| .
CONTENTS
q
The
Breast – Introduction
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What
Is The Breast Made Up Of?
q
What
is Breast Cancer?
q
How
Common Is Breast Cancer?
q
What
Are The Risk Factors?
q
How
Can We Fight Breast Cancer?
q
Does
Early Detection Save Lives?
q
How
Does Breast Cancer Present?
q
How
Is Breast Cancer Diagnosed?
q
How
Is Breast Cancer Classified?
q
How
Do We Treat Breast Cancer?
q
What
Does Locoregional Treatment Consist Of?
q
What
Does Systemic Treatment Consists Of?
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Rehabilitation
After Breast Cancer Treatment
q
Support
Groups
A.
The Breast - Introduction
The biological function of the female breast is to
produce milk for the young. However,
this role is often forgotten in our modern society.
Instead the female breast is now portrayed as the symbol of
feminity and is admired for its aesthetic form.
A woman afflicted with breast cancer is thus dealt with 2
blows; one of cancer and the other of mutilation to the breast due
to the cancer and from its subsequent treatment.
B.
What Is The Breast Made Up Of?
| he female breast consists of a core made up of milk glands
(called lobules) and ducts. This
core is surrounded by a layer of fat, which in turn is covered by
the skin. Milk is
produced in the milk glands or lobules and collects in small ducts
called terminal ducts. These
terminal ducts joined together to form larger ducts, which
eventually drain, via the nipples.
|
Each female breast has about 12 to 15 breast lobules.
This understanding of breast anatomy is important because
breast lumps including cancer develop mostly within the milk ducts
and glands. (See
diagram of anatomy of breast).
|
 |
The
female breast starts to grow from puberty and is fully developed
when the woman is in her twenties.
During a woman’s reproductive period (approximately 20 to
40 years old), the breast is under the influence of oestrogens and
progesterone (female hormones) whose levels vary with the
menstrual cycle.
This influence can cause the breast to be tender, hard and
lumpy especially premenstrually.
When a woman enters her thirties, the breast undergoes
regression in which the milk glands and ducts become smaller and
are replaced by fibrous and fat tissue.
C.
What Is Breast Cancer?
Our
human body is made up of billions of cells.
Each cell reproduces by division (cell division) and this
process normally occurs in an orderly manner.
If the cells divide in an uncontrolled manner and invade
the surrounding tissues, a cancer or malignant lump is formed.
Breast cancer usually originates from the cells lining the milk
ducts and glands.
Ductal cancer (i.e. arising from the ducts) are more common
than lobular cancers (i.e. arising from the lobules).
At this early period of cancer growth, the malignant cells
are confined within the milk ducts and glands and have not invaded
into the surrounding tissue known as the stroma.
When breast cancer is detected at this stage known as
non-invasive or in-situ cancer, treatment is easier and patients
live longer.
However,
when cancer cells have broken out of the milk ducts and lobules
and invaded the surrounding stroma, the cancer is called an
invasive cancer.
In the stroma are found blood and lymphatic vessels.
Hence an invasive cancer can gain entry into the lymphatic
system and spread to the lymph glands (called nodes) in the
armpit.
Likewise, the cancer cells can enter the bloodstream and
spread to other organs in the body.
When these cells reach a new site, they may form a new
tumour, often referred to as a secondary or a metastasis.
The organs most commonly affected are the lungs, bones and
liver.
In this advanced stage breast cancer is usually incurable
and patients may only have months to live.
|
What is Lymphatic System?
This system is made up of channels known as ducts
which run alongside blood vessels and to help to drain fluid
from the body back into the blood circulation.
An important function of the lymphatic system is the
protection of the body against foreign invasion e.g.
bacteria or other micro-organism.
These foreign bodies are destroyed in lymphatic
glands (called lymph nodes) which are situated in certain
parts of the body such as the neck, armpits and groin.
|
D.
How Common Is Breast Cancer?
Breast
cancer is the commonest cancer in Singapore women and about 1000
women are diagnosed with the cancer annually.
Women of all the 3 major ethnic groups (Chinese, Malay,
Indian) are equally affected.
Significantly, the number of women diagnosed with breast cancer is
increasing at an average of 3% annually.
Women of all age groups are affected but are more common in
women above 40 years old.
The incidence rate of breast cancer in Singapore is about
one-third of that of American women and half that of European
women.
It is estimated that an American woman has a 12% chance of
developing breast cancer in her lifetime.
In Singapore this chance is lower, estimated at 4 to 5%.
E.
What Are The Risk Factor?
Research
has uncovered many of the risk factors associated with this common
cancer.
By identifying the risk factors, we are closer to finding
the cause of breast cancer and also by modifying these risk
factors, we can reduce our risk.
This is the first strategy to combat breast cancer namely
prevention or eradication of the cancer.
However, this objective is difficult to achieve as some of
the risk factors cannot be modified e.g. family history, or
lifestyle factors such as child bearing.
Despite the intensive search for the cause of breast
cancer, the exact cause of breast cancer remains unknown.
About 50% of our breast cancer patients have no
identifiable risk factors.
They can be grouped into the following: -
q
Age &
Sex
q
Family
History
q
Factors
Associated with Reproductive History of a Woman
q
Dietary Risk
Factors
q
Body Weight
and Physical Activity
q
Intake of
Hormones
q
Previous
Abnormal Breast Biopsy
q
Age & Sex
The
risk of breast cancer increases with age.
It is uncommon in a woman before 40 years old.
70% of all breast cancers are diagnosed in women 40 years
of age and older.
