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Breast Cancer

  • What is breast cancer?

    Breast cancer is an abnormal growth of tissue in the breast that can sometimes be felt as a lump. The tumour develops when cells in the breast divide without control and produce extra tissue. It can be benign (non-cancerous) or malignant (cancerous). Cancerous cells can spread within the breast, to lymph nodes (glands) in the armpit and to other parts of your body.

    breast cancer tumour

    According to the International Agency for Research on Cancer, there are approximately 2 million women around the world who were diagnosed with breast cancer in 2018, making it the most common cancer among women worldwide. Similarly, it is the most commonly diagnosed female cancer among Singaporean women. Almost 1 in 13 women in Singapore will be diagnosed with breast cancer in their lifetime. But what causes it and how can we prevent this type of disease?

    Stages of breast cancer

    Breast cancer is assessed in 5 stages:

    • Stage 0: This stage is often referred to as ductal carcinoma in situ (DCIS). During stage 0, the cells are still limited to within a duct and have not yet started spreading to the surrounding tissues.
    • Stage I: At this stage, the tumour is <2cm. However, it has not begun to affect the lymph nodes and other surrounding tissues..
    • Stage II: The tumour is between 2 – 5cm, and may have started spreading to nearby lymph nodes..
    • Stage III: The tumour has become >5cm and/or has spread to surrounding lymph nodes and surrounding tissues. It may have also invaded the skin or chest wall..
    • Stage IV: The cancer has spread to distant body organs such as the brain, liver, and lungs..

    Stage 0 and 1 breast has close to 100% relative survival rates at 5 years, while Stage 2 and 3 breast cancers have lower 5-year relative survival rates of 90% and 70% respectively. Stage 4 breast cancer, however, has a relative 5-year survival rate of 23%.

    Types of breast cancer

    There are 2 most common types of breast cancer among women – invasive ductal carcinoma (IDC), where cancer cells grow from within the ducts and invades the surrounding breast tissue, and invasive lobular carcinoma (ILC), which originates from the breast lobules and invades the surrounding tissue. These 2 types of breast cancer account for 70 – 80% and 10 – 15% of all breast cancers respectively.

    There are other rarer forms of breast cancer like mucinous, papillary and tubular carcinomas. These usually have better prognoses than ductal and lobular cancers.

    Paget’s disease of the nipple is a condition when breast cancer manifests as changes of the nipple, usually as a rash, and may be mistaken for eczema. An associated breast cancer is typically diagnosed on further imaging of the breast, although the cancer is rarely limited to the nipple.

    Inflammatory breast cancer is an uncommon but aggressive form of breast cancer. The breast has a red and swollen appearance, sometimes without the presence of a breast lump. When what appears to be breast infection (mastitis) does not resolve with antibiotic treatment, a biopsy is required to exclude inflammatory breast cancer.

  • The causes of breast cancer are not known and it is likely multifactorial, with genetic, environmental and lifestyle factors. All women, regardless of age and status, are at risk of getting breast cancer.

    However, certain risk factors can increase the risk of breast cancer.

    Age is a significant risk factor. Women over the age of 40 are more likely to get breast cancer than younger women, and those who have family members with the disease (a genetic cause) will be at a higher risk. A higher lifetime exposure to oestrogen, such as menstruating at a younger age (below 12 years old), late childbirth, or having menopause at a later age (above 55 years old), is also known to increase the risk of breast cancer.

    Preventing or reducing the risk of breast cancer

    While there is no certain way to prevent breast cancer, certain healthy habits can help lower your risk. Here are some of them:

    How to prevent risk of breast cancer in all women?

    • Maintain a healthy weight
    • Engage regularly in physical activities
    • Limit or avoid alcohol
    • Breastfeed

    How to prevent breast cancer for women with high risk of breast cancer?

    • Monthly breast self-examinations for early signs of breast cancer
    • Regular breast checks by your doctor, who will also order imaging scans for close monitoring
    • Undergo genetic counselling and testing
    • Taking hormonal therapy to lower breast cancer risk
    • Preventive surgery (for women with very high risk)
  • Breast cancer symptoms include the following:

    • A painless lump in the breast
    • Bleeding or unusual discharge from the nipple
    • Dimpled or puckered skin over the breast
    • Persistent itch and rash around the nipple
    • Pulled in or retracted nipple
    • Swollen and thickened skin over the breast

    Breast cancer screening guidelines for women

    Women are advised to regularly conduct breast examination and screening.

    For women 39 years and below, monthly breast self-examination is needed. For women aged 40 – 49 years, an annual screening mammography along with monthly breast self-examination are required. For women 50 years old and above, they must undergo 2 yearly screening mammography and monthly breast self-examination

  • Breast cancer is diagnosed either when symptoms and signs are noted by the woman herself, or during breast screening when there are no symptoms.

    The initial assessment will include standard imaging tests like mammogram and breast ultrasound. The mammogram is a special x-ray imaging tool that detects abnormalities in the breast like calcium deposits, architectural distortion or asymmetries, and tumours.

    The ultrasound scan is an imaging modality used for further assessment of the abnormalities found in the mammogram. It tells whether there is an occurrence of a solid mass which may be a cancer, or a fluid-filled cyst which is usually not cancer.

    Another common imaging modality is the magnetic resonance imaging (MRI). This is usually used for screening younger women with a high risk of breast cancer. Combining MRI with mammogram picks up cancers at an earlier stage in this group of women. MRI is also useful when lesions found on mammogram or ultrasound scans require further evaluation.

