Breast Cancer

How common is breast cancer?

Among deaths caused by cancer, breast cancer currently takes the lead among women in Singapore – around 17% of cancer-related deaths in women. Almost 1 in 16 women in Singapore will be diagnosed with breast cancer in their lifetime. It is by far the most common type of cancer among Chinese, Malay and Indian women. The highest rate of breast cancer occurs in women between the ages of 40 and 69 years. Fortunately, with earlier detection and improved treatment, more women are surviving the disease.

Singapore Cancer Registry Annual Report 2018, National Registry of Diseases Office (released 31 March 2021)

What causes breast cancer?

Although the causes of breast cancer are still unknown, there are certain factors that may put you at higher risk of developing breast cancer. These risk factors include:

• Age – women over the age of 40
• Beginning menstruation early (before 12 years old)
• Developing menopause late (after 55 years old), with or without the use of postmenopausal hormone therapy to delay menopause
• Family history of breast cancer
• Having a personal history of breast cancer or non-cancerous breast conditions

Effective treatment is available for breast cancer if it is detected early, making regular screening a very important factor in increasing the success rates of treatment and recovery.

Symptoms of breast cancer may include any of the following:

• Bleeding or unusual discharge from the nipple
• Nipple becomes pulled in or retracted
• Painless lump in the breast
• Persistent itch and rash around the nipple
• Skin over the breast is dimpled or puckered
• Skin over the breast is swollen and thickened

 

Guidelines on breast screening for normal-risk women without symptoms:

39 years and below	Monthly breast self-examination
40 – 49 Years	Monthly breast self-examination Mammogram screening once a year
50 – 69 years	Monthly breast self-examination Mammogram screening once every 2 years

Women over the age of 40, or have a family history of cancer, have a higher risk of developing breast cancer. Other risk factors include: menstruating at a younger age (below 12 years old), late childbirth, or having menopause at a later age (above 55 years old).

Consult a doctor for a different screening schedule and seek medical attention promptly should you notice a breast lump or suspect breast cancer.

Breast cancer is diagnosed either through breast self-examination when unusual signs and symptoms are noticed, or during breast screening procedures when abnormalities in the breast are detected.

Breast Self-examination

Breast cancer is one of the few cancers that can be detected at home through monthly self-examination.

During self-examination, women should look out for:

• Lump(s), swelling, or thickening in the breast or underarm area
• Changes in the size or shape of the breast
• Puckering or dimpling of the skin on the breast or nipple
• Persistent rash or change in the skin around the nipple
• Changes in the nipple, such as inversion or retraction
• Bleeding or unusual discharge from the nipple
• Skin redness or soreness of the breast
• Accentuated veins on the surface of the breast
• Unusual swelling in the upper arm
• Any enlarged lymph nodes in the armpit and collarbone areas

Look for visible changes in the breasts and nipples by turning them slowly from side to side and feel for changes in the breasts, underarm, and collarbone areas.

Should any lumps or unusual signs be noticed in the breast, consult a doctor for more in-depth tests, such as a mammogram.

Mammogram

A mammogram is a special X-ray imaging tool that can detect abnormal masses in the breast like calcium deposits, cysts and tumours. The X-ray pictures make it possible to detect cancerous tumours that cannot be felt by hand, or lumps in the breast that are not yet cancerous but may grow into cancerous tumours.

The mammogram is currently one of the most reliable screening tools for breast cancer. Regular mammograms can help detect breast cancer early, thus allowing for early treatment. It is recommended for women between 40 – 49 years old to take annual mammograms.

Tomosynthesis (3D Mammography)

Some breast tumours may be difficult to identify on standard mammography because they are hidden or obscured by overlapping or dense breast tissue. Tomosynthesis uses low dose X-rays to take mammogram images of the breast and shows only a few layers of the breast at a time. It has been shown to achieve a higher accuracy of cancer detection and lower false positive cases as compared to digital mammography.

Breast Ultrasound

A breast ultrasound uses high frequency sound waves to produce images of the internal structures of the breast. Ultrasound imaging helps in the detection and diagnosis of breast tissue abnormalities, as it can tell the difference between a solid mass, which may be a cancer, or a fluid-filled cyst, which is usually not cancer.

Breast MRI

A magnetic resonance imaging (MRI) scan takes images of the breast using strong magnetic fields and radio waves. It is usually used for screening younger women who are at high risk of breast cancer. MRI scans are also useful as a supplemental tool, when lesions found on the mammogram or ultrasound scans require further evaluation.

If an abnormality is found during screening, a biopsy may be required to confirm if the tumour is benign or cancerous. The doctor will remove a small sample of breast tissue or cells to be examined closely under a microscope. Depending on the location of the abnormality, different image-guided breast procedures may be recommended.

MRI-guided Core Needle / Vacuum-assisted Biopsy

Magnetic resonance imaging is used to guide the radiologist’s instruments to the site of abnormal growth in the breast. Small tissue samples are then removed with a hollow needle and tested for cancer.

