Breast cancer happens when abnormal cells grow in either the ducts or the fat lobules of the breast. It is the most common cancer among Singaporean women, accounting for 29.7% of all female cancers, with the highest rates reported among those aged between 45 and 49 years.
A patient’s prognosis will depend mainly on the stage of their breast cancer and the breast cancer subtype. Breast cancer specialists stage the disease from stage one, where the cancer cells are still confined to the breast, all the way to stage four, where the cancer has spread out of the breast and the lymph nodes to other parts of the body.
We sit down with medical oncologist Dr. Lynette Ngo and breast cancer surgeon Dr. Jesse Hu as they share more about the many facets of breast cancer. This includes the different types of breast cancers, what gets taken into consideration when planning your treatment options, and the importance of breast cancer screening.
According to Dr. Lynette, there are actually a few subtypes of cancer that patients may get, such as hormone receptor positive breast cancer, which accounts for around 50 to 60 percent of all breast cancers. These breast cancer cells have estrogen or progesterone receptors, or both. They can be treated with hormone therapy drugs that lower your estrogen levels or block the estrogen receptors. Another 20% of breast cancer cases carry the Her2 protein, which promotes the growth of cancer cells.
“This defines a more aggressive sort of breast cancer. They tend to spread faster,” shares Dr. Lynette. “They also tend to grow very quickly.” Then there is the triple-negative breast cancer, which is the rarest subtype. It comprises about 10–15 percent of breast cancer, but is also an aggressive cancer, as it tends to grow quickly and spread very easily to other parts of the body.
The risk factors for breast cancer can be broken down into two categories: non-modifiable and modifiable risk factors. Modifiable risk factors are factors that can be controlled, or you can take steps to change them, whereas non-modifiable risk factors cannot be controlled.
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Non-Modifiable Risk Factors |
Modifiable Risk Factors |
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Age is a primary risk factor for breast cancer, as evidenced by studies where it was found that the median age of Asian women diagnosed with breast cancer is between 40 and 50 years old.
“Why do old people get cancer? It’s a very simple thing,” Dr. Jesse explains. “As you get older, your cells change. It cannot be fixed. It’s like a car, after a while, things break down, and that's when cancer starts. If you look at our population, maybe 50 years ago, Singapore didn't have that many people with cancer because they would have died from infectious diseases. But now that we live longer, we have more patients with cancer because it happens with age.”
She adds, “That’s why if we pick up breast cancer in a young patient under the age of 40, we are more concerned about whether there is a genetic component, if it is hereditary, and that’s when we send them for genetic testing.”
Although women are at a higher risk of breast cancer, Dr. Jesse and Dr. Lynette also treat male patients with breast cancer.
“We don't treat male patients any differently from female patients, except that breast cancer is so rare in men that there must be an underlying reason for that.” Dr. Lynette shares. “A lot of the time it is related to hereditary breast cancer, so we would often send them for genetic counselling and discuss genetic testing with them. This is an important part of the management of breast cancer for them.”
“When they come to us, they usually have a lump, or sometimes they’ll have changes to their nipple or nipple discharge, and then we do a biopsy to confirm that there's a cancer on one side of the breast,” Dr. Jesse shares. “Then, as part of the work-up, we usually need to make sure there's no cancer on the other side too, and part of the work-up is to send them for a mammogram on the other side.”
“So, if a lady tells me that 'my breasts are too small for a mammogram’, I'll tell them that if a man can go for a mammogram, you can too.” Dr. Jesseu adds, stressing the importance of mammograms.
The treatment for breast cancer depends not only on the staging and subtype of the cancer, but also on the patient themselves.
“We also look at the patient themselves — the age of the patient, their fitness, whether they can tolerate treatment or not,” Dr. Lynette shares. “When personalising treatments according to the subtype of breast cancers, we look at whether they are hormone sensitive or whether they are an aggressive subtype like the Her2 and the triple negative.”
She adds, “We want to prevent the cancers from spreading quickly, a lot of the times we start with chemotherapy treatment first and/or targeted treatment against the Her2 cancers and then followed by surgery. On the other hand, for the slower growing subtypes like the hormone receptor positive cancers, surgery is usually the first treatment for them.”
Offering chemotherapy first is also known as neoadjuvant chemotherapy, and it is performed on patients with the aim of both downsizing the tumor prior to surgery and prognosticating how well the tumor will respond to chemotherapy as a treatment method.
Unfortunately for breast cancer patients hoping to skip going under the knife, surgery is currently unavoidable as part of your breast cancer treatment. “The aim of surgery is to remove the cancer while the aim of every other therapy, be it radiotherapy, chemotherapy, endocrine therapy, targeted therapy or immunotherapy is to reduce the chance of cancer coming back.” Dr. Jesse explains. “They all work together; one doesn't go without another.”
According to the Singapore Cancer Society, mammograms are currently the most reliable tool to screen for breast cancer. During a mammogram, a patient’s breast is placed on a flat support plate and compressed with a paddle. Small doses of x-rays are then given to pass through the breast to a detector on the opposite side.
On the mammogram film, low density tissues such as fats will appear translucent, while denser tissues such as glandular tissue or tumors will appear whiter. When examining your mammogram, your radiologist will look for high density regions that look different from normal tissues.
A breast ultrasound is another screening methods doctors use to identify cysts, solid masses and abscesses. However, instead of a replacement to the mammogram, Dr. Jesse states that it serves to be used in conjunction with the mammogram. “I do have patients who say, ‘Oh, I had an ultrasound scan, can I not do my mammogram?’ You can't because they are complementary. One doesn't replace another, they offer slightly different things.”
According to Dr. Jesse, mammograms are able to help pick up early cancer, otherwise referred to as stage zero breast cancer or ductal carcinoma in situ. These don’t present as lumps early on and instead present as microcalcifications or white spots on the mammogram that cannot be seen on an ultrasound. Meanwhile, ultrasounds are complementary to mammograms as some breast tissue are very dense, hence masses that may not show up on a mammogram because of this will be better picked up on an ultrasound.
“Screening is actually very individualised nowadays,” she adds. “It depends on the patient profile and family history. So, we tailor that accordingly to how frequently you need to be screened and what kind of modality should be used. It's best to talk to your doctor about it.”
Aside from breast cancer screenings, the doctors also advocate for women to perform breast self-examination from home.
“Breast examinations are not about being an expert in examining breasts,” Dr. Jesse explains. “It is about being an expert on your own breasts, as you will know how your breast tissue feels like and if there's are any changes.” Early detection of breast cancer will give you better treatment options and a higher chance of recovery and better outcomes. As such, regular breast screening and self-examination are key.
“The earlier we pick it up, the better the outcome and the less we’ll need to do to treat it.” Dr. Jesse says.
Dr. Lynette adds that breast cancer treatment today has come a long way from previous treatments and there is no need to fear it, “Nowadays patients are managing their treatments so well that they are able to continue their jobs while maintaining a good quality of life.”
Remember, cancer is a word and not a sentence.
Or as Dr. Jesse puts it, it is just “a little speedbump”. With early detection and care, you are more than able to go back to living a full life after cancer treatment.
