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Hale and Hearty

October is Breast Cancer Awareness Month. The incidence of breast cancer, which is the most common cancer among women, has tripled since the ’70s. However, the mortality rate has not risen as much, and this is in part due to the diagnosis of more early-stage disease which is highly curable. DR LEE GUEK ENG, an oncologist with ICON Cancer Centre in Mount Alvernia Hospital,  keeps  us  abreast  of  things.

Earlier detection: The incidence of breast cancer in young women is high in Asia, for instance, the population of breast cancer in women younger than 44 years of age makes up for 18% of our breast cancer population. It is important to draw awareness to breast cancer in young women by encouraging them to do breast self-examinations, go for screenings and report changes in their breasts to their doctors. Changes that warrant further investigation include lumps in the breasts, changes in skin texture and the shape of the nipples and breasts, and nipple discharges. However, not all may indicate the presence of breast cancer.

Benign lumps: Benign lumps can be due to other pathologies such as cysts or fibroadenomas. However, they need to be evaluated to be deemed as benign and not malignant. That usually entails seeing a doctor for a clinical examination followed by a mammogram with or without ultrasound and further investigations. If the imaging is inconclusive, then a biopsy needs to be undertaken to give further information. Even if the lump is benign, we usually follow up with an interval mammogram or ultrasound to ensure that it is not growing or developing  malignant  features.

Breast cancer subtypes: Based on the absence or presence of hormone receptors for progesterone and estrogen, and receptors for HER2 (a protein), we characterise the cancer as one of three sub-types – hormone receptor-positive, HER2-positive and triple negative. For example, hormone treatment is generally only suitable for patients with hormone receptor-positive sub-types of cancer. Hormone receptor-positive breast cancers are generally less aggressive than HER2-positive and  triple-negative  cancers.

Treatment options: The treatment for each patient is highly individualised, depending on their breast cancer sub-types. Before developing a treatment plan, we look at the stage and profile of the cancer. Most treatment plans adopt a multi-disciplinary approach; for early stage breast cancer, the primary treatment is surgery to remove the breast cancer, followed by adjuvant therapies in the form of chemotherapy, radiotherapy, hormonal therapy, and/or targeted therapy to reduce cancer recurrence. In the case of stage IV cancer, the usual process would be a systemic treatment with the aim of prolonging life and ensuring quality of life.

Severity of side-effects: These vary from patient to patient. We advise our patients not to be deterred by horror stories from other patients or friends and personally go through the journey to see how their body reacts to their treatment. Though nausea and vomiting is a common side effect, with the use of modern anti-nausea medicine, this has improved dramatically over the years.. Hair loss is also quite common, but is only temporary. Once the chemotherapy has been completed, the hair will grow back. Wigs and scarves can of course help women boost their confidence  during  their  treatment.

Bone density loss is another side-effect for post-menopausal women undergoing hormone treatment for breast cancer. Supplements and injections for preventing bone loss during hormone treatment in post-menopausal women are quite effective, but should always be combined with diet and exercise.

Cancer treatment and fertility: This is a very important issue for younger patients who have not completed or even begun their family planning. For women who desire childbirth after a breast cancer diagnosis, we strongly encourage them to consult a gynaecologist for fertility preservation before commencing their treatment. A lot of patients may have the misconception that they are delaying cancer treatment substantially and hence choose to give up an important priority in their life in future for starting cancer treatment immediately. However, with improved and modern procedures, the process of oocyte and embryo cryopreservation can be completed within two weeks and timely treatment for breast cancer can then be carried out.

Survival rates: We do not predict survival rates according to the age of the patient, but by the stage of the cancer and the biology of the cancer. For Stage I cancer patients, the five-year survival rate is more than 90%; for Stage II, it is around 80%. The survival rate decreases as the stage of the cancer increases. When the original breast cancer recurs in other organs such as the lymph nodes, lung, liver, brain and so on, it is considered a Stage IV cancer. Though Stage IV cancers are not curable, they are very treatable with various modern medicines  and  therapies.

Recurrence of cancer: The first step is to do a biopsy to determine whether the cancer is of the same type as the previous one. There is a high chance that it is so, but this is not always the case. The new cancer will be characterised according to biology and stage before the treatment  plan  is  decided.

Risk of other cancers: It depends whether there is a genetic cause, which is more likely in young patients. If there is a hereditary cancer gene, there is a possibility that they may be predisposed  to  getting  other  forms  of  cancer.

BRCA genes: BRCA1 and BRCA2 genes produce proteins that help to repair the genetic material of our bodies. When these genes are damaged, the genetic material can be altered during the renewal process, which can lead to cancer formation. It can be passed down to both males and females, and predisposes carriers to breast cancer and ovarian cancer, as well as prostate  cancer  in  men,  and  pancreatic  cancer.

Pre-emptive (prophylactic) mastectomy and salphingo-oopherectomy: In the setting of a BRCA1/2 mutant gene carrier, this is a highly personal decision; and some patients will be more receptive than others to the idea. For example, actress Angelina Jolie carries the mutated BRCA1 gene and chose to undergo bilateral prophylactic mastectomy (removal of both breasts) and salphingo-oopherectomy (removal of fallopian tubes and ovaries) so as to decease her risks of breast and ovarian cancer. While risk-reducing surgeries can reduce cancer risks, they do not obliterate them completely. Hence, it is important to have a detailed discussion with your treating oncologist to come out with a personalised treatment plan, taking into account the stage of life you are in.

Conclusion: Due to established screening programmes, breast cancer can now be detected early and treated more effectively. Hence, patient outcomes tend to be better for breast cancer patients than other cancer patients. Furthermore, compared to other cancers, genetic testing for breast cancer can determine the presence of specific mutated genes that heighten the risk for  developing  the  disease.

Remember, not all cancers are terminal. If you are diagnosed with an early stage-cancer, it is generally still curable. Live well and take heart from the fact that, as science is getting smarter and treatment is becoming increasingly personalised, the prognoses for cancer patients is  getting  better  all  the  time.

Checklist for lowering your risk of breast cancer

  • Know your family’s medical history
  • Exercise regularly (30 minutes, five times a week)
  • Go for regular check-ups and screenings
  • Be aware of your body and conduct regular breast self-examinations
  • Highlight changes in your breasts to your doctor
  • Follow a healthy balanced diet with plenty of fresh fruits and vegetables
  • Limit your intake of processed foods and fatty meats
  • Keep a healthy body mass index / weight
  • Cut down or stop drinking alcohol
  • Stop smoking
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