q The Breast – Introduction
q 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?
q 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
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
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
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
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
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
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
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
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
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
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
Many relatives developing breast cancer at an early
(< 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
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
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
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
(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
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
? Omega 3 oil found in fish. Some studies showed
that it could reduce a woman’s risk from breast
? 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
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
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
q They are offered breast screening at an earlier
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
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
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
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
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
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
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
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
What Are Our Government’s Guidelines For Breast
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
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.
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
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
Based on these three tests, a doctor is able to
suspect whether a lump is present and whether it is
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
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
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
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
2 Invasive cancer > 2 cm with lymph gland invasion
3 Large invasive cancer > 5cm with invasion of skin
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
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
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
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
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
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
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
Is SLN biopsy suitable for all patients?
The SLN biopsy is a treatment option of patients
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
This new technique is controversial and being
evaluated. It is not recommended for routine use.
Is there any hope of ‘Saving The Breast’ after
Yes. The breast can be reconstructed and there is a
new improved technique of breast reconstruction
called Skin Sparing Mastectomy (SSM) and
Points to note in Breast Reconstruction following
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
? 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.
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
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
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
? ‘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: The rest
Women in the low risk group are offered tamoxifen or
none while women in the high-risk group are offered
Type of Systemic Treatment
There are 3 main forms of Systemic Treatment:
(1) Cytotoxic Chemotherapy (2) Hormonal Manipulation
(3) Ovarian Ablation
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
? 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
What is the immediate side effects and how to cope
Even though these acute side effects can be severe,
they are usually tolerable and temporary.
List of immediate side effects following
q Low total white cell count (Less than 2000/ mm3)
q Hair loss
q Platelets count (Less than 50,000/ mm3)
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.
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
? 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)
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
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
Chart for Systemic Treatment of Breast Cancer
Pre menopausal Post menopausal Pre menopausal Post
(E+, LN-, O, G1, T1 tumour size <1cm)
Tam or none
Tam or none
ChemoRx + tam
ChemoRx _ tam
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
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.
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.
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
q Avoid any procedures e.g. blood taking
q Avoid infection of the arm
q Encourage lymphatic drainage by exercises daily or
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
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