​Breast Cancer - Doctor Q&A

Breast cancer is the top cancer diagnosed in women, and the annual incidence of breast cancer is increasing. Do you know what are the symptoms to look out for? What factors put you in the higher risk group? What are the types of breast cancer surgery and treatments available? In this article, specialists from the SingHealth group will address your questions about breast cancer.

This As​k The Specialist forum has closed. Thank you for your interest and participation.

1. Question by L********@yahoo.com
Dear Dr,
I have a breast cyst for several years now, can breast cyst become breast cancer?
Can exercise/sport help prevent cancer?
Thank you

Answered by Dr Lim :
Dear Lucy,
Most of the times, breast cysts are non-cancerous. If you had this breast cyst for many years and there was no change in the cyst size and features over these years, then this cyst is unlikely to become breast cancer. 

Regular exercise has several benefits and may lower your chance of getting breast cancer. However, it will not prevent breast cancer altogether.

2. Question by F***** 
Dear Doctor,
My daughter is 15. She has got few lumps on her right breast. Size: 5.0X3.2 cm, 2.6X1.5 cm and 3.0X1.6 cm. After necessary examination through ultra sound and FNAC doctors confirmed that it is Fibroadenoma and recommended surgery to fully remove this.

I went through available literatures on Fibroadenoma on internet and came to know that in most cases doctor don’t recommend any surgery as often it naturally removes. So usually doctors observe the lump/s for a period and go for surgery only if there are some special situations.

I am a bit confused and therefore looking for your opinion. Would highly appreciate your response.

Answered by Dr Lim :
Dear F*****,
As you have rightly pointed out, fibroadenoma is a benign condition. However, there are certain situations that will require removal. In this case, I will recommend that you arrange for your daughter to be examined by a specialist. Together with your daughter’s breast imaging and fine needle aspiration cytology (FNAC) results, the specialist can individualise a treatment plan for your daughter. 

3. Question by J*** 
My mum was diagnosed with breast cancer in her 60s. The doctor told her that her cancer was genetic and not caused by hormones, so she was not given any chemo post breast resection. Since it is genetic, is there anything my sisters and I can do to reduce our risk of getting breast cancer? Thanks

Answered by Dr Lim :
Dear J Lee,
Based on what you had shared, if your mother’s cancer is truly due to a genetic cause, your mother would most probably had undergone a genetic blood test to confirm the genetic cause. If a genetic mutation is detected in your mother, then you and your sisters can also go for genetic testing. If any of you are tested positive for genetic mutation, then you could undergo prophylactic bilateral mastectomy, like what Angeline Jolie did, as one of the options to reduce the risk of breast cancer. There are also other ways to reduce breast cancer risks which are recommended only for high-risk genetic mutation carriers. Please seek a further assessment with a breast specialist.

4. Question by S*** 
Hi Dr Lim,
I did an ultrasound in April 2019 and note that there’s a septated cyst at 11 o’clock measuring 2cm from nipple but no solid component was found. I could not really feel this 11 o’clock cyst at that point of time or maybe it was not noticeable to me during then. 

I also had a lobulated tall nodule which I had later done a biopsy for in May and the results is just mildly inflamed cyst with no papillary structures. 

Recently I find that the 11 o’clock septated cyst got more obvious as in i can feel it as a lump and if I press down with pressure, I can feel very slight pain. My question is am I required or when do you think will be more suitable to come back for another ultrasound again given that I just did one in April 2019? Thanks.

Answered by Dr Lim :
Dear S***,
If you had now found a breast lump which was more obvious, please kindly make an appointment for another consultation. As new breast lesions can occur anytime, we need to be sure that the lump that you are feeling is truly the 11 o’clock cyst and not a new breast lesion around the same area, which had appeared in the interim since your last consult this year. I would generally advise a consultation first so that the most appropriate type of breast imaging for you can be ordered. 

5. Question by M****
Hi Doctor
I am in my early 30s. My mum has breast cancer at 55 years old and my Grandmother has uterus cancer at age 65. 
Is it a huge cause of concern if I:
1.Don’t exercise
2.Don’t limit my diet
3.Have 10 over lumps in my left breast and 15 over lumps in my right breast?

Answered by Dr Lim :
Dear M****,
In general, adopting a healthy and balanced diet and regular exercise help to maintain health. However, even if you perform regular exercise and have a healthy diet, these measures do not guarantee that you will not develop breast cancer in your lifetime. As for your multiple breast lumps, please seek further assessment with a specialist to exclude a cancer in any of these lumps. 

6. Posted by S****
I was very traumatised by my last breast screening session. I absolutely dislike the mammogram machine. 
Science has advanced so much in these recent years. But breast cancer testing is still seem so ancient and uncomfortable. 
So my question is are there new alternatives of breast cancer screening besides the mammogram. 
How accurate is the genetic testing? 