Stereotactic Core Needle / Vacuum-assisted Biopsy

A special mammography machine uses X-rays to guide the radiologist’s instruments to the site of the breast abnormality, before tissue samples are removed and tested for cancer.

Ultrasound-guided Core Needle / Vacuum-assisted Biopsy

In ultrasound-guided breast biopsy, ultrasound images are used to locate breast abnormalities, typically a tissue mass or lump. Small tissue samples are then extracted using a fine needle to remove cells or a hollow needle (core biopsy) to be tested for cancer.

Wire Localisation for Surgery (MRI, Stereotactic or Ultrasound-guided)

Relying on MRI, stereotactic or ultrasound techniques, wire localisation is used to pinpoint the exact location of a breast lump that is too small or vague to be felt accurately by hand. The surgeon will insert a tiny wire into the breast, such that the tip lies within the abnormal area. A biopsy or surgery will be performed afterwards to remove tissue samples for diagnosis.

Stage	Extent of Spread	Average 5-year Survival Rate (%)*
0	Non-invasive cancer	99
I	Small invasive cancer (less than 2cm without spreading to the axillary lymph nodes)	90
II	Invasive cancer (between 2 – 5cm or/with lymph nodes invasion)	70
III	Large invasive cancer (more than 5cm with skin invasion or spread to multiple lymph nodes)	40
IV	Widespread or metastatic cancer	20

*Individual patients may have a different experience depending on the specific characteristics of their breast cancer, and will influence which therapies can be used to target their cancer.

These characteristics of breast cancer can affect the chances of relapse and the patient’s survival rate.

Tumour Grade / Histologic Grade

This refers to how much the tumour cells look like normal cells when examined under the microscope, rated from grade 1 – 3. Grade 3 tumours contain very abnormal and quick growing cancer cells. The higher the histologic grade, the greater the chance of the breast cancer returning.

Lymph Nodes

The number of invaded (positive) lymph nodes in the armpit on the side of the affected breast is an important indicator of the chances for a successful recovery. A higher number of positive nodes will often result in a less positive outcome and requiring more aggressive treatments.

Tumour Size

In general, the larger the size of the tumour, the greater the chance of the breast cancer returning.

Oestrogen/Progesterone Receptors

Close to 2 out of 3 breast cancers cases involve significant levels of oestrogen and/or progesterone receptors. They are also known as oestrogen receptor positive (ER+) tumours. These tumours tend to grow less aggressively and may respond well to treatment with hormones.

HER2

HER2 is a protein that helps the growth of cancer cells and can be found on the surface of certain cancer cells. A HER2-positive tumour is a type of tumour with an excess of the HER2 protein on its cells. These tumours tend to grow more quickly than other types of breast cancer tumours, and 20 – 25% of all breast cancer cases have these HER2-positive tumours.

Knowing if a cancer is HER2-positive can affect the choice of treatment because women with such tumours can benefit from HER2-targeted therapies. These include therapies that use drugs like trastuzumab (Herceptin®), pertuzumab (Perjeta®) or TDM-1 (Kadcyla®).

Surgery

Surgery can be a direct way to remove cancer from the body. Forms of surgery include:

1)    Breast-conserving surgery

• Lumpectomy or wide local excision – Removal of the cancer and a small amount of the surrounding tissue
• Quadrantectomy – Removal of the quarter of the breast where the cancer is found

 

2)    Mastectomy – Removal of the whole breast

During breast surgery, some of the lymph nodes under the armpit may also be removed for examination.

Radiotherapy

Radiotherapy uses high-energy rays to target and kill cancer cells. It can be used with other treatment procedures to kill any remaining cancer cells in or around the breast, thus lowering the chances of the cancer returning in the breast.

Radiotherapy can be vital after a breast-conserving surgery like lumpectomy, since much of the breast tissue is left intact.

Most women who have a mastectomy do not need radiotherapy. However, it can be used to treat the chest wall and the lymph nodes in the armpit if the risk of the cancer returning is high.

Systemic Therapy

Systemic therapy involves the use of drugs to treat the cancer cells wherever they are in the body.

• Chemotherapy
• Hormonal therapy
• Targeted therapy, e.g. trastuzumab (Herceptin®) or pertuzumab (Perjeta®)

Rehabilitation

Physical rehabilitation includes:

• Shoulder exercises after the surgery
• Arm care, to avoid the beginning of lymphoedema (swelling of the arm(s) due to fluid retention)
• Balanced nutrition and lifestyle changes to improve recovery

Mental rehabilitation involves:

• Close support from your spouse, family and friends, as well as support groups
• Reassurance through a better understanding of the chances of survival
• Regular reviews with the doctor

At Gleneagles Hospital, our patients come first, and we are committed to helping our female patients take active steps to beat breast, and other female cancers, with early detection and treatment.

With over 300 multi-disciplinary specialists, including dedicated oncologists and surgeons, supported by a team of experienced nursing and allied healthcare professionals, we have been providing quality healthcare with proven clinical outcomes for over 60 years.

Speak with us, and let us help you address your cancer concerns.

 

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