Breast Cancer – What you need to know

04 April 2019

Breast cancer is the commonest cancer in women in Malaysia. It is estimated that 1 in 19 Malaysian women will develop breast cancer in their lifetime. However, the rate differs between the three main races, the Malays, Chinese and Indians with 1 in 16 Chinese, 1 in 17 Indian and 1 in 28 Malay women developing breast cancer at some stage in their lives. The commonest age at presentation is between 40-49 years, with just over 50% of the cases under the age of 50 years, 16.8% below 40, and 2% under 30.

Survival improves with early detection

Breast Self Examination still plays an important part in the detection of breast cancer in developing country. Self-examination increases breast awareness. Every woman from her teens onwards should know how to examine her breasts and become familiar with them so that they can detect any change or anything unusual in them.

Screening mammogram is probably the only most effective modality in breast cancer screening. Women aged 40 to 75 should undergo a mammogram every two years with or without supplementary ultrasound.

All women presenting with breast symptom should have a full clinical examination and where a localised abnormality is present, patients should have mammography and/or ultrasound. If women presenting with breast symptoms which are strongly suspicious of breast cancer they will have to have a core biopsy to complete the triple test approach to exclude or establish a diagnosis of breast cancer before any definitive surgical procedure.

Risk Factors for Breast Cancer

There are a number and variety of risk factors that cause the complex multifaceted nature of breast cancer.

1. 1.Gender
   Female has higher risk to develop breast cancer than their male counterparts. The rate for male to develop breast cancer was 1.15 per 100,000 men years compared to female at 42.6 per 100,000 women years.
2. 2. Age
   The risk increases from the age of 40 years old for pre-menopausal group and 50 years old for the post menopausal group.
3. 3. History of Neoplastic Disease of the Breast
   • • Prior history of breast cancer carries an elevated risk of developing new primary breast cancer.
   • • Person with breast carcinoma in situ (lobular carcinoma in situ and ductal carcinoma in situ) are at high risk to develop invasive breast carcinoma.
   • • Person with breast tissue biopsy showing proliferative disease with and without atypical cells has an increased risk to develop future breast cancer. Benign breast disease with atypical hyperplasia lesion carries the highest risk to develop breast cancer.
4. 4. Family History
   Family history of breast cancer is an independent risk factor. The risk is higher in women with breast cancer among young first degree relatives. Sister carries more risk than mother. Carriers of BRCA1 and BRCA2 genetic mutation are at high risk to develop future breast cancer.
5. 5. Radiation Exposure
   • • Multiple exposures of therapeutic radiation to the chest for cancer at an early age (less than 20 years old) pose a high risk of developing breast cancer.
   • • Contralateral breast cancer has been shown to develop after exposures of high dose radiation used during radiotherapy for breast cancer.
   • • Patients with Hodgkin’s disease receiving radiotherapy at high doses are at high risk to develop breast cancer.
   • • Screening using mammography has not been shown to significantly affect the breast cancer status.
6. 6. Reproductive Factors
   • • First full-term pregnancy more than 30 years old.
   • • No children.
   • • Breastfeeding for duration more than 12 months is protective of breast cancer.
   • • Oral contraceptive use poses a mild increase of breast cancer risk especially if it is use before the first full term pregnancy. However, the risk is lower with low dose preparation.
   • • Unopposed estrogen use in hysterectomised women mildly increases the risk of breast cancer and only after longer term use ( > 15 years).
   • • Combination hormone replacement therapy has a mild risk for breast cancer.
   • • Age at menopause of more than 55 years old.
   • • Age at menarche less than 12 years old.
7. 7. Breast Density
   Higher breast density from mammography. The risk ranges from two times in scattered fibroglandular density to four times in an extremely dense breast.
8. 8. Lifestyle
   • • A body mass index (BMI) of more than 25 has an increased risk to develop breast cancer with higher death rate. Small waist and waist-hip ratio (WHR) give a significant protection against breast cancer in pre-menopausal women.
   • • Alcohol (especially beer) consumed more than 10 g/day especially among postmenopausal women is a risk factor for developing invasive breast cancer.
   • • Moderate to vigorous exercise of more than seven hours in a week of physical activity was inversely related to breast cancer.

Prompt treatment can save life

Surgery is the mainstay of treatment for early breast cancer. However, women with breast cancer are often concerned with not only how successful their condition can be treated, but also how their breast will appear after surgery. Depending on the disease’s nature and progression, breast cancer patients may have two approaches to surgical treatment. A traditional mastectomy involves the removal of the whole breast, while breast conservation surgery involves excision of the cancerous lump and the immediate surrounding tissues, preserving the rest of the breast. The patient then has to follow up with radiotherapy to ensure that all the cancerous cells are destroyed.

Conservation is not only cosmetically pleasing and retains the body’s balance, it is also beneficial to the patient’s psychological, emotional and sexual health. Nowadays, breast surgeons tend to do more conserving surgery as much as possible, especially as there are modern techniques available to enable it. These Oncoplastic technique are a combination of cancer surgery and plastic surgery, where the remaining breast tissue is sculptured and to realign the nipple and areolar with the aim to restore a natural appearance to the breast shape. The opposite breast can also be modified to breast symmetry.

If breast conservation is out of the question, such as when the cancer has spread too widely, then a mastectomy will be performed. The patient then has a choice of whether or not to reconstruct the breast. There are three main way in which the breast can be reconstructed mainly using a silicon implant alone, swinging in tissue from the back or tummy with its blood supply attached.

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