    When an abnormal finding is noted on imaging, a biopsy procedure will be required to confirm the presence of breast cancer.

  • Treatment for breast cancer depends on the size and stage of the cancer, type of cancer, characteristics of cancer cells, and other factors of the patient’s health.

    Breast cancer treatment includes:

    Locoregional treatment

    This breast cancer treatment method makes use of both surgery and radiotherapy to treat cancer cells in your breast and lymph nodes. It comprises of the following treatment methods:

    • Lumpectomy: Often referred to as breast-conserving surgery, this procedure involves the removal of the tumour and a small margin of the surrounding tissue. This leaves the rest of your breast untouched. A lumpectomy is usually recommended for removing small tumours. For patients with larger tumours, there are options of partial breast reconstruction if breast conservation is still preferred.

    • Mastectomy: A mastectomy refers to a surgical procedure to remove the whole of your breast, including your nipple, lobules, areola, ducts, and fatty tissue. However, other surgical techniques may be an option in selected cases to improve the overall appearance of your breast. Mastectomy will be recommended if the tumour to breast size ratio is large, or if there are multiple foci (more than one area) of cancer in the breast. Your doctor will discuss the various options of immediate breast reconstruction with you if a mastectomy is required.

    • Sentinel lymph node biopsy (SLNB): This procedure involves the removal of the first few lymph nodes where the lymph flows to and testing them for cancer intra-operatively. If cancer is not found in the sentinel lymph nodes, the chance of finding it in the remaining lymph nodes will be quite slim. Hence, no other nodes will be removed. However, if the axillary lymph nodes contain cancer cells, surgical clearance of the axillary lymph nodes will be performed.

    • Radiotherapy: Radiation therapy involves treatment with high-energy rays that destroy the cancer cells. Some patients with breast cancer may need radiation in addition to other treatment methods. The need for radiotherapy will largely depends on the stage of cancer, and the type of surgery that you had gone through. Large tumours may also need radiotherapy. This breast cancer treatment method can be used after mastectomy or breast-conserving surgery. It may also be used if your cancer cells have spread to other parts of the body, such as the brain or bones.

    Systematic treatment

    These breast cancer treatment options utilise chemotherapy or hormonal drugs to manage clumps of breast cancer cells that may be circulating in your body. Systemic breast cancer treatment methods include:

    • Chemotherapy: Chemotherapy refers to the use of drugs to destroy fast-growing cells in your body. Chemotherapy is sometimes given before breast cancer surgery in women with larger tumours. The primary goal of chemotherapy in such a situation is to shrink the tumour in size to facilitate easier surgical removal. Your doctor may also recommend chemotherapy after surgery to decrease the risk of your breast cancer recurring.

    • Hormone therapy: 60 – 70% of breast cancers are oestrogen receptor positive (ER positive) or progesterone receptor positive (PR positive). These cancers grow in response to the female hormones in your body. Hormone therapy works by blocking the action of progesterone and oestrogen or lowering their levels in your body as a way of treating the cancer. Hormone therapy is usually used as the last part of your treatment to decrease the risk of cancer recurring.

    • Targeted therapy: About 15 – 20% of breast cancers have HER2 growth factor protein on the cell surfaces. Targeted therapy uses antibodies to attach to HER2 protein, in order to inhibit the cancer growth.

    Rehabilitation

    • Nutrition and lifestyle support to help with recovery
    • Shoulder exercises and arm care to avoid stiffness and swelling

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  • As you manage breast cancer symptoms, you also have to be cautious of other health concerns. Breast cancer can lead to other diseases and complications. Knowing the possible complications that may result from this disease can make you seek medical help as soon as possible. Potential complications of breast cancer include:

    • Bone resorption or breaking down of bones
    • Fractures due to weakening of bones
    • Spinal compression or pressure on the spinal cord and nerves – can cause neck or back pain, numbness, tingling sensation, difficulty in walking, problems in bladder and bowel control
    • Hypercalcaemia or high level of calcium in the blood – can lead to irregular heartbeat, kidney stones, kidney failure, confusion, dementia or coma
    • Lung complications that lead to chest discomfort, shortness of breath, wheezing, cough, tumour, pleural effusion or fluid in the lungs
    • Liver complications that lead to stomach pain, weight loss, vomiting, problems with waste removal and jaundice
    • Brain complications that lead to frequent headaches, dizziness, nausea, vomiting and seizures.

    Complications of Cancer Treatment

    In any breast cancer treatment, even the normal cells are affected. Thus, treatments may lead to side effects and complications. Below are some treatment-related complications:

    • Mouth sores
    • Nausea
    • Nerve damage
    • Diarrhoea
    • Burning pain and scarring due to radiation therapy
    • Post-surgery pain
    • Lymphoedema or swelling
    • Infection
    • Hematoma – blood build-up outside the blood vessels
    • Seroma – fluid build-up underneath the skin
    • Negative reaction to anaesthesia
    • Heart disease
    • Secondary cancers like leukaemia and soft tissue sarcoma

    Before undergoing treatment, discuss with your doctor your concerns regarding breast cancer complications and related diseases. The medical team will educate you on what can be done to lessen the risk of developing complications. Likewise, your doctor can assess which treatment option will work best for you.

    If you experience any complications and side effects, tell your doctor immediately. The medical team will monitor these problems and recommend the right pain management and treatment for the related diseases.

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