If I find out I’m high risk - can I choose to carry out mastectomy for both my breast and cosmetically rebuild them. How long is the downtime from mastectomy and recovery from the whole process. Can the cosmetic rebuilding of breast be done immediately after the mastectomy?

Answered by Dr Lim :
Dear S****,
I am sorry to hear about your last mammogram experience. However, a mammogram is still the recommended way for screening early breast cancer. Other methods have limitations or are still experimental. 

To decrease the discomfort associated with mammogram, you could try scheduling your mammogram on the week after your period. You may also consider taking a mild painkiller, such as paracetamol, before the mammogram. Also, please communicate your concerns to the mammographer attending to you so that she can make adjustments accordingly. These measures may make your next mammogram less uncomfortable.

Genetic testing involves the testing of certain genes which are currently known to cause breast cancer. If it is performed in a validated laboratory, the results are quite accurate. It is also most informative when the test result is positive for a genetic mutation, then your risk for breast cancer will be markedly increased. If tested negative, unfortunately, you may still get breast cancer in your lifetime, probably due to other risk factors or other gene mutations which are still unknown for testing. Having said this, genetic testing is indicated only for certain groups of patients.

If you are truly confirmed to be at high risk for breast cancer by your doctor, you can undergo mastectomy for both breasts and rebuild them cosmetically. The hospitalisation stay may range from five days to about two weeks or longer, depending on the success of the operation. Most people would return to work about four to six weeks after operation. The cosmetic rebuilding of the breast is best done immediately after the mastectomy for the best cosmetic outcome, unless there are certain reasons to delay the rebuilding the breasts, such as the patient is unfit for long operations, etc.

7. Posted by G**
My questions:
1.If my mum has breast cancer in her 40s, does it mean that I will definitely get breast cancer later in my life?
2.I have micro calcification in my breast, will these develop into cancer later in my life? I am aged 51. For my past 2 mammogram, there are no changes and doctor only recommend yearly monitoring. It is kinda of like a time bomb to me and living in fear.

Answered by Dr Lim :
Dear G**,
It does not mean that you will definitely get breast cancer in your lifetime if your mother had breast cancer. Unless your mother’s breast cancer was related to a genetic cause and you also inherited that gene, then your chances of getting breast cancer will be markedly elevated.

However, I also understand that you are now 51 years old and still free from breast cancer, hence the chance of a genetic-related breast cancer is not high.

Microcalcifications can be harmless findings, especially if they had not changed for a long time. In these cases, these stable microcalcifications can be left alone. Your doctor will be the best person to reassure you about your microcalcifications.

8. Question by J*
Dear Mdm,
I have completed the treatments for breast and lymph nodes cancer. 
Done right side mastectomy on 7/6/18, sentinel lymph nodes removal, 8 cycles of chemo, 15x radiotherapies, 18 jabs of SC Herceptin because it was triple +ve, taking Nolvadex D since 26/12/18.

Can you please advise me if I need to remove Mirena (had prolonged 6 mths menses in 2015), ovaries (one side dried), uterus and cervix? To prevent chance of relapse? 

Last ultrasound 2 weeks ago, discovered a 4.8mm cyst on left side of the breast. It's same place of which a cyst was removed in 2000 and excretion on 7/6/18 because there were 3 cysts on different parts in same breast, 2 o'clock, 5 o'clock and 11 o'clock. Therefore, this cyst is 3rd time in same place. What should I do about it? 

What is the survival rate for me? Heart functioning at 58.5% after Herceptin 600ml SC x 18 cycles. 
My mum deceased at 49 yrs old due to uterus cancer, elder sister had cervical cancer 5 yrs ago. So, is it genetic? 
Your kind and professional advice would be appreciated. Thanks.

Answered by Dr Lim :
Dear J*,
Depending on the reason why Mirena is needed in your case and the stage of your breast cancer, you may wish to discuss further with your breast specialist and gynaecologist on the risks and benefits of keeping Mirena. In general, there are currently limiteddata about the link of breast cancer and Mirena, though the use of hormonal contraception is generally not advised in breast cancer patients.

Although removing the ovaries will decrease the chances of breast cancer relapse, it may carry some risks associated with premature menopause. Certain factors, such as age, desire for further children and characteristics of breast cancer, etc, are taken into consideration when deciding whether the ovaries, uterus and cervix are to be removed. As such, it is best that you discuss with your breast specialist on your most suitable treatment plan.

Cysts are generally harmless, especially if they do not exhibit any suspicious features on imaging. It is most appropriate that the doctor reviews your ultrasound images and reports to determine your next course of action.

Survival rate is dependent on multiple factors which include your co-existing medical conditions and the stage of your breast cancer, which includes the size of your breast cancer and the number of lymph nodes involved, etc. Your breast specialist who knows your condition the best will be the most ideal person to advise you on your survival rate.

I am sorry about your mother and your sister. Although it is unlikely that their cancers and your breast cancer are linked to a genetic cause based on what you had shared, a full assessment can only be made after a detailed family history and/or genetic testing. As a result, I would recommend that you consult your breast specialist who knows your case to do a more detailed assessment. 

