterns), are usually of "basal-like" cell type, and have fewer targeted medications that can be utilized in their treatment.
As you may be aware, all breast cancer survivors will be advised to continue lifelong surveillance with your managing surgeon and/or oncologist. Best practice guidelines recommend clinical evaluation every 3 to 6 months for 3 years, every 6-12 months for the next 2 years, and annual thereafter. Survivors should also be monitored with annual mammography. Other imaging modalities such as chest X-rays, CTs, bone scans and PET-CT scans are reserved for patients with specific symptoms and/or lesions that require a duration of surveillance.
I believe the best advice one can give for all cancer survivors is to stay healthy and happy - Manage the factors you can control! Do exercise, maintain a healthy weight and diet, and keep ahead of any other medical issues.
To be more specific, the Singapore Health Promotion Board recommends 150 minutes of moderate aerobic activity or 75 minutes of vigorous activity each week. Research has shown that physical activity can decrease our risk of breast cancer with an average risk reduction of 25 to 30%. While the reasons for this are still unknown, we believe this could be related to generally positive impact on our immune system, improved body composition with reduced-fat that accumulates around the abdominal organs (visceral adipose tissue), the effect of exercise-induced hormonal release, and decreased exposure to free estrogen that promotes the risk of breast cancer development. For cancer survivors, exercise can also reduce treatment-related fatigue syndrome, potential depression, help regain a sense of self, improve the quality of life, as well as improve survival. This is possibly related to our improved physical performance capacity, body composition and mood.
Posted by KC
Hi,
I did an operation in year 2019 and followed with 4 chemotherapy and currently on temoxifen and hormone jab every 3 months. My memory has still not improved and my weight have been increasing even with strict diet, my temper also has been super bad. What can I do to improve my memory and focus?
Dear KC,
"Chemo brain" or "Chemo fog" is a common colloquial term used by cancer survivors to describe what you may be experiencing. The causes of cancer and/or chemo-related cognitive impairment or dysfunction aren’t well understood, adding to frustration and debilitation of those who experience it in their daily lives. One might find they have difficulty concentrating and have a shorter attention span, finding the right words, take longer to complete their usual routine tasks, feel disorganized, or even experience short-term memory loss and/or confusion. The reasons for this are usually multifactorial. It has been postulated that certain cancers may produce chemicals that affect memory, or this may also be related to anxiety and depression surrounding the diagnosis, treatment, and its side-effects. Rarely, it may be due to cancer spread to the brain, and one should consult their oncologist for dedicated imaging if this is a major concern. Occasionally, this is instead related to other medical conditions that one may have developed over time, such as diabetes, thyroid problems, or nutritional deficiencies.
If this is your experience, first and foremost, share this with your medical oncologist. You may require additional investigations, or a referral to a neurologist, psychiatrist, neuropsychologist or occupational therapist, so that a specialist in the field can provide you help and guidance through these difficult times.
As I mentioned to "Moty1234"in a separate reply (scroll up for reply), regular exercise also has proven benefits for cancer survivors and may help with your weight-related issues. Exercise has also been shown to reduce treatment-related fatigue syndrome, potential depression, help regain a sense of self, improve the quality of life, as well as improve survival.
There are also multiple advantages to joining a survivor support group. Fellow cancer survivors with similar experiences give you a chance to discuss your own journey, talk about your feelings, enable you with practical solutions and help you cope in general. There has also been evidence suggesting that a supportive social environment that advocates positivity can improve cognitive processing, stress management and conflicting evidence suggests a possibility of prolonged survival.
Posted by POON
Dear Dr,
Check with you, my mother has breast cancer at stage 4, any solution can help and cure in order can last a few years for her life. Thanks.
Dear Poon,
Thank you for sharing. I’m very sorry to hear of your mother’s diagnosis of stage IV breast cancer.
For women with metastatic breast cancer, our treatment considerations include the patient’s background health and fitness, the biology of the cancer (subtype), the organs affected by cancer spread, the most common of which include the liver, lung, bone and brain, and of course, the patient’s wishes. The aim of any treatment is to prolong quality life and address any specific cancer-related symptoms and complications.
The mainstay of treatment is systemic therapy, which may involve chemotherapy, targeted therapy, hormonal therapy and/or immunotherapy. These may act to improve symptoms, retard cancer growth and progression, and prolong survival. Surgery and/or radiation therapy may be useful to address specific situations, such as fungating wounds, brain and spinal cord complications, fractures, or relieve pain, bleeding, and other symptoms etc.