Breast cancer can also affect the male but the risk is very low
compared to the female. However,
when a breast cancer is diagnosed in a male it is often at an
advanced stage because of the small size of the male breast.
q
Family History
A
woman with this risk factor has a first degree relative (i.e.
sister, mother or maternal grandmother) with breast cancer.
Her risk is doubled (2X) when compared to a woman without
this risk factor. (See
side bar on How to Estimate one’s risk from breast cancer?)
However, family history is not a significant risk factor as
only 10% of breast cancer patients have it.
Our recommendation for woman with this risk factor is to
start breast screening at an earlier age at approximately 35 years
old.
This
risk factor comes from the inheritance of genes from our parents
and ancestors. Genes
contain encoded information and are stored in our cells and passed
on from generation to generation.
The information contained in our genes is needed for the
normal function of our cells.
When our genes are damaged, cell function become abnormal
and a cancer may be formed.
We
have identified certain genes, which may be responsible for breast
cancer. Inheritance
of abnormal forms of such genes increases
a woman’s chance of getting breast cancer.
Two such genes recently identified are BRCA1 and BRCA2
genes and inheritance of abnormal copies of either of such genes
increase a woman’s risk by several fold!
Such a woman will have a 40 to 60% of developing breast
cancer in her lifetime.
Tests
to detect such abnormal genes are at present difficult and
performed mostly in research laboratories.
If you are interested in such tests, you should
consult your doctor. There
are laboratories in Australia and America, which offer this
service.
There
is another way to identify a woman with these abnormal genes
(BRCA1 and/or BRCA2). Her
family history is more extensive and stronger with the following
features:
| § |
Many
relatives developing breast cancer at an early age
(< 40 years).
|
| § |
Woman who
develop breast cancer in both breasts at the same time (i.e.
bilateral).
|
| § |
More than
two generations of relatives with breast cancer.
|
|
§ |
Relatives
with cancer of the ovary. |
Fortunately,
such women only form a small proportion of women with breast
cancer, estimated at only 1%. A big controversy surrounds the management of such women and
most of the cancer centers at our major hospitals have special
departments to cater to them.
|
How
to estimate one’s risk from breast cancer
The
most important risk estimate is the absolute risk
i.e. the risk of developing breast cancer in one’s
lifetime. For
a Caucasian woman in America, this risk is about 12%.
As breast cancer is less common in Singapore women,
the lifetime risk is about 5% i.e. the chance of a
Singapore woman developing breast cancer in her lifetime
is about 5%.
Doctors often quote another risk estimate called the
relative risk. For
example,
a woman with a family history of breast cancer has
relative risk of 2.0 i.e. her risk is doubled compared to
a woman without this risk factor.
Her absolute risk becomes 10% (2 x 5%).
|
q
Factors
Associated with The Reproductive History
of a Woman.
Research
has identified certain aspects of a woman’s reproductive history
that can increase her risk from breast cancer.
These risk factors are:
| § |
Woman
with no children or having the first child late
(after 35 years old)
|
| § |
Early
onset of menses (earlier than 11 years old)
|
| § |
Late
cessation of menses (later than 55 years old) |
These
risk factors are associated with an early and prolonged exposure
to oestrogen, which is one of the female sex hormone.
A
woman attempting to modify these risk factors to reduce her risk
from breast cancer will find it difficult to do so as it could
mean substantial alterations in her lifestyle.
There are calls in America to make changes in colleges and
the work place to facilitate a woman’s wish to have children
early.
Another measure that is being considered is to encourage
young girls to exercise more, as it is known that physical
activity can delay the onset of menses and suppress the secretion
of oestrogen.
Can breast-feeding alter this exposure of oestrogen and hence
reduce a woman’s risk?
Yes, but only if the period of breast-feeding is prolonged
(e.g > a year).
q
Dietary Risk Factors
It
has been known for a long time that eating too much red meat and
animal fat and too little fibre (vegetables & fruits) may
increase a woman’s risk of breast cancer.
Recent research has failed to prove this conclusively and
controversy still surrounds the role of diet as a risk factor.
However, Health Authorities such as the National Institute
of Health and American Cancer Society recommend limiting intake of
saturated animal fats (less than 20% daily fat allowance) and
increasing intake of fruits and vegetables (5 servings daily) to
reduce our risks from cardiovascular disease and cancer especially
breast, colon and prostate cancer.
There
is less controversy regarding alcohol as a risk factor for breast
cancer. Studies have
shown that drinking 1 to 2 glasses of alcohol daily can increase a
woman’s risk (relative risk 1.5 times)
Other
nutrients that have been identified to alter a woman’s risk from
breast cancer are:
| § |
Soy
products as in tauhoo, soya bean juice have been shown in
studies to reduce a woman’s risk from breast cancer.
This may explain why Asian women have a lower risk
from breast cancer compared to American women.
|
| § |
Omega
3 oil found in fish.
Some studies showed that it could reduce a
woman’s risk from breast cancer.
|
| § |
Other
nutrients that have been found to be protective against
breast cancer are vitamin A, selenium, vitamin C & E. |
q
Body
Weight and Physical Activity
Weight
gain especially in postmenopausal women is associated with an
increased risk from breast cancer.
This can be a combination of high calories and fat intake
as well as a lack of exercise.
Some Europeans studies have correlated physical activity to
the risk of breast cancer. Physical exercise reduces a woman’s risk of breast cancer
by lowering her body’s level of oestrogen.
A woman should engage in regular physical activities and moderate
her calories and fat intake and avoid weight gain.