9. Question by C*
Dear Dr, 
Per ultrasound - Right small solid nodule likely a fibroadenoma with well defined hypoecheic lesion seen measuring 5mm. The Axillae are unremarkable. Best option is to observe and re- scan 6 months later or see a surgeon for biopsy of the lesion immediately? Your advice please. Thanks.

Answered by Dr Lim :
Dear C*,
Your ultrasound report suggests that you have a right breast lesion which has favourable features. However, I will still recommend a consultation with your doctor, who could also examine you, in order to correlate your ultrasound findings with your physical examination. In this way, the most suitable treatment could be planned for you.


10. Question by H**
I am a 42 yrs old breastfeeding mum, both my breasts have multiple cyst, a ultrasound of breasts or mammogram can I do to screen my breasts for breast cancers?

Answered by Assoc Prof Tan :
Women 40 years and above may consider doing a mammogram for screening. There are changes in a lactation breast, hence you should inform the radiographer that you are breast feeding before the mammogram. The milk in the breast may also make it difficult to detect abnormalities. Hence, it may be useful to also have an ultrasound of the breasts. To get the best images, try to “empty” the breasts just before the mammogram &/or ultrasound.

11. Question by s****
If there’s occasional pain or throbbing on the right side of breast after an upper body massage, is that a cause for concern?

Answered by Assoc Prof Tan :
Breast cancer does not usually present with pain. Hence if there are no other symptoms, the pain may be due to other causes. Commonly throbbing pain is due to muscle ache or strain. A large muscle called the Pectoralis Major is situated across the chest and behind the breast. This muscle is in use when you lift loads like grocery, laundry or when mopping the floor. Straining this muscle may give rise to throbbing pain. However, if in doubt, please see a doctor.

12. Question by J******
Does large/daily consumption of grapefruit increase a person's risk of breast cancer?

Answered by Assoc Prof Tan :
The link between grapefruit and a potential increase in breast cancer risk came about from an article in 2007. There are limitations & flaws in this article as pointed out by various British & American Healthcare experts. Hence, there is no scientific evidence that grapefruit increases the risk of breast cancer. It is advised that you have a healthy balanced diet consisting of carbohydrates, proteins, fat & fibre. Together with regular exercise and adequate rest, it would help you to maintain a good immune system.

13. Question by S********
Dear Doctor, one of my friend's wife aged 40 yrs has been diagnosed with breast cancer (initially stage 3) since August 2018. She has been given many sessions of chemo & harmone therapy since then and in addition surgery is made on her left breast. Last month she was diagnosed with metastasis (stage 4?) spreading to her bones and lungs. With utmost desperation and anxiety they are seeking second medical opinion on her further treatment and survival rate. We therefore seek your advise Doctor. Thank you very much.

Answered by Assoc Prof Tan :
I am sorry to know of your friend’s wife’s condition. Breast cancer in young women tend to be aggressive and can progress despite being on treatment. With the cancer having spread to the lungs and bones, she would benefit from treatment that is systemic ie delivered throughout her body. Depending on the features of the cancer, different strategies may be applied. Consultation with a medical oncologist would be more appropriate.

This is a difficult time for your friend & his wife. Other than medical treatment, emotional support is important, which can come from friends & family. I wish them all the best.

14. Question by B****
I just had a mammogram done. Is there any cause for concern if vascular calcifications are noted in my right breast? I had cancer in my left breast about 15 years ago.

Answered by Assoc Prof Tan :
Vascular calcification are deposits of calcium within the wall of blood vessels. They do not affect the breast tissue and therefore are not a risk factor for breast cancer.

15. Question by D****
I have a question here:
1.What is suspicious Ductal carcinoma in-situ?
2.Histology shows cores of breast tissue and small free lying fragments of atypical epithelial cells (negative staining and diffuse ER positivity) focally associated with necrosis and calcification. Absence of any intact ducts precludes assessment of architecture. The appearances are suspicious, but not diagnostic, of DCIS, intermediate and low nuclear grade.

What does the above means? Do they mean that it is confirmed as DCIS and is it serious?
Thank you.

Answered by Assoc Prof Tan :
The above statement appears to suggest that there are abnormal (atypical) cells that are suspicious of DCIS but not enough evidence to be confirmatory.

DCIS (ductal carcinoma-in-situ) is a non-invasive form of breast cancer, which with proper treatment can give almost 100% cure rates. DCIS if left untreated may progress to invasive cancer, which has poorer prognosis.

Hence, further evaluation would be advised to establish if indeed the diagnosis is DCIS, if so then you may have early treatment to get the best cure rates. This may involve requesting for a re-look at the histology slides or obtain more tissue to assess by doing a repeat core biopsy or an excision biopsy.

16. Question by C*
I did a mammogram last month and ultrasound a week after the test.
Result - 
Followed up test for MAMMOGRAM. 
Cysts found on both of the breasts for ultrasound. 