For your strong consideration, some studies also suggest a possibility that women with metastatic breast cancer can live longer if they join a breast cancer support group. Even if this were not so, a strong social network can be helpful in maintaining positivity, take away any feelings of isolation or hopelessness, and help empower our loved ones to continue living their best lives.
Posted by Carol
Are there any diet restrictions or lifestyle changes needed for patients who have been diagnosed with Stage 1A breast cancer (hormone receptor positive, HER2 negative, ONCOtype recurrent score <15) and have undergone lumpectomy, radiation therapy and hormone therapy? I would like to understand if there are specific types of food or lifestyle habits that could trigger a recurrence. Thanks.
Dear Carol,
Congratulations and all the best on your journey in breast cancer survivorship! It is no easy feat to have experienced and completed ideal cancer treatment, and understandably prevention of recurrence weighs heavily on our heart and minds.
To minimise our risk of breast cancer, evidence suggests that we should avoid a sedentary lifestyle, obesity, and alcohol consumption. There is no conclusive evidence to suggest any specific food one should avoid. In general, one should still aim for an overall healthy balanced diet, do regular exercise and maintain a normal weight range. These simple principles will already protect you against breast cancer recurrence and other detrimental health issues.
To be more specific, eat a balanced diet of whole grains, fruit, vegetables, and protein. The occasional treat may help to maintain your spirits! Regular exercise is imperative towards maintaining your goals and research has shown that physical activity can decrease our general risk of breast cancer with an average risk reduction of 25 to 30%. Aim to maintain a body mass index (BMI) of 18.5 to 23.0 kg/m2 whenever possible. These efforts will help empower your body to heal from the effects of treatment, any complications (side effects), and correct potential nutritional deficiencies.
Would to know if one's chances of having breast cancer will get higher or lower after menopause and also whether the chances will get higher or lesser when one ages into her 60s/70s/80s?
Dear tsg987,
In general, the risk of breast cancer increases with age. So yes, the chances will increase as we "age into our 60s, 70s, 80s" etc.
Menopause itself is not associated with an increased risk of breast cancer. However older age at menopause (55 years and above) is a known factor that may confer increased risk, when analyzed together with age of menarche (first menstruation), parity (how many children one has), age of first live birth, and duration of breastfeeding (which is protective). This is related to an increase in lifetime estrogen exposure that may increase one’s risk of breast cancer. Several studies have also established the association between obesity (high BMI and adult weight gain) and increased risk for breast cancer in postmenopausal women. This increase in risk has also been attributed to increase in circulating endogenous estrogen levels from fat tissue.
The overarching advice for all ladies is still to be consistent with breast health awareness – known your risks, optimize your lifestyle choices, perform regular breast self-examination and do age-appropriate mammogram screening. Early detection saves lives!
Posted by R Poolman
Is a mastectomy a good idea to prevent breast cancer in the future? I am 55 years.
Dear R Poolman,
With the information you have provided, I hope it’s alright if I presume you are a 55-year-old lady, with no current breast cancer, who is of average risk for breast malignancy. That said, I will touch on the alternative situations pertaining to personal breast cancer risk in hope that I may clear any doubts more thoroughly.
To provide you with a better idea as to the risk-benefit of undergoing major prophylactic (preventative) surgery such as a mastectomy, we should first assess your personal risk for developing breast malignancy. One could be said to be of "average risk" (same as the general population) or "high risk" of developing such a condition.
There are multiple factors that influence our risk of developing breast cancer including personal, genetic, hormonal, environmental and lifestyle factors. To be more specific, these include your profile (age, family history breast density, and possible inherited genetic conditions), past medical history (especially previous breast cancer or high-risk breast lesions), the possibility of increased lifetime estrogen exposure, and your lifestyle choices.
An individual may be said to have "high risk of breast cancer" if they have:
Individuals with a high risk of breast cancer due to an established genetic mutation may be offered risk-reducing strategies, which may include lifestyle modification, agents such as hormonal therapy, and/or surgical mastectomy and bilateral salpingo-oophorectomy. For all these patients, we seriously consider and discuss the potential medical and psychosocial effects of preventative treatment. Any lady who has been offered a mastectomy should have options for reconstruction discussed as well.
Bear in mind that a mastectomy is not a 100% foolproof measure. The risks would outweigh the benefits of surgery in ladies with an otherwise average risk of breast malignancy.
