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What is…

   Breast cancer
   Treatment Options
   Follow Up

What is Breast Cancer

Breasts are made up of fat and gland tissue. All glandular tissue in the breast
is made up of individual cells that reproduce under the control of hormones.
Sometimes this process goes out of control and an abnormal cell develops.
This is the beginning of cancer.
Cancers of the breast usually start in the cells of the milk ducts.

How common is Breast Cancer

Breast cancer remains the most common female cancer in Singapore since
population-based registration started in 1968. Up to 20% of all cancers
diagnosed in women are breast cancers. During 1998-2002, an annual
average of 1100 women was diagnosed with breast cancer and an annual
average of 273 women died from the disease. The peak incidence of breast
cancer in women in Singapore is from 55-59 years.

However, nine out of 10 women who go to their doctors with breast lumps
have a benign disorder, not cancer. Normal changes associated with the
menstrual cycle can make breasts feel lumpy.


While the aetiology of breast cancer is multifactorial, most women with breast
cancer have no high risk factors and may differ between individual women
and racial groups. It is clear that breast cancer has a genetic basis upon
which internal hormonal influences, diet and external environmental factors

   Age and gender

    The risk of breast cancer increases with age. Most women who are
    diagnosed with breast cancer are more than 45 years old.

   Hormonal influences

       Prolonged fertile period, i.e. the first menstrual period at a young age
        and the late onset of menopause. A woman who has menopause at 55
        years has twice the risk of a woman who has menopause at 45 years.
        Women who have never been pregnant also have a high risk of breast
        cancer. Getting pregnant for the first time after the age of 30 also
        increases the risk. On the other hand, breast-feeding protects against
        breast cancer.
       Hormone replacement therapy after menopause may increase the risk
        but is effective against many other diseases. These issues should be
        discussed with a gynaecologist before embarking on hormone
        replacement therapy.
       Use of oral contraceptive pills. Birth control pills may slightly increase
        the risk for breast cancer, depending on age, length of use, and other
        factors. No one knows how long the effects of the pill last after stopping

   Family history and genetic factors

       Between 5 to 10% of all breast cancers are associated with genetic
        factors. The genes BRCA1 and BRCA2 have been identified and may
        be associated with breast cancer. But not everyone with the abnormal
        gene will develop breast cancer. Testing for these genes is not widely
        available as yet.
       Some studies show previous breast, uterine, ovarian, or colon cancer,
        and a strong history of cancer in the family may increase the risk for
        breast cancer. Such history may indicate genetic factors.

   Radiation exposure

   Obesity

    Obesity is controversial as a risk factor. Some studies report obesity as a
    risk of breast cancer, possibly associated with higher levels of estrogen
    production in obese women.

   Diet high in saturated fat and alcohol.

    Significant alcohol use (more than 1-2 drinks a day) has been associated
    with an increased risk of breast cancer.

Types and Stages of Breast Cancer

There are several different types of breast cancer.

       Ductal carcinoma begins in the cells lining the ducts that bring milk to
        the nipple and accounts for more than 75% of breast cancers.
       Lobular carcinoma begins in the milk-secreting glands of the breast
        but is otherwise fairly similar in its behavior to ductal carcinoma. Other
        varieties of breast cancer can arise from the skin, fat, connective
        tissues, and other cells present in the breast.

Classification based on

       Tumour properties
           Size of the primary tumour.
           Receptor status (type of hormone receptors in breast cancer
             cells): Breast cancer cells are classified as estrogen receptor
             positive and negative and progesterone receptor positive or
           The estrogen receptor is a protein in breast cancer cells that
             binds to estrogen. About half of all breast cancer patients have
             this protein and are called estrogen receptor positive (ER+).
             Patients lacking this protein are classified as estrogen receptor
             negative (ER-).

       Other characteristics
            Nodal status - the presence or absence of cancer cells in glands
              or lymph nodes; if so, how many and which nodes.
            Metastasis - the spread of cancer into other tissues.


