IT IS a sobering statistic. Breast cancer is the most commonly occurring cancer in women in Singapore, with one in 13 being diagnosed with the disease by the age of 75.
Between 2016 and 2020, the Singapore Cancer Registry reported 12,303 breast cancer cases affecting females. Thankfully, only 2,245 of these women died from it, and this is largely owing to earlier detection, routine screening and modern advances in breast cancer treatment.
Leading causes
According to breast surgeon Sabrina Ngaserin, head and consultant at Sengkang General Hospital’s (SKH) Breast Service, multiple factors influence the risk of developing breast cancer. Among them are personal profile such as age, medical history which includes high-risk breast lesions, a family history of cancer, breast density, inherited genetic conditions and increased lifetime estrogen exposure.
But while any individual with the hereditary risk of breast cancer may have up to an 85 per cent lifetime breast cancer risk, only about 5 to 10 per cent of breast cancer cases are thought to be inherited.
Preventative measures
There are things women have control over in minimising the risk of getting breast cancer.
Increased endogenous estrogen exposure in women raises the probability of developing the disease. So, women can lower their risk if they breastfeed after having children, as this is a break from estrogen exposure.
Obesity raises risks because there is increased estrogen hormone production from the fat tissue. Additionally, obesity results in high levels of leptin, a fat-derived hormone that regulates our appetite and energy homeostasis, and which has been associated with breast, colon and ovarian cancer.
Studies also reveal that being overweight has a significant effect on the disease development process itself. “Obese women with breast cancer actually are susceptible to having larger tumours, greater incidence of disease spread and may become resistant to hormonal treatment,” says Assistant Professor Ngaserin.
Similarly, alcohol can raise estrogen levels in the body, hence affecting breast cancer risk.
Women should therefore aim for a healthy, balanced diet and engage in physical activity. Research has shown that 150 minutes of moderate physical activity or 75 minutes of vigorous physical activity per week can lead to an average risk reduction of 25 to 40 per cent. As far as possible, females should maintain a body mass index of 18.5 to 23 kg/m².
“For breast cancer patients, these efforts also empower their bodies to heal from the effects of treatment and any complications they may have,” says Asst Prof Ngaserin. “For everyone else, these simple principles already protect you against not just breast cancer but other detrimental health issues.”
For those with a high risk of breast cancer due to genetic mutations, there are risk reduction strategies including hormonal therapy or surgeries such as a double mastectomy, which is the removal of both breasts, or the removal of ovaries and fallopian tubes because of the associated risk of ovarian cancer.
“For these patients, we seriously consider and discuss potential medical and psychosocial effects of these preventative treatments,” says Asst Prof Ngaserin. “And any lady who has been offered a mastectomy should definitely have options for minimally invasive approaches and immediate reconstruction.”
Spot it early
Symptoms and signs of breast cancer most commonly include textural changes followed by development of a breast lump, dimpling, pitting, redness or ulcer in the overlying skin or nipple-areola complex and nipple discharge.
Women should conduct monthly breast health self-examinations from the age of 20 and be attentive to changes in size, shape, appearance of the breast, the overlying skin, nipple, areola and axillary (armpit) regions.
That said, the superior strategy is to detect, diagnose and treat breast cancers early or even at the pre-invasive and pre-cancerous stages, before signs and symptoms of the disease are seen or felt. When detected at the earlier stages, which range from 0 to 4, one’s chances of successful treatment and long-term survival are higher. Hence, it’s imperative women undergo regular screening with breast imaging.
Treatment regime
For the best possible outcome, breast cancer treatment is multi-modality and multi-disciplinary, with evolving evidence continuously refining treatment strategies.
Treatments that address the breast, axilla and surrounding structures include surgery and radiation therapy, while treatments that traverse the entire body system include chemotherapy, targeted therapy, hormonal therapy and immunotherapy.
The length of treatment depends on several factors, including the biology and stage of the cancer, as well as the patient’s morphology and choice of surgery. The simplest treatment for early breast cancer could involve just one surgery. When radiation therapy is also required, the treatment duration could be two to three months. The longest protocol, on the other hand, could take up to a year. And that would include chemotherapy and other treatments. After that, some patients may remain on oral medication such as hormonal therapy for five to 10 years.
“Obviously, if we diagnose it at an early stage, fewer things are necessary in the multimodal treatment regime,” says Asst Prof Ngaserin. “But if diagnosed at later stages, not only are more things necessary, there is also a lot more potential impact in terms of side effects and so on.”
Newer options
Today, there are newer and more advanced surgical options for cancer management. These include oncoplastic breast surgery and minimally invasive breast surgery techniques. At SKH, breast conserving surgery, which aims to surgically remove the cancer but preserve healthy breast tissue, is currently the preferred strategy for eligible patients.
A mastectomy is sometimes required for widespread disease or if the patient has an extremely high lifetime risk of developing breast cancer. This usually involves scars on the breast – on the nipple areola region itself, or lengthy scars along the bra line or lateral breast.
One relatively new approach here is minimally invasive surgery, or keyhole surgery. Using fine surgical instruments and a single incision of about 3 to 5 centimetres under the armpit or bra line, the cancerous breast tissue is removed in one piece. This is to avoid breaking up the tissue and reintroducing cancer back into the area.
In addition to the aesthetic benefit of concealing these surgical scars, these incisions also result in less pain, minimal operative scarring and decreased nipple, skin and wound complications.
More importantly, the breast can be immediately reconstructed in this two-in-one procedure.
The patient’s own skin, fat and blood vessels are taken from one area of her body, such as the abdomen, back or buttocks, and used as a new breast mound. The results in a reconstructed breast that looks and feels more natural and is a lifelong solution over implants, which have 15-year lifespans.
Given that Singapore’s five-year age standardised relative survival rate increased dramatically from 49.9 per cent in the 1970s to 82.4 per cent today, the prognosis for breast cancer patients post-surgery, is good.
“Again, this is largely owed to earlier detection through routine screening and modern advances in breast cancer treatment,” says Asst Prof Ngaserin. “Our own statistics suggest that stage 0 and 1 breast cancers now have a close to 100 per cent relative survival rate at five years for women in Singapore. Stage 2 and 3, slightly lower rate, 89.5 and 73.3 per cent, but still really good. And for stage 4 patients diagnosed with distant metastases, we are a bit more guarded because the survival rate is 27 per cent for five years. And this is why we have to diagnose the disease at the pre-invasive or early stages.”
A life-changing experience
Compared to other forms of cancer, those suffering from breast cancer do face a unique set of medical, practical, emotional, social and financial challenges. The myriad of emotions change constantly as one journeys through diagnosis, treatment, recovery, and ultimately the gradual transition back to everyday life.
“Breast cancer mainly affects women in Singapore incrementally from the age of 40. However, one in six cases still occur in young ladies before the age of 45. This means that most women are generally interrupted by disease at the prime of their lives,” notes Asst Prof Ngaserin. “They face disruption not just in health, but in career opportunities, relationships, family planning, finances, body image and mental health.”
She has had patients who were just about to get married, pregnant women diagnosed with cancer or new mothers who felt a lump while breastfeeding.
“So these are the very sensitive age groups that really suffer a lot of distress when a diagnosis is received.”
A supportive medical team, says Asst Prof Ngaserin, will aim to see patients through difficult choices, empathetically partner them through the challenging effects of therapy, and hopefully empower them with confidence to take back control of their lives.
“Every woman is at some potential risk of breast cancer, and that really increases with age,” she says. “So my general advice as a woman is to act to maximise our personal benefits, by performing a monthly breast self-examination and commencing mammography screening at the age of 40.”