Her weight should not be more than 20% above her ideal
weight.
q
Intake of Hormones
There
are 2 periods in a woman’s life that she wants to take oestrogen
(±
progesterone) supplement:
| § |
Hormone
Replacement Therapy (HRT).
A postmenopausal woman has a choice of taking HRT
or not. There
are PROS and CONS of such a choice and this is not the
forum for such a controversial topic.
Recent studies from America have shown that long
term or current users of HRT have an increased risk of
breast cancer (up by 30%) and this risk disappear 3 to 5
years after stopping HRT.
A woman should enter into a close discussion with
her doctor/doctors before making a decision.
|
| § |
Oral
Contraceptive Pill (OCP).
The Pill is a popular form of birth control and the
worry was whether it would increase a woman’s risk of
breast cancer. The
conclusion from all the many studies performed is that
there is little or no increased risk from taking the oral
contraceptive pill. Only
a small subgroup of woman may be at a higher risk –
early and prolonged usage of the OCP (i.e. late teens,
more than 10 to 15 years). |
q
Previous
Abnormal Breast Biopsy
A
woman with a previous breast cancer is at an increased risk of
developing cancer of her opposite breast.
She should be on regular reviews with her doctor.
A few types of breast biopsies are known to have an increased risk
of breast cancer, namely: atypical ductal hyperplasia, atypical
lobular hyperplasia and lobular carcinoma in-situ.
Woman with such breast biopsy reports should have regular
screening starting from her mid thirties.
What Can I Do if I Am at High Risk
From Breast Cancer?
Doctors
can now give a fairly good estimate of a woman’s risk from
breast cancer by taking a detailed family, social and medical
history.
Women who are at high risk from breast cancer will be offered
counselling as to how to cope with this knowledge:
| q |
They
are offered breast screening at an earlier age
|
| q |
They
are advised on means to alter their lifestyle and diet to
reduce their risk.
|
| q |
A
recent study from America has shown that tamoxifen, an
important anticancer drug can significantly reduce the risk
of breast cancer in these women.
|
| q |
These
women can consider preventive prophylactic mastectomies as a
means to reduce their risk from breast cancer.
A recent study from America has shown that high-risk
women who underwent bilateral mastectomies have a 90%
reduction in their risk.
After removal of the breast, it is reconstructed
using a woman’s own body tissue or an implant.
Because of the psychological consequence and
extensive nature of the surgery involved, a woman must
consider very carefully this option before deciding on it.
|
F.
How Can We Fight Breast Cancer?
There
are 3 methods of controlling breast cancer.
| q |
Prevention
is possible only by elimination of known risk factors and
this is a difficult and long term goal, e.g. change of diet
and lifestyle habits.
|
| q |
Early
Detection is currently the most promising method to fight
breast cancer. The
main advantages are (a) improved survival (b) less
mutilating surgery (c) less toxic drug therapy.
This method is easier to implement and yield results
faster than prevention.
|
| q |
Better
Treatment is an expensive method to fight breast cancer as
it involves development of tertiary medical services.
New drugs and surgical technique usually take time
and effort to develop. |
G.
Does Early Detection Save Lives?
What
is the Aim of Early Detection Or Breast Screening?
The
aim of Breast Screening is to detect breast cancer early
so that with effective treatment women can live longer.
How
Does It Work?
When
breast cancer develops it goes through a stage whereby its cancer
cells are confined within the breast ducts.
This is known as the non-invasive stage.
If we can detect breast cancer at this stage we know that
the cancer cells have most likely not spread to the armpit lymph
nodes or elsewhere in the body.
What
are The Advantages of Early Detection?
When
a breast cancer is detected and treated at an early stage there
are several advantages.
| q |
Most
important of course is the fact that such women can live
longer
|
| q |
These
tumours are often small (less than1 cm diameter) and are
suitable for less mutilating surgery e.g. Lumpectomy as
compared to Mastectomy.
|
| q |
There
is also a higher chance of avoiding Chemotherapy after
surgery
|
| q |
If
no cancer is detected by Breast Screening, a woman can
feel more reassured.
|
What
Are The Methods Of Early Detection?
The
only effective and proven method to detect breast cancer early is
an X-ray of the breasts called Mammogram.
Mammogram is able to detect microcalcifications (calcium
dots), which is an early sign of non-invasive duct cancer, and
also breast cancers that are too small to be detected by clinical
examination (less than 1 cm diameter).
Other methods such as Breast Self Examination, Clinical
Examination, Ultrasound Scan (Breasts) have not been proven to be
effective.
Is
Mammogram Painful?
A
certain amount of compression of the breast is required to obtain
a clear image on the mammogram.
This may be uncomfortable and painful.
However in a survey in UK, only 10% of women said it was
painful.
Is
Mammogram Harmful?
The
common belief is that since mammogram is a form of X-ray it is
harmful to our body. However
the radiation dose from mammograms is quite low and hence the risk
to our health remains low. The
risk is comparable to smoking 3 cigarettes!
Is
There Any Proof That Breast Screening Works?
YES.
Studies in US and Europe have shown that regular breast
screening in women aged 40 years and above can reduce the risk of
death from breast cancer by up to 50%.
This translates into lives saved.
Is
Breast Screening Effective In All Women?
Studies
have shown that Breast Screening is most effective in women 50 to
70 years old. The
effectiveness of breast screening for women in her seventies
remains unproven.
Where
Can I Go For Breast Screening?