   In Situ ("in place") disease in which the cancerous cells are in their
    original location within normal breast tissue. Known as either DCIS
    (ductoral carcinoma in situ) or LCIS (lobular carcinoma in situ)
    depending on the type of cells involved and the location, this is a pre-
    cancerous condition, and only a small percentage of DCIS tumors
    pregress to become invasive cancers.
   There is some controversy within the medical community on how to
    best treat DCIS. Options include removal of the tumour (lumpectomy)
    and the breast and surrounding tissues are irradiated (radiation
    therapy) or the entire breast (mastectomy).

   Tumours are 2 cm or less in size
   No lymph node involvement

    Usually the lump is surgically removed (lumpectomy) and the breast
      and surrounding tissues are irradiated (radiation therapy). The radiation
      destroys any remaining tumour cells.

      Additional chemotherapy or hormonal therapy may be considered
       depending on the clinical situation.

   Tumours are more than 2 cm but no more than 5 cm in size.
   Lymph nodes may be involved (which means tumour has traveled from
    the tumour located in the breast via the lymphatic system to lymph
    nodes lying along the course of lymphatic vessels located in the

    The tumor (lumpectomy) or the entire breast (mastectomy) as well as
      any affected lymph nodes are surgically removed.

In addition:
     Radiation therapy will be used if a lumpectomy was performed.
     Chemotherapy will usually be given to destroy any cancer cells that
       have spread beyond the breast.
     Hormone therapy may be used, usually for postmenopausal women
       who have ER-positive tumors.

    Tumours are more than 5 cm with lymph node involvement.
    Removal of the entire breast (mastectomy) and the affected lymph

      Chemotherapy may be used prior to surgery to reduce the size of the
       tumour, or after surgery to eliminate any cancer cells remaining in the
       breast or other regions of the body.

      Hormonal therapy may be used after surgery to eliminate any cancer
       cells remaining in the breast or other regions of the body for ER-
       positive tumours.

   Advanced cancer in which the cancer cells have spread (metastasized)
    to other parts of the body, most often the lungs, brain, bones, or liver.

    The goal is to stabilize the disease.
    Tumour is surgically removed where possible, especially in cases
      where symptoms must be alleviated.
    Systemic therapy (treatment that goes throughout the entire body) may
      be used.
    Hormone therapy is used for ER-positive tumours and sometimes used
      for ER-negative tumours, although the patient's menopausal status and
      how progressive the cancer is will also affect this treatment decision.
    Tumour may be treated with chemotherapy and / or radiation therapy.

Stage 1

Stage 2

Stage 3

Stage 4

Expectation (Prognosis)

 The clinical stage of breast cancer is the best indicator for prognosis
(probable outcome), in addition to some other factors. Five-year survival rates
for individuals with breast cancer who receive appropriate treatment are
     95% for stage 0
     88% for stage I
     66% for stage II
     36% for stage III
     7% for stage IV

Symptoms and Signs of Breast Cancer

About 80% of women with breast cancer first consult their doctor with a
symptom they notice themselves. The most common is a breast lump.
Sometimes the nipple may be increasingly puckered or there is change in the
appearance of the skin on the breast, such as redness or the appearance of
pits, like orange peel. There may also be a discharge from the nipple.

Lymph glands of the armpit may also be enlarged and appear as lumps.

In advanced stages, breast cancer can spread to the liver, lung, bone and
brain. Abnormalities in these organs may also be present.

Any worrisome breast changes should be confirmed and investigated by a
medical professional.

After getting as much information as possible about the symptom and any risk
factors, the physician performs a physical examination including both breasts,
armpits, and the area of the neck and chest.


(See investigations for Breast lumps)

   Mammography

   Ultrasound scan of the breasts

   Biopsy

-   Fine needle aspiration cytology (FNAC)
-   Core needle biospy
-   Open surgical Biopsy

Metastatic and Treatment Workup

If breast cancer is diagnosed, additional testing is performed, including chest
X-ray and blood tests. Surgery, radiation, chemotherapy, or a combination of
these may then be recommended, not only for treatment, but also to help
determine the stage of disease and whether the cancer has spread. Staging is
important to help guide future treatment and follow-up, and to give some idea
of what to expect in the future.