Question is do I need to go for follow up test for the mammogram? 
Since I did the ultrasound test. 

Thank you.

Answered by Assoc Prof Tan :
What was the reason for performing the ultrasound a week after the mammogram?

If it was to assess an area of shadow detected on mammogram, which then correlates (on ultrasound) it to be cysts, then it depends on the nature of the cysts. If the cysts were reported to be simple, then the next mammogram could be done, following the guidelines, depending on age: 40-49 years, annually, 50 and above, once every 2 years.

However, if the ultrasound did not address the issue that requires follow-up with a mammogram, then a repeat mammogram would be necessary.

17. Question by C*
I am 42 years old. 
Did a mammogram last month, felt pain and discomforted much later after the test. Ultrasound results are cysts on both breasts. 

I will still feel the pain and discomfort ever now and then. What should I do?
1.To see a doctor but under which Specialist?
2.Will this link to finger (last) numb (a bit)?

Answered by Assoc Prof Tan :
It is unlikely that the discomfort from a mammogram can last so long. There are many causes of breast pain. If your mammogram & ultrasound done last month did not reveal any worrisome features, it is an unlikely symptom for breast cancer. If you have a regular family doctor, you may approach him/her for an assessment, alternatively, you may see a breast surgeon.

18. Question by L*****
Hi, I am a 38 year old mum. I had mammogram and ultrasound done and the diagnosis was likely to be intraductal papillomas. Can you recommend a specialist in government hospital?

Answered by Assoc Prof Tan :
An intraductal papilloma is a growth arising from the inner lining of the milk duct (tube). Further assessment is usually advised, as most breast cancer arises from the milk ducts. The breast surgeons in the various SingHealth Hospitals (CGH, SGH, NCC, SKH) would be able to address your problem.

19. Question by K**
Discharge from the nipple is often a sign of abnormality. Does it usually happen with no other symptoms or with lactation symptom for example breasts feeling engorged on and off but never prolonged?

Answered by Assoc Prof Tan :
There are many causes of nipple discharge. It may or may not be associate with other symptoms. All nipple discharge should be properly evaluated to exclude underlying problems with the breast.

20. Question by l*
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 Ngaserin:
Dear L*,
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:

1.Tumor characteristics. BCS is done preferably for monocentric (single) or multifocal tumors (which are limited to a quadrant of the breast), as opposed to multicentric cancers (more than one separate cancer located across various breast quadrants). Any pattern of suspicious widespread microcalcifications should be taken into consideration.

2.Oncological safety. Your surgeon should be able to achieve complete tumor resection with adequate concentric ‘cancer-free’ margins. Should any cancer cells be seen to occur at or near the edge of resection on post-operative pathological evaluation, the patient should also be willing to accept a 10-15% risk of the need for a second minor (and usually day-surgery type procedure) for additional resection of margins. While the risk of a second breast operation is negligible in a mastectomy (given all breast tissue is completely resected), it will always exist with BCS even with pristine intraoperative judgement and surgical technique, for this reason.

3.Morphology of the breast in terms of location and relative tumor to breast tissue ratio. The surgical outcome should be judged to be cosmetically acceptable to the surgeon and more importantly, the patient. There is a fine balance between resecting too little or too much around the edge of the cancer, your cosmetic outcomes, and most importantly, minimizing your risk of local recurrence. The nipple can be spared if there is no evidence of direct cancer involvement clinically, radiologically or pathologically. While the traditional belief was to limit resection of the breast to 10-15% of the total breast tissue, oncoplastic surgical techniques have been known to extend these limits up to >25%.

4.The patient has no contraindications and can accept the risk-benefits of intra-operative or adjuvant radiotherapy. A majority of patients who undergo BCS will also require intra-operative or adjuvant radiotherapy (RT) to minimize their rate of locoregional recurrence (within the breast and/or lymph node region). As such, patients should not have any contraindications to RT and be willing to accept the risk-benefits of such treatment.

5.Genetic conditions that predispose the patients to a high lifetime risk of breast cancer. For example, patients with mutations that involve BRCA 1 or 2 genes should instead be counselled on the risk-benefit of therapeutic and/or prophylactic mastectomy.

6.Pregnancy. While BCS can still be planned, we take into consideration maternal and fetal safety, which will include considering the patient’s trimester of pregnancy on diagnosis. 

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.

21. Question by m*******
any maintenance suggestions for tnbc, post mastectomy & chemotherapy?

Answered by Asst Prof Ngaserin:
Dear m*******,
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.

22. Question by K*
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?

Answered by Asst Prof Ngaserin:
Dear K*,

Thank you for your question!

"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.

23. Question by P***
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.

Answered by Asst Prof Ngaserin:
Dear P***,
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.

24. Question by C****
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.

Answered by Asst Prof Ngaserin:
Dear C****,
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.