In general, 1 in 13 women in Singapore will develop breast cancer by the age of 75, and for the average risk population, ideal prevention and potential for early diagnosis still comes from regular breast self-examinations and screening mammography. To answer your question in a more individualized and scientific manner, your breast surgeon can perform a clinical review and embark on a more detailed discussion!
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.
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.
Posted by PJ
I would like to understand how come the Breast Cancer Screening Programmme organised by Health Promotion Board only target women 50 years and older?
How about age group of 40 – 49 years old, we could be in high risk as well. As I learn from MOH screening guidelines that 40% of the breasts cancer cases are diagnosed in women below the age of 50.
Dearest PJ (and Yu),
I’m so glad your questions have given me the opportunity to touch on the issues surrounding the appropriate age to start screening mammograms. I hope you don’t mind that I answer them together because they touch on the same topic.
There has been intense worldwide ongoing debate regarding the appropriate age to start screening mammograms for ladies who are of average risk for breast cancer. Actually, the Breast Cancer Screening Programme under the Singapore Health Promotion Board’s Screen for Life (SFL) Programme does offer screening mammography to all ladies aged 40 and above. Ladies can sign on as long as we are:
As you may have noticed, the recommendation is clear above the age of 50, but advises ladies to “speak to their doctors” about the benefits and limitations in going for mammogram screening from ages 40 to 49. I’m grateful for the chance to further address this.
In the last decade, as breast cancer mortality started to decline, a number of studies and medical professionals had started to question the value of screening mammograms, suggesting that while they do save lives, for each breast cancer death prevented, several other women suffered false-positive results, were over-diagnosed, and over-treated.
False positives, over-detection, and over-treatment can bring about “unnecessary” physical and psychological and economic costs. Such controversies enhanced disagreement about the role screening mammography played in the declining rate of breast cancer mortality.
In response to this, multiple large-scale studies targeted at answering these doubts were launched and published as recently as 2020. They have gone on to prove more conclusively that screening mammograms under 50 years also saved lives in the long term. To be more specific, both screening mammography and improvement in modern treatment contributed to positive overall outcomes. Although the overall survival benefit for women aged 40 to 49 is less compared to women above 50, multiple health organizations still conclude that even modest potential benefit outweighs the risks of false positive results, over-diagnosis and over-treatment. This means that overall current evidence does suggest that screening mammogram significantly reduces the risk of death due to breast cancer for women aged 40 and above.
As a result, current internationally well-recognized guidelines concur that it’s definitely appropriate to start screening mammography from 50 years and above, because the increased risk of breast cancer plus the evidence for survival benefit to this age group is clear. While there is no perfect agreement for younger ladies, some guidelines still describe it as a choice with informed discussion, while others recommend it strongly in ladies 40 to 49 years of age. At 40-49 years, increased frequency is also advised as younger women tend to have more dense (less fatty) breasts, such that a mammogram may not be able to detect abnormal tissues as well. This is why annual screening is recommended instead of 2 yearly, so that more subtle changes can be better detected at closer intervals. Ultimately, guidelines are formulated based on scientific evidence with the intention to maximize patient benefit and minimize harm, take into consideration overall socioeconomic impact, and all guidelines evolve with evidence and time.
To answer Yu on your question of informed consent – A screening mammogram is not an invasive study, and ultimately does not pose direct harm to your health. The radiation risk from a mammogram is about the amount a person would expect to get from natural background exposure over 7 weeks and has never been shown to cause harm. While plenty of forward-thinking ladies appreciate detailed advice, mammogram screening would not require formal “informed consent” and documentation.
The reality is that every woman is at some risk of breast cancer, and that risk does increase with age. The most recent published statistics suggest that 29% of invasive breast cancers occurred in ladies in Singapore under 50 years of age, and the remaining occur in ladies 50 and above (National Registry of Diseases Office, Singapore, 2013-2017).
So my general advice as a woman is to act to maximize our personal benefit – All women of average risk for breast malignancy, should be performing monthly breast self-examinations and commence screening mammography at age 40 (fully understanding the above described rationales), so long as they are in good health, and desire a chance at early intervention for breast cancer.
Sign up for your SingHealth Screening Mammogram via this link/form: https://form.gov.sg/#!/5f50934b1e0c6e0011fad28e
Posted by Yu
I have a health screening check by a medical centre, the check includes mammogram screening, the result on the report is "normal appearance".
Later on I found the medical centre did not go through the benefits, limitations and potential harms associated with screening mammography.
May I know why it is important to go through the benefits, limitations and harms for age 40 - 49 year old ? do we also need to sign an informed consent?
Dearest (PJ and) Yu,