   Chest X-ray: to look for spread to the lungs

   Bone scan: to look for spread to the bone

   Ultrasound of the liver: to look for spread to the liver

   Computed Tomography (CT): sometimes used to verify or confirm the
    findings from the chest X-ray or ultrasound scan of the liver.

   Heart Scan: may be performed if chemotherapy is recommended


Management of patients with breast cancer may involve surgery,
radiotherapy, systemic chemotherapy, hormonal therapy or a combination of
these. The availability of a breast care nurse and a multidisciplinary team is
helpful in guiding a patient through the required treatments.


Surgery is almost always required to treat breast cancer.

1. Local (Breast) Surgery

    The aim is to conserve the breast if possible. This is done by wide
    excision, i.e. the removal of the cancer with an appropriate amount of
    surrounding tissue. When this is not possible either due to a large tumour
    or presence of multiple tumours in the breast, total removal of the affected
    breast, i.e. mastectomy, is required.

2. Regional (Axillary) Surgery

    Lymph glands under the armpit (axilla) are usually removed, i.e. axillary
    clearance at the same time for Stage 1 and above. This can be
    undertaken as sentinel lymph node sampling (for small breast tumours) or
    a standard axillary lymph node dissection.

3. Breast reconstruction

    Breast reconstruction after mastectomy is also possible with collaboration
    with the plastic surgeons and this can be done either at the time of surgery
    or as a delayed procedure. Options include the use of implants and the
    patient’s own tissue flaps. Techniques including skin sparing mastectomy
    have improved the aesthetic results.

   Pain may occur after surgery for the first few days but this can be
    controlled by medication. It is also common for patients to feel tired or
    weak for a while. The length of time it takes to recover varies from patient
    to patient.

   Complications of surgery include hematoma or seroma formation
    beneath the skin flaps, wound infection, flap necrosis, nerve injury,
    shoulder stiffness, pain and upper limb lymphoedema.


   Aim: Cancer cells left in the remaining breast tissue may cause the cancer
    to recur in the breast at a later date, i.e. local recurrence, therefore,
    radiotherapy may be necessary after surgery. In radiotherapy, high-energy
    rays are used to kill cancer cells and stop them from growing and dividing.
    Like surgery, radiotherapy is a local treatment; it can affect cancer cells
    only in the treated area. Radiotherapy is usually given on an outpatient
    basis, 5 days a week, for 5 to 6 weeks. Patients are not radioactive during
    or after treatment.

   Radiotherapy is almost always mandatory if only a wide excision of the
    cancer is performed.

   Patients with mastectomy may also be recommended chest wall
    radiotherapy if they have spread to the armpit (>4 nodes) as this is
    associated with increased risk of recurrence


   Aim: Treatment with medicines to kill cancer cells is called chemotherapy.
    Chemotherapy aims to eradicate the occult distant spread, to prevent
    cancer recurrence in other parts of the body such as the lung, liver and
    other tissues. It is usually recommended for younger women where the
    breast lump was larger than 2cm at time of diagnosis or if the cancer also
    involved the lymph glands in the armpits.

   Most of these medications are injected into a vein or a muscle. The
    medicine flow through the bloodstream to nearly every part of the body,
    damaging cells that are rapidly dividing and growing. Normal cells that are
    rapidly dividing and growing, such as white blood cells, will also be
    affected by chemotherapy. Because cancer cells are often more immature
    and fragile than normal cells, chemotherapy affects cancer cells more than
    they do normal healthy cells.

   Type: The exact choice of drugs will depend on the person's general
    health and other medical illnesses, and the stage of the cancer.
    Chemotherapy is generally given in cycles over 4 to 6 months: a treatment
    period is normally followed by a rest period, then another treatment period,
    and so on. Most chemotherapy can be given on an outpatient basis.