25. Question by C****
Hi A.Prof,
I am below 40 and suspected to have serious hyperplasia, it affected my milk supply greatly. Can it be cured without medical intervention, is there alternative cure and will it eventually turn into a form of breast cancer?
Does it mean that after having breast surgery, woman can no longer generate breastmilk for their babies?

Answered by Asst Prof Ngaserin:
Dear C****,
If you are referring to epithelial hyperplasia or proliferative breast disease, that is usually diagnosed on biopsy or surgical excision of an image-detected or palpable breast lesion whereby pathological assessment demonstrates overgrowth of the cells that line the ducts or the milk glands (lobules) inside the breast. 

Hyperplasia can be described as either ‘’usual’’ (whereby the cells look very close to normal cells) or ‘’atypical’’ (with abnormal cellular distortion on microscopic appearance). 

◦Lesions associated with atypical hyperplasia should be completely removed to exclude the presence of a coexisting malignancy. This can be achieved by vacuum-assisted biopsy or surgery depending on what is appropriate on a case-by-case basis. Atypical ductal and lobular hyperplasia is linked to a higher risk of breast cancer therefore patients are advised to continue vigilant breast cancer screening, which includes yearly mammography. You can discuss the pros and cons of using hormonal therapy to decrease your lifetime risk of breast cancer.

◦Meanwhile, usual hyperplasia does not change your cancer risk profile, and does not require any further intervention.

There is no evidence to suggest that hyperplasia can influence lactation and the volume of milk supply. Conversely it is mammary hypoplasia that suggests insufficient glandular tissue, which may cause a struggle in milk supply despite good breastfeeding management. Breast milk supply can be improved with a healthy balanced diet, adequate hydration, relaxation techniques, and regular latching or pumping so that supply may be encouraged to meet the demand.

As for your question pertaining to breast surgery and breastfeeding – as long as there is glandular tissue present (for milk generation) and a preserved ductal network (to carry the milk to the nipple), there is always a potential for lactation. Breastfeeding will be impossible should one undergo a complete mastectomy as the aim of the surgery is primarily to remove all breast tissue and hence this capability. However, lactation remains a possibility for breast cancer patients who undergo breast conserving surgery, patients who have had breast lump/lesion excisions, and breast augmentation. Radiotherapy to the breast has been reported to affect lactation, but attempts to make this journey a success should not be discouraged. The ultimate success of lactation will depend on the extent of disruption of glands and ducts, however rest assured that the other unaffected breast should still function as per normal. Future lactation should not be overtly affected by an isolated biopsy. Your breast surgeon is generally careful to provide appropriate counselling and advice depending on what needs to be done and what you hope to achieve.

26. Question by t*****
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?

Answered by Asst Prof Ngaserin:
Dear t*****,
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!

27. Question by R*******
Is a mastectomy a good idea to prevent breast cancer in the future? I am 55 years.

Answered by Asst Prof Ngaserin:
Dear R*******,
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:

1.A known genetic predisposition to breast cancer, including those with gene mutations to BRCA1, BCA2, p53, PTEN, and others;
2.Compelling family history of breast cancer that is suggestive of a genetic predisposition, whereby referral for formal genetic assessment/counseling is recommended;
3.Prior thoracic radiotherapy before the age of 30, e.g. to treat Hodgkin’s disease;
4.A lifetime risk of ≥20%, based on models largely dependent on family history, calculated by a cancer genetics professional. 

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!

28. Question by D****
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 Ngaserin:
Dear D****,
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).

​Stage ​5-year survival rate
​I ​100% 
​II ​89.5% 
​III ​73.3% 
​IV ​27% 

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.

29. Question by P*
Hi Dr,
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.

Answered by Asst Prof Ngaserin:
Dearest P*,
I’m so glad your questions have given me the opportunity to touch on the issues surrounding the appropriate age to start screening mammograms.

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:

1.Singaporeans or Permanent Residents
2.Aged 40 and above: 
◾Above the age of 50 years, and have not gone for a screening mammogram within the past 2 years 
◾Between the age of 40 to 49 and have decided to go for your mammogram after consultation with your doctor, and have not gone for a screening mammogram within the past year

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 positive’ results (suspicious findings on mammograms that turn out to be normal), are ultimately good news, but require further investigations and potential procedures to reach that conclusion. 

◦‘Over-diagnosis’ of a condition suggests that screening mammograms detected suspicious areas that on complete investigation were shown to be benign, would have never negatively affected the woman’s health, that the cancer prognosis may not have been affected, or perhaps even never detected in a person’s lifetime. 

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. 

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

30. Question by S******
What is the cause of having breast cysts?

Answered by Dr Beh:
Hi S******,
A breast cyst is a fluid-filled round or ovoid mass derived from the terminal duct lobular units (TDLU). Cysts begin as fluid accumulation in the TLDU because of distension and obstruction of the efferent ductule. Breast cysts are common masses found in pre-menopausal, peri-menopausal and post-menopausal women. They are influenced by hormonal functions and fluctuation.