Breast
Screening is available as part of a general health check in Well
Women Clinics found in most government outpatient clinics and
Singapore Cancer Society. Breast
screening involves a clinical breast examination performed by the
doctor followed by a mammogram.
Facilities for mammogram and X-rays are available in most
hospitals.
The
Ministry of Health has just launched a nationwide campaign to
screen women above 40 years for breast cancer.
The cost of mammogram is heavily subsidized.
What
Happens If A Woman’s Mammogram Is Abnormal?
This
does not mean that the woman has breast cancer. A large proportion of the abnormalities found on mammogram
are not due to cancer. The
woman will be recalled by the doctor for further tests such as
magnification views of the mammograms and ultrasound scans.
Only in a small proportion of women, an abnormality
suspicious of cancer is confirmed by these further tests.
These women are offered a surgical biopsy to rule out a
cancer.
What
Is A Surgical Biopsy?
This
is a small operation to remove the abnormality in the breast for
laboratory examination to rule out a cancer.
This operation is usually performed under general
anaesthesia as a day surgery procedure.
What
Are The Disadvantages of Breast Screening?
| q |
I
have mentioned earlier that mammogram is painful to some
women and there is a small risk from radiation exposure
|
| q |
Unfortunately
no diagnostic tests including mammogram are 100 percent
accurate and some normal women may have mammograms showing
an abnormal result. They have to undergo further tests and surgical biopsy to
rule out a cancer. This
can be costly and inconvenient to these women.
Such women may also be subjected to unnecessary
mental stress.
|
| q |
On
the other hand, some women with breast cancer may have a
normal mammogram i.e. the cancer was missed by the tests.
Such women may be falsely assured. |
What
Are Our Government’s Guidelines For Breast Screening?
|
|
|
40
years and below
|
Monthly
Breast Self Examination
|
|
|
Clinical
Breast Examination every 3 years
|
|
|
|
40
to 49 years
|
Monthly
Breast Self Examination
|
|
Clinical
Breast Examination yearly
|
|
Mammogram
yearly
|
|
|
|
50
years and above
|
Monthly
Breast Self Examination
|
|
Clinical
Breast Examination yearly
|
|
Mammogram
every 2 years
|
|
|
H.
How Does Breast Cancer Present?
The
commonest presentations of a breast cancer in decreasing order of
frequency are:
q
Breast
lump
q
Bloody
nipple discharge
q
Skin
changes
q
Itchy
rash of the nipple
q
Breast
pain
Are all breast lumps cancerous?
The
answer is no. In fact
8 out of 10 breast lumps are benign or non cancerous.
The type of breast lump depends on the woman’s age.
|
Twenties |
The
commonest type of breast lump in this age group is a
fibroadenoma. It
also known as a breast mouse as it is mobile i.e. it can be
moved within the breast.
This lump is non cancerous.
|
| Thirties |
The
commonest type of lump in this age group is known as fibroadenosis
or
fibrocystic disease.
It is often a painful hard area in the outer guardant
of the breast and is associated with the female sex hormone,
oestrogen. It
is non cancerous.
|
| Forties and beyond |
Two types of
breast lumps are common in older women.
One is a breast cyst which is a lump filled with
fluid. Breast
cyst can be diagnosed by an ultrasound scan and is treated
by needle puncture to extract the fluid.
Breast cancer is the other
type of breast lump to consider in older women.
This lump is usually hard irregular and fixed inside
the breast. Changes of skin over the cancer may be seen (thickening,
redness depression, skin sore). |
I.
How Is Breast Cancer Diagnosed?
The
doctor depends on three tests to help to diagnose a breast cancer:
| q |
Clinical
Examination. Depending
on his experience, a doctor can suspect whether a breast
lump is cancerous or not by performing a clinical breast
examination. Breast
lumps or cancers smaller than 1.5cm diameter or situated
deep in the breast cannot be detected by clinical palpation. Accuracy of this diagnostic method is approximately 60 to
70%.
|
| q |
X-ray
Mammogram. This
is an x-ray examination of the breast and a cancer can
appear as an irregular mass, clustered microcalcifications
or distortion of the breast tissue.
Mammogram can detect breast cancer when it is small
and not clinically palpable and hence is very useful in
early detection of breast cancer.
See section on Breast Screening for more details on
this test.
|
| q |
Breast
Ultrasound Scan. This
method which uses sound waves to generate an image of the
breast is useful in detecting breast lumps in the younger
women (less than 35 years) in whom the breast is often lumpy
and hence difficult to palpate and whose mammograms are
difficult to interpret.
Presently ultrasound scan is especially useful to
differentiate between a solid lump and a cyst.
A breast cancer appears as an irregular tall mass
with indistinct margins on the ultrasound scan. The role of breast ultrasound is to complement x-ray
mammogram. |
Based
on these three tests, a doctor is able to suspect whether a lump
is present and whether it is cancerous.
Very
often, a doctor will recommend a BIOPSY of a breast lump detected
by any of the three tests in order to exclude a malignancy.
A biopsy is an invasive technique in which some tissue is
obtained from the lump for laboratory tests to determine its exact
nature.
The
common biopsy techniques are:
| q |
Fine
Needle Aspiration (FNA).
A small needle is introduced into the breast lump to
sample it. The
aspirate is smeared onto a glass side and analysed in the
laboratory. An
experienced pathologist is able to tell whether the cells in
the aspirate are cancerous after studying them under the
microscope. Even
though it is simple and easy to perform, FNA is not as
accurate as the other biopsy techniques for several reasons
(a) inadequate number of cells sampled (b) inexperienced
pathologist (c) inability to diagnose a noninvasive breast
cancer (which requires a piece of the breast cancer for
diagnosis)
|
| q |
Core
Needle Biopsy. The
core needle is a slightly bigger needle and is able to
obtain slices of a breast lump for analysis.