    Current first line regime is an anthracycline-based regimen for about 4
    months id the patient is fit for it.

   Side effects are usually mild nausea or vomiting, hair loss, lethargy or
    tiredness, and loss of appetite. Most women will be able to carry on
    working during this period. Radiation therapy may also cause a temporary
    lowering of the white blood cell count, cells that help protect the body
    against infection. The side effects are usually temporary, developing
    gradually over the weeks of the treatment, and improving gradually after

    treatment is completed. Medication will usually be prescribed to minimise
    these side effects.

   Neoadjuvant chemotherapy: If the breast cancer was especially large,
    more than 5 cm at time of diagnosis, chemotherapy is given to shrink the
    tumour before surgery is performed.

   In certain medical centres, high dose chemotherapy and bone marrow
    transplantation or peripheral stem cell rescue is offered as an experimental
    option after surgery to try to prolong survival in women considered to have
    an extremely high risk of cancer recurrence.

Hormonal therapy

   Since breast cancer is hormone dependent, hormone treatment may have
    an effect on certain types of breast cancer. So in older women and women
    who have reached menopause, tamoxifen may be prescribed for 5 years.

   This is used to block the effects of estrogen that may otherwise help
    breast cancer cells to survive and grow. Most women with breast cancers,
    which express estrogen or progesterone on their surface benefits from
    treatment with tamoxifen.

   Its side effects are well tolerated including hot flushes, weight gain and
    vaginal dryness. However, it is associated with a small increased risk of
    venous thrombotic disease, endometrial hyperplasia and cancer.

   A new class of medicines called aromatase inhibitors, such as Aromasin,
    has been shown to be as good or possibly even better than tamoxifen in
    women with stage IV breast cancer.

Biological Therapy

   Biological therapy, also called immunotherapy, is an entirely new type of
    anti-cancer drug. It uses the body's own immune system to fight infection
    and disease or protect the body from some of the side effects of other
    forms of treatment. It can be used alone or with chemotherapy.

   Trastuzumab (Herceptin) is an example of this class of drugs. It affects
    how cancer cells function and grow. Some 20 - 25% of breast cancers
    respond to trastuzumab. Trastuzumab is not chemotherapy, but it may be
    combined with chemotherapy. Recent studies show that adding
    trastuzumab to chemotherapy or treating with trastuzumab after
    chemotherapy helps prevent the cancer from coming back and can make
    people who had HER2-positive breast cancer live longer.

   Monoclonal antibodies, interferon, interleukin-2, and colony-stimulating
    factors such as GM-CSF and G-CSF, are forms of biological therapy.

   These treatments often cause temporary flu-like symptoms such as fever
    and chills, muscle aches and weakness, loss of appetite and diarrhoea.

Breast Care Service

   Pre-operative counselling.
   Assessment of post operative patients
   Provide follow up care


A 2-view examination is usually done. Further evaluation with cone
magnification may be indicated for suspicious lesions.

It is recommended that women aged 40 - 49 should go for mammography screening
once a year, and women above 50 should go for one once in 2 years.

Mammography is currently the most reliable way to detect breast cancer in
asymptomatic patients. It can detect lumps even before they are felt by the hand.
Such early detection can greatly increase chances of recovery as well as provide
more treatment options.

Appendix 2


Breast care

Breast cancer can be a devastating experience for patients. They require
psycho-social support and encouragement to cope with the disease and
subsequently surgery. The breast care nurse clinician plays an
important role as a counsellor to help patients and their families cope
with the physical and emotional difficulties arising from the treatment.

She also runs the Breast Clinic where patients come for follow-up
review and teaches them exercise that will help them regain their
mobility. A firm advocate of breast screening and breast self-
examination for early cancer detection, she actively promotes this
awareness among patients and the nursing staff by giving talks and
providing informational materials.


    Scope of service
    Functions
    Breast care education
    Breast cancer support

A. Scope of Service

B. Functions

1.   Pre-operative counselling.
2.   Assessment of post operative patients
3.   Provide follow up care
4.   Provide other support


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