31. Question by J*********
Other than going for regular mammogram and maintain healthy lifestyle, is there any kind of food that we should avoid (eg: dairy) to reduce risk of getting breast cancer?

Answered by Dr Beh:
Hi J*********,

As you have rightly pointed out, screening mammogram and healthy lifestyle are important. With respect to diet, I would suggest adopting a healthy and balanced diet.

Followup question by J*********
What is your advice regarding the choice of lumpectomy vs mastectomy when a lump is found? If found at very early stage, is it advisable to go for mastectomy to reduce risk of recurrence in the future?

Answered by Dr Beh:
Hi J*********,
Thank you for your question. This discussion usually takes place between the surgeon and patient. There are many aspects to the decision. 

For example: What is the ratio of breast lump / tumor to the breast volume. Are there other suspicious lumps on imaging? The patient’s preferences are also taken into consideration.
Adjuvant radiation is recommended to most patients with breast conserving surgery. The local recurrence rate after contemporary treatment with breast conserving treatment is no longer considered higher than after mastectomy.

32. Question by G*********
Hi. This year I am 58.  6 months ago I started HRT just to test whether my general well-being may be enhanced by that (I started suffering from oesteopenia and vaginal dryness). The question to you is whether HRT increases the risk of breast cancer. My hormone doctor says that is does not. No breast cancer in the family, but colon cancer yes.  Regards.

Answered by Dr Beh:
Hi G*********,
Hormone replacement therapy (HRT) has its risk of breast cancer while its benefit includes reduction of fracture. If your concern is bone health, I would suggest to ensure adequate calcium and vitamin D intake, engage in regular physical activity, achieve normal body weight and avoid smoking and alcohol use. As for vaginal atrophy symptoms (dryness) I would suggest using vaginal estrogen cream.

33. Question by R**
Hi Dr, I have a IUD Mirena for a year. I have PMS symptoms every month but no periods for many months. My breasts will swell every month for about 10-14 days prior to period. The swelling will cause some pain on my right breast, near the breastbone. It will go away after "period" day is over. It recurs the next month or so. Will this swelling cause any hardening of the breast tissue and eventually a lump may occur? I'm scheduled for my mammogram next Jan. My last scan was 2 years ago. I'm 44 this year. Can I get breasts ultrasound to check on them?
My mother died of breast cancer and had it when she was 57. 

Answered by Dr Beh:
Hi R**, 
If you are concerned about the breast swelling or lump(s), I would advise you to go to your preferred primary health physician for an assessment and he / she can decide whether to refer you for earlier scans.

34. Question by l*******
Dear Dr Beh,
So far my breast nodules do not show up on mammogram but were discovered by chance when I felt the hard lumps. They do show up when followed up with a ultra sound scan though. Will a hard breast nodule of  4X3X5mm turns malignant over time if it is not removed? Why is biopsy not the standard operating procedue for following up on hard nodules (regardless of the size) before it is too 'late'?  
Thank you!

Answered by Dr Beh:
Hi l*******, 
It really depends on the appearance of the breast nodule(s) on the ultrasound. Please discuss further with your treating physician if you are still concerned about his / her recommendation.

35. Question by S******
Hi Dr Beh, I observe that the areola at my right breast has tiny protruding spots surrounding the nipple. I can feel itchiness occassionally but no pain so far. Is it normal?

Answered by Dr Beh:
Hi S******, 
Thank you for your question. I am unable to tell for sure whether these spots are benign or not based on your description. I would suggest that you see your preferred primary care physician for an assessment.

36. Question by m*******
any maintenace treatment for Tnbc? 
Mastectomy & 4 sessions of Taxotere + Cytoxane  on 9/2019?

Answered by Dr Beh:
Hi m*******,
If your chemotherapy was given before operation, which we call neoadjuvant chemotherapy, post-operation (adjuvant) chemotherapy may be considered in some cases. Otherwise, there is no further treatment recommended.

37. Question by Anonymous
I would like to ask Dr Beh if she knows if hormone receptor breast cancer patients can drink bird nest and chicken essence pls?

Answered by Dr Beh:
Yes. I would recommend leading a healthy lifestyle including having a healthy, balanced diet. 

38. Question by M*****
Dear Dr Beh Sok Yuen,
My breast ultrasound shows that I have cysts. I had biopsy done in 2018 and result showed benign fibroadenoma. Do I need to do both ultrasound and mammogram screening every year? I am 50 years old.

Answered by Dr Beh:
Hi M*****,
Follow up of fibroadenoma will depend on your ultrasound findings too. If it is just a simple solitary fibroadenoma, the patient will usually only need to undergo mammogram screening every two years. I see that you mentioned your ultrasound showed more than one cyst. Your doctor will advise you on the frequency of follow-up depending on the appearances of the other cysts.

39. Question by M*******
Dear Dr Beh I'm already aged 67. My last mammogram was in 2015. Do I need to go for it again? 
Where can I go to get cheaper or subsidised rate as I'm not working? Thank you.