Core needle biopsy is more accurate as it is based on
analysis of a piece of the breast lump under the microscope
(i.e. histological diagnosis).
It can also diagnose noninvasive breast cancer.
Automated core needle biopsy systems have been
invented in which many slices of a breast lump can be
obtained via one small skin puncture.
|
| q |
Excision
Biopsy. A
doctor may recommend that the whole breast lump be removed
(i.e. excised) for histology.
This procedure can be performed under local
anaesthesia or more often general anaesthesia.
The advantage of excision is that the lump is wholly
removed from the woman’s breast.
|
| q |
Frozen
Section. This
is a technique to prepare tissue for histological
examination quickly (duration 15 to 30 mins).
With frozen section, a breast cancer can be diagnosed
with the patient under general anaesthesia and the proper
cancer operation carried out.
This saves the patient having to undergo two
hospitalizations, one for the excision biopsy and the other
for the cancer surgery. |
J.
How Is Breast Cancer Classified?
For
practical purposes, breast cancer can be classified according to
the stage (extent of spread), grade (index of
aggressiveness of the cancer cells) and oestrogen receptor
status (ER). These
information are vital and help to predict survival and determine
the treatment.
Staging
is determined based on the following:
| q |
Information
regarding the tumour size and invasion of the lymph glands
in the armpit based on microscopic examination of the tumour
and operated specimen.
|
| q |
Diagnostic
Imaging Studies to study the extent of spread within the
body, which includes chest x-ray, ultrasound scan of liver
and bone scan.
|
| Stage |
|
Average Survival (%) |
| 0 |
Non
invasive cancer |
90 |
| 1 |
Small
invasive cancer
|
75 |
| 2 |
Invasive
cancer > 2 cm with lymph gland invasion
|
60 |
| 3 |
Large
invasive cancer > 5cm with invasion of skin
|
50 |
| 4 |
Widespread
or metastatic cancer |
50 |
Grade
is determined by examining the cancer cells under the microscope
and labeling the cancer cells as grade 1 (well differentiated),
least aggressive; grade 2 (moderately differentiated), moderately
aggressive and grade 3 (poorly differentiated), most aggressive.
Estrogen
receptors
are markers found on the surface of breast cancer cells and their
presence is determined by tests on the breast cancer.
If present, the breast cancer is labeled estrogen receptor
positive (ER+) and if absent; the breast cancer is labeled
estrogen receptor negative (ER-). This has an important bearing on determining the type of
systemic treatment for the patient (see treatment).
K.
How Do We Treat Breast Cancer?
Broadly
speaking, treatment consists of two parts:
| q |
Locoregional
Treatment which is the use of Surgery together with
Radiotherapy to eliminate the cancer from the breast and
armpit lymph nodes (also called axillary lymph nodes)
|
| q |
Systemic
Treatment which is the use of Chemotherapy or Hormonal drugs
e.g. tamoxifen
to
eliminate cancer cells in the body.
Modern research has shown that clumps of cancer cells
called micrometastases may be circulating in the body of a
woman with breast cancer. |
L.
What Does Locoregional Treatment Consist Of?
| q |
Local
control of the cancer. The two techniques are Mastectomy, which is the removal of
the whole breast including the nipple or Lumpectomy, which
is also known as Wide Excision.
The newer technique is Wide Excision, which is
removal of the tumour with a margin of normal breast tissue.
The rest of the breast is untouched to maintain good
cosmesis.
|
| q |
Axillary
or Armpit Surgery |
Is Wide Excision a safe option compared
to Mastectomy?
After
Wide Excision, Radiotherapy is given to the breast for 6 weeks.
Research has shown that Wide Excision plus Radiotherapy is
a safe option as it also has a low recurrence rate.
Which
patients are suitable for Wide Excision plus Radiotherapy?
q
Tumours
less than 2 to 3 cm diameter
q
Breast
of a suitable size
q
Tumour
situated away from the nipple
Which
patients are not suitable for Wide Excision plus Radiotherapy?
q
Young
women (less than 30 years old) have a high recurrence rate after
this procedure.
q
Women
with connective tissue disease are not suitable for radiotherapy
q
Pregnant
women
q
2
or more tumours within the same breast
Why
is Axillary Surgery required?
Axillary
Surgery is required to remove lymph glands (called nodes) for
diagnostic and therapeutic purposes. Knowing whether the lymph glands are infiltrated by cancer is
important in determining the stage of the cancer. Removal of the lymph nodes also prevents recurrence of the
cancer in the axilla.
In
this operation called Axillary Clearance or Dissection, the
surgeon removes all or most of the lymph nodes in the axilla.
Some patients may after Axillary Dissection suffer from
temporary shoulder stiffness and arm swelling (lymphoedema).
What
is sentinel lymph node biopsy (SLN biopsy)?
Recent
research has shown that 1 or 2 lymph nodes act as gateway to the
axilla and if there is cancerous involvement of the axillary lymph
nodes, they will be affected first (sentinel lymph nodes).
By
identifying these sentinel nodes and biopsying one of them can
determine whether the rest of the axillary lymph nodes are
involved by the cancer.
Hence
if the SLN biopsy is negative, there is no involvement of the
axillary nodes and vice versa.
Because of the limited extent of the surgery, SLN biopsy
has fewer side effects compared to Axillary Dissection.
Is
SLN biopsy suitable for all patients?
The
SLN biopsy is a treatment option of patients with:
q
Small
tumours
q
Non-palpable
nodes in the axilla.
It
is not suitable for patients in which the chances of nodal
involvement are high e.g. large tumours, palpable nodes.
In such patients an Axillary Dissection should be
performed.
It
is also not suitable for patients in which the chances of nodal
involvement are low e.g. non-invasive tumours. In such patients no Axillary surgery is required.
Is
SLN biopsy a safe option compared to Axillary Dissection?
This
new technique is controversial and being evaluated.
It is not recommended for routine use.
Is
there any hope of ‘Saving The Breast’ after mastectomy?
Yes.
The breast can be reconstructed and there is a new improved
technique of breast reconstruction called Skin Sparing Mastectomy
(SSM) and Reconstruction.
Points
to note in Breast Reconstruction following mastectomy:
| q |
Timing
of Reconstruction |
|
· |
Immediate:
The Reconstruction is performed after the Mastectomy at the
same operation. A
new modified technique of mastectomy in which more skin is
preserved, called Skin Sparing Mastectomy is performed and
the breast is reconstructed with an artificial implant and a
skin flap harvested from the back to cover the hole left
after removal of the nipple.
|
|
· |
Delayed:
The Reconstruction is performed at a second operation
anytime after treatment for the breast cancer is completed.
This is usually one year after the Mastectomy.
The breast is reconstructed with either an artificial
implant or skin and muscle flap from the abdomen (TRAM flap)
or the back (Lat. Dorsi flap).
|
| q |
Is
Reconstruction safe? The
presence of an artificial implant or a reconstructed breast
has not been found to interfere with the detection of local
recurrence of the cancer or to increase the risk of local
recurrence.
|
| q |
What
are the types of Reconstruction?
As discussed earlier the breast can be reconstructed
using an artificial implant (usually silicon) or a
skin-muscle flap from the woman’s body.
The implant method is quicker (hence less expensive)
but some women object to the presence of a foreign body
inside them. There has been a lot of controversy whether a silicon implant
can cause long-term side effects and the US Food & Drug
Administration (FNA) banned the use of silicon implants for
cosmetic purposes at one stage.
The flap method is the natural method but it takes
much longer (hence more expensive) and there may be some
problems at the donor site.
|
| q |
Is
Breast Reconstruction popular?
Not among Singapore women.
Only 10% or less of our local women opt for
Reconstruction after Mastectomy in a survey conducted and
the reasons were |
|
· |
More
worried about the cancer and less concerned about cosmesis
|
|
· |
‘Extra’
surgery involved and the costs
|
|
· |
The
lopsidedness after Mastectomy is less in local women as the
Asian breast is smaller.
|
|
· |
Availability
of external implants worn in the bra |
What
is the role of Radiotherapy?
Radiotherapy
is the use of radiation to treat breast cancer.
Currently the most important indication for radiotherapy is
local treatment of the conserved breast following a Lumpectomy for
breast cancer. It is
given over a 6-week period with daily outpatient treatment
sessions. Side
effects are usually tolerable, few and confined mainly to the
treatment area. Another
indication for RT is for women after Mastectomy in which the risk
of local recurrence is high (lymph nodes +, large tumour >
4cm).
M.
What Does Systemic Treatment Consist Of?
There
are two questions to answer for a woman with breast cancer
considering Systemic Treatment:
q
Does she need the Systemic Treatment?
q
Which
Systemic Treatment?
Criteria for Systemic Treatment
Based
on the information obtained from microscopic analysis of the
breast cancer and axillary lymph nodes and results of imaging
studies, a woman is divided into the low risk and high-risk
groups.
| Low
risk: |
-
Oestrogen
receptor positive
-
Lymph
node negative
-
Grade
1 (well differentiated) tumour
-
Tumour
size less than 1cm
|
| High
risk: |
|
Women
in the low risk group are offered tamoxifen or none while women in
the high-risk group are offered systemic treatment.
Type of Systemic Treatment
There
are 3 main forms of Systemic Treatment:
(1)
Cytotoxic Chemotherapy
(2) Hormonal Manipulation
(3) Ovarian Ablation
Cytotoxic
Chemotherapy?
This
is the administration of toxic drugs usually into the veins
(intravenous). Research
has identified these drugs as effective in killing cancer cells,
at the same time they are toxic to our body.
Hence they are administered at controlled dosage over a
period of time to limit their toxicity and at the same time
achieve their target of eliminating cancer cells.
There
are 3 main regimes, each a combination of cytotoxic drugs and the
doctor will select which regime is most suitable for the patient.
The drugs are then administered at 3 weekly intervals over
4 to 6 months. These
regimes are
| · |
CMF
(cyclophosophamide, methotrexate and 5-florouracil)
|
| · |
AC
(Adriamycin, cyclophosophamide)
|
| · |
Taxol
based regime |
What
are the side effects?
Most
patients are concerned about the side effects of cytotoxic
chemotherapy and it is important to answer a few key questions.
Can
cytotoxic chemotherapy kill?
Fortunately death resulting from chemotherapy is very
uncommon with an incidence of 0.9% reported from one large
chemotherapy study. Deaths
are caused by overwhelming infection or formation of blood clots
in the veins (thromboembolism) and occur in very sick patients.
What
is the immediate side effects and how to cope with them?
Even
though these acute side effects can be severe, they are usually
tolerable and temporary.