Answered by Dr Beh:
Hi M*******, 
Women aged 50 years old and above are recommended to go for a mammogram once every two years. You can find helpful information on screening eligibility and subsidy in English, Chinese and Tamil via HealthHub's website: www.healthhub.sg

40. Question by H****
Hi Dr Beh,
My mother has breast cancer at 62 years old. I'm 29. Should I start going for mammograms now? If yes, how often?

Answered by Dr Beh:
Hi H****,
For individuals with a family history of breast cancer but no proven hereditary mutation, an annual mammogram is recommended to commence as early as 5 to 10 years prior to age of onset in the youngest family member to contract breast cancer. However, the annual mammogram should not done be earlier than 25 to 30 years old and not later than 40 years old. 
In your case, I would advise you to start going for mammogram at 40 years old.

41. Question by s*******
hi i would like to check, one of my family member went for mammogram and ultrasound and the ultrasound grade came back as BIRAD 3 . the 5CM lesions were stable prior to the previous ultrasound which was done in FEB 2019 ( which is 1.5 years gap from then to now ) . No changes or anythink suspicious seen . 

mammogram came back as BIRAD 2.
now she decided to go for a biopsy as DR gave her an option ,,  its either she does a biopsy and not follow up or she follow up for every 6 month .
what are the chances for the 5CM lesion to be cancer ?

Answered by Dr Beh:
Hi s*******, 
BI-RADS is a radiological assessment of the likelihood of cancer and does not take into account clinical findings and presentation. Therefore, if the patient received a negative imaging evaluation but has a clinically suspicious lump, a biopsy may still be indicated even though the BI-RADS category is 1 or 2. 

I am unable to predict the chances of cancer based on the size of the breast lesion seen on the imaging scans. This would have to be advised and guided by the doctor who has seen your family member.

42. Question by A***
Hi Dr Beh, 
My mother passed away forty three years ago of breast cancer at the age of seventy years old. 
Dutifully I’ve been monitoring myself by doing a bi-annual mammogram until the last two years. I’m now seventy years old and had two biopsies done before. Both turned out to be negative.
I have two questions:
1. At what age is it safe to stop this bi-annual mammogram.
2. Is it true that I have a lower risk of hereditary genetic breast cancer since my mum had it when she was in her late sixties.
Thank you and looking forward to your advice.

Answered by Dr Beh:
Hi A***, 
Mammographic screening in older women should be individualised by considering the potential benefits and risk of mammography in context of an individual’s current health status and estimated life expectancy. Given your family history of breast cancer, you may consider mammographic screening every 2 years till the age of 75, weighing the benefit against your general health. Please discuss this further with your preferred primary care physician.
Based on the age of your mum’s breast cancer diagnosis alone, I would agree that your family has a low genetic risk for breast cancer.

43. Question by D****
Hi, I would like to understand what does all this means when Oestrogen receptor status...Negative 
Progesterone ..Negative.
HER2..Positive 3+
Does this results tell the patients what food must be avoided & what is Good for them to prevent reoccurrence?
Thank you & look forward for your advice.

Answered by Dr Beh:
Hi D****,
Personally, I do not advise my breast cancer patients (of any subtype) in general to adopt any special diet. I would refer them to Health Promotion Board website for recommendations on healthy diet and living. 

44. Question by P*
I had a general health screening to check my breasts, I filled-in a history questionnaire and the medical centre performed a Mammogram screening procedure. The Radiology Report stated "Dense breasts are noted, otherwise normal appearances". I am aged 40 – 49 years old and there is no staff or doctor went through the report and nobody briefed me anything about the benefit and limitation of Mammogram screening. 

May I know what is the general standard practice for this age group with dense breasts?

Answered by Dr Beh:
Hi P*,
You are absolutely right that mammography is less effective in identifying cancers in women under 50 years old because their breast tissue tends to be denser in pre–premenopausal women. I would encourage ladies at your age to discuss with the doctor about the potential benefits, limitations and harms associated with screening mammography. They should base screening mammography decisions on the benefits and harms of screening, as well as on the individual’s preference and breast cancer risk profile. If screening is to be performed, screening mammogram should be done annually if you are not deemed to be a high risk profile.

45. Question by Y***
Can general cancer be caused directly or indirectly by having a congenital defect/anomaly such as Marfan Syndrome? --> Association between malignancies and Marfan syndrome: a population-based, nested case–control study in Taiwan (found in google)

Answered by Dr Beh:
Hi Y***,
Based on case-control study and multiple case reports, there appears to be an association between malignancies and Marfan syndrome, but these have been unsuccessful in proving a cause-effect relationship. Based on the information we have to date, we should be aware of this risk when treating patients with such condition.