List
of immediate side effects following chemotherapy:
q
Low
total white cell count (Less than 2000/ mm3)
q
Fever
q
Infection
q
Nausea
q
Diarrhea
q
Hair
loss
q
Platelets
count (Less than 50,000/ mm3)
q
Thromboembolism
q
Cystitis
q
Weight
gain (More than 10%)
Women
on chemotherapy can seek advice on how to cope with these side
effects from various sources:
q
Reading
materials
q
Doctors
and breast care nurses
q
Support
groups
What about long
term side effects?
3
major long-term side effects associated with chemotherapy have
been identified:
| q |
Premature
Menopause. A
woman in her forties has a 50% of premature menopause if
she undergoes chemotherapy.
The effects of menopause is more severe in a
younger woman and varies from hot flushes, palpitations,
dry skin to more debilitating conditions such as
osteoporosis and increased risk from cardiovascular
disease. Fortunately
a lot can be done to alleviate these effects.
|
| q |
Cardiac
Toxicity. Adriamycin
(alias Doxorubicin) is a commonly used drug in
chemotherapy, which unfortunately has an effect on the
heart, which could lead to heart failure.
The incidence of this side effect is low (less than
5%) and can be decreased by several measures: |
|
§ |
Assessment
of cardiac function in women receiving adriamycin based
chemotherapy
|
|
§ |
Limiting
the dose administered (cumulative dose of less than
300mg/m2)
|
|
§ |
Method
of administration
|
| q |
Risk
of a second cancer. A few cases of chemotherapy-induced
leukemia (cancer of the white blood cells) have been
recorded. Fortunately
this serious side effect is rare in long-term studies of
patients after chemotherapy. |
Hormonal
Manipulation
This
term refers to measures to alter or stop the secretion of estrogen
in the woman’s body in order to treat the breast cancer.
These measures are:
| q |
Tamoxifen.
This is a well-known drug that has been used to
treat breast cancer for the last 20 years.
It is given orally once daily (20mg) and is well
tolerated with little side effects.
It is effective for the following categories of
women: |
|
§ |
Women
at high risk of breast cancer as a preventive drug.
|
|
§ |
Women
whose breast cancer is oestrogen receptor positive (ER+)
and is at low risk of recurrence, tamoxifen is given as
the sole systemic drug.
|
|
§ |
Women
whose breast cancer is ER+ and at high risk of recurrence.
Hence tamoxipfen is combined with chemotherapy or
other measures of hormonal manipulation.
(See table for further details) |
Ovarian Ablation
This
refers to methods to stop the secretion of oestrogen in a
woman’s body in order to reduce the stimulation of cancer cells
and hence reduce the chance of cancer recurrence.
This method applies only to premenopausal women and lead to
premature menopause. Ovarian ablation can be achieved by surgical and non surgical
methods:
| q |
Surgical
Oophorectomy. Surgery is required and is permanent. Seldom used nowadays. |
| q |
Radiation
Castration. Radiotherapy
given to the patients over a 2 weeks period can “dry
up” the ovaries, and stop the secretion of oestrogen
permanently. It
is a quick and relatively painless method |
| q |
Ovarian
suppression. Secretion
of oestrogen by the ovaries is under the control of a
master gland (pituitary gland) situated in the brain.
Drugs known as GnRHagonist or Groserelin can alter
this control mechanism leading to temporary suppression of
oestrogen secretion.
Ovarian function usually recovers once the drug is
stopped. This
drug is usually administered via a subcutaneous injection
once a month or once in 3 months.
This is a relatively expensive method. |
Research
has shown that ovarian ablation is as effective as chemotherapy in
the systemic treatment of women with breast cancer.
For women at high risk from cancer recurrence and whose
cancer is ER+, ovarian ablation can be an alternative to
chemotherapy.
Chart
for Systemic Treatment of Breast Cancer
|
| |
ER + |
ER - |
| Pre menopausal |
Post menopausal |
Pre menopausal |
Post menopausal |
|
Low Risk
(E+, LN-, O, G1, T1 tumour size <1cm)
|
Tam or none
|
Tam or none |
Not applicable
|
|
High Risk
|
Ovarian ablation
±
tamp
OR
ChemoRx
+ tam |
Tam
OR
ChemoRx _ tam |
ChemoRx
|
ChemoRx |
ER=
Estrogen Receptor, tam= Tamoxifen,
ChemoRx= Chemotherapy and Radiotherapy
What
are the side effects of tamoxifen?
About
half of the women on tamoxifen will suffer from menopausal
symptoms e.g. hot flushes, vaginal discharges, and irregular
menses. However these symptoms have not caused women to stop
tamoxifen as the compliance rate is about 70%.
An uncommon side effect of tamoxifen therapy is ocular
toxicity resulting in cataract formation.
Women
taking tamoxifen should not get pregnant, as the effects of
tamoxifen on the foetus are unknown.
There are 2 serious side effects, which have caused women
taking tamoxifen much worry.
| q |
Tamoxifen
can stimulate the growth of the lining of the uterus (called
endometrium) leading to thickening (called hyperplasia) and
occasionally the formation of uterine cancer.
The clinical presentation is irregular unusual
vaginal bleeding and diagnosis is made by an ultrasound scan
of the uterus and/or D & C (Dilatation and Curettage)
procedure to obtain tissue for microscopic
examination. The
incidence of uterine cancer is rare but as a precaution
women on tamoxifen should have a 6 monthly gynaecological
review with ultrasound scan.
|
| q |
In
women taking tamoxifen there is a higher risk of blood clot
formation. This
can lead to inflammation of surface veins (phlebitis) or
deep veins thrombosis (DVT).