46. Question by M*****
I have been having nipple itch (affecting both sides - sometimes 1, sometimes both) for 2 years. I have a history of eczema and am currently peri-menopausal (about 51 y.o.). 
My mammogram last year was normal. I've also seen a dermatologist and have tried using mometasone/desonide (steroid cream) and tacrolimus ointment/pimecrolimus cream for the nipple itch, but it never fully resolves, coming back when I tried to taper off the medicated creams. 
May I know how likely that this 2-year nipple itch is actually Paget's disease? Nipples look normal, but more protruding, and can ooze/crust during bad flares.

Answered by Dr Beh:
Hi M*****,
Based on your description alone, I am unable to comment. I would recommend you to book an appointment and have an assessment made by a breast surgeon.

47. Question by B******
If I had blocked ducts while breast feeding, and some didn't go away after I stopped breast feeding, should I worry about them? During the initial days after delivering, there were even swollen lumps in my armpits. I haven't gone got any mammogram yet. I'm 42 this year. Every month before my period, I experienced slight soreness in the affected breast.

Answered by Dr Beh:
Hi B******,
Blocked ducts during breast feeding has not been associated with increased risk of breast cancer. It is normal to experience breast changes pre and during the menstrual period. If you are still concerned, please see your preferred primary care physician for a physical assessment.

About Dr Lim Geok Hoon

Dr Lim Geok Hoon is the Head and Senior Consultant at KK Breast Centre, KK Women's and Children's Hospital and Adjunct Assistant Professor with Duke-NUS Medical School. She is a trained oncoplastic breast surgeon and believes that a good cosmetic breast result is as paramount as a safe oncological outcome.

She has several publications with most of her works focusing specifically on the surgical oncoplastic techniques most applicable to Asian women. She also has a special interest in genetic breast cancer, which is why she pursued a year-long fellowship in the United Kingdom on breast cancer genetics and oncoplastic surgery.

She founded the Singapore Breast Oncoplastic Surgery Symposium (SBOSS) in 2015 to increase the regional awareness of oncoplastic breast surgery. She pioneered the minimal scar mastectomy technique and is also the inventor of the world's first virtual breast oncoplastic surgery simulator (VBOSS) used for the training of oncoplastic surgery.

About Assoc Prof Tan Su-Ming

Associate Professor Tan Su-Ming is the Head of Breast Surgery, Director of Breast Centre and Senior Consultant at Changi General Hospital (CGH), a member of the SingHealth group. She has more than 20 years of experience in the field of breast cancer.

After graduating from the School of Medicine, National University of Singapore, she was accepted as a surgical trainee. She completed her training in 1999 and was awarded the HMDP fellowship as a clinical fellow at the renowned Nottingham City Hospital (the largest breast centre in UK) and at the NHS Royal Marsden Hospital in London. After returning to Singapore in 2000, she spearheaded the Breast Centre at CGH, providing an integrated, one-stop service for patients with breast conditions.

In recognition of her excellence in patient care, she has been conferred several awards, amongst which are the (PS21 Star Service award (Individual) 2016, Healthcare Humanity Awards, Courage Fund 2017, “WOW Awards” for exceptional patient care 2018).

She teaches medical students from NUS, Lee Kong Chian School of Medicine and Dukes Post-Graduate Medical School. She is also actively involved in research, having several publications in the field of breast cancer and screening.


Dr Sabrina Ngaserin is a Consultant of Breast Service in the Department of Surgery at Sengkang General Hospital (SKH). She is also part of the SingHealth Duke-NUS Breast Centre.

Her practice covers breast cancer screening and detection, benign breast diseases, breast cancer, surgical management and follow up. Experienced in a wide range of breast procedures, Dr Ngaserin performs breast biopsies, breast lump excisions, breast cancer surgeries such as breast conserving cancer surgery including that with intraoperative radiotherapy, oncoplastic breast surgery including mastopexy, mammoplasty, and intercostal artery perforator flaps, mastectomies including simple mastectomy, skin-sparing and nipple-sparing mastectomy and minimally invasive surgery for breast reconstruction, sentinel lymph node biopsy, and axillary clearance. She also performs endoscopy and general surgery operative procedures.

Dr Ngaserin's main interest is in breast cancer therapy - she believes in meticulous diagnostic and therapeutic discussions, and creation of a personalised oncoplastic approach involving our multidisciplinary services, to guide each patient and their loved ones through their treatment journey and survivorship.

She is also passionate in education and academic teaching, and is an Assistant Professor of Duke-NUS Post-graduate Medical School, Clinical Block Lead for Lee Kong Chian School of Medicine, Clinical Faculty with the Yong Loo Lin School of Medicine, National University of Singapore, and Physician Faculty with SingHealth Post-Graduate Year 1 (PGY1) Program and Singhealth Residency. Active in research, she has published scientific papers in peer-reviewed journals, and actively participates in local and international conferences and scientific meetings.

About Dr Beh Sok Yuen

Dr Beh Sok Yuen obtained her basic medical degree from University of Auckland, New Zealand. She then completed her specialty training in medical oncology and was conferred fellowship by the Royal Australasian College of Physicians.

Ref: M19