DVT can be a serious life threatening condition
because of the possibility of pulmonary embolism but its
incidence is rare in women taking tamoxifen (less than 1%). |
N.B.Good
news. Tamoxifen
is also known to have several beneficial effects apart form its
effect on inhibiting cancer growth.
| q |
Maintaining
bone density in postmenopausal women thus preventing
osteoporosis. |
| q |
Lowering
blood cholesterol leading to a lower risk of cardio vascular
disease. |
| q |
Lowering
blood cholesterol leading to a lower risk of cardio vascular
disease. |
N.
Rehabilitation After Breast Cancer Treatment
After
breast cancer treatment, a woman can be exhausted both mentally
and physically. Foremost
in her mind would be what is my prognosis (chance of survival).
She would also be worried about her recovery from her
surgery and chemotherapy and whether she is fit to resume her role
as a mother, housewife or worker.
Physically she would be exhausted from the effects of
surgery, radiotherapy and chemotherapy treatment.
Mental
Rehabilitation
| q |
A
woman should be fully aware of her prognosis i.e. chance of
survival. E.g. a stage I breast cancer patient has a 80% chance of
surviving 5 years compared to a 60% chance for a stage II
breast cancer. (It
is important to note that a woman without breast cancer and
of the same age does not have a 100% chance either).
Knowing her prognosis will calm a woman and allow her
to ‘pickup the pieces’ and carry on her life and assume
her place in home, workplace and society.
|
| q |
She
should not miss her medical reviews with her doctors.
This will enable any recurrence to be detected
earlier and treated promptly.
The follow up schedule is usually 3 to 4 monthly
first 2 years, 6 monthly third to fifth year and annually
thereafter. Blood
and diagnostic imaging tests are performed either 6 monthly
or annually.
|
| q |
Her
spouse, children, family and friends should be involved in
her rehabilitation. We
live in communities and encouragement and help from others
will enable a woman to heal faster and recover stronger from
her disease and treatment.
|
| q |
She
should consider joining support groups to listen to how
other women cope with their disease and to find mutual
support (see support groups for breast cancer for list of
such groups in Singapore)
|
| q |
She
should consider changing her lifestyle to improve her health
and reduce her chance of recurrence. This would include changing her diet. She should increase intake of fluids, vegetables, fruits,
nuts, soya products and cut down on salt, saturated fats,
red meat and roasted meat.
She should do more exercise e.g. 30mins of brisk
walking, jogging or swimming 3 times per week.
Low fat and meat diet and physical activity are both
associated with lower risk of breast cancer. She should take time off to relax and reduce the level of
stress in her life. This
is a difficult factor to quantify and has not been proven to
prolong the survival of breast cancer patients. |
Physical
Rehabilitation
As
with any major surgery, women after breast cancer operation
usually feel weak physically and may take up to 6 to 8 weeks to
fully recover their strength, vitality and health.
| q |
Surgical
wounds on the breast and armpit usually heal within 2 weeks.
Pain slowly subsides.
|
| q |
Shoulder
stiffness on the side of surgery is due to axillary surgery
to remove the lymph glands.
With daily graduated exercises most women can
overcome this stiffness and regain back full range of
movement within a few weeks.
|
| q |
Lopsidedness
due to the loss of a breast can be overcome by wearing an
external prosthesis in the bra.
In the first few months when the wound is still
tender, a prosthesis made up of cloth with cotton wool is
used. Later on
a permanent silicon prosthesis made in the shape of a breast
is used
|
| q |
Lymphoedema
or swelling of the arm on the side of surgery.
This usually starts off as a swelling on the back of
the hand and forearm. If neglected the swelling gets bigger
and spreads up into the upper arm.
It also becomes permanent and is unsightly. |
The
cause of the swelling is due to accumulation of lymphatic fluid in
the arm. One reason
would be a recurrence of the cancer in the armpit blocking the
lymphatic drainage. This
is uncommon. The more common reason is that lymphatic drainage is affected
as a result of removal of the lymph nodes.
Thus with overuse of the arm, lymphatic fluid can
accumulate leading to a swollen arm.
Fortunately
the incidence of arm swelling is low, less than 5%. It can be prevented by simple measures, which include
q
Avoid
over-using the arm
q
Avoid
impeding the lymphatic drainage e.g. tight clothing
q
Avoid
any procedures e.g. blood taking
q
Avoid
infection of the arm
q
Encourage
lymphatic drainage by exercises daily or by wearing
compression stockings
The
patient should discuss with her doctor in detail ways to avoid arm
swelling and also to seek her doctor’s help quickly if she
notices any arm swelling.
O.
Support Groups
For
further information, you can contact:
| q |
Reach
to Recovery
Singapore Cancer Society: 221-9577, 221-9578, 221-9579
|
| q |
Oncology
Support Group: 221-9577, 221-9578, 221-9579
|
| q |
Hospice
Homecare Team: 221-9578, 421-5804 / 05 / 06
|
| q |
Breast
Care Nurse / Therapist at the various hospitals |
|
§ |
National
University Hospital: 770-5555
Staff nurse: CATHERINE KOH: 772-4727 (DID)
|
|
§ |
Singapore
General Hospital 222-3322
Nursing officer: SARA: 321-4474 (DID)
|
|
§ |
Tan
Tock Seng Hospital: 256-6011
Staff nurse: PATHMA: 357-8032
|
|
§ |
Changi
General Hospital: 788-8833
Nursing officer: MARGARET CHEW (CINIC F – 850 2760) |
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