SUNDAY STAR, 14 OCTOBER 2018
BREAST CANCER AWARENESS
ACCORDING to the latest cancer
survival data from the Health
Ministry, the five-year survival rate
for breast cancer patients in
Malaysia diagnosed between 2007
and 2011 was 61%, which is lower
than survival rates reported in
high-income countries.
Emeritus Prof Datuk Dr Yip
Cheng Har, consultant breast
surgeon at Subang Jaya Medical
Centre, says that this is because
most patients seek medical
treatment in hospitals at a more
advanced stage of breast cancer,
which increases the risk of
recurrence.
“The survival of breast cancer
patients depends on the stage of
diagnosis and access to adequate
treatment. There are a lot of
times when patients refuse
treatment and resort to
alternatives before coming back
with a later stage of cancer,”
explains Dr Yip.
According to her, the risk of
recurrence among breast
cancer survivors depends
mainly on the stage of
diagnosis, which is
obtained from a
pathologist.
Known as prognostic
factors, the cancer
profile provided
Various options for treatment
BREAST cancer is the second most
common form of cancer
worldwide and most common
form among women.
Symptoms of breast cancer
include discharge from the
nipple, changes on the skin such as
dimpling, erosion or eczematous
changes, and palpable lumps.
Despite the high number of
breast cancer cases, many women
are not aware of the importance of
immediate medical attention and
following through with their
treatment.
Dr Tan Gie Hooi, consultant
breast and oncoplastic surgeon
at ParkCity Medical Centre, says,
“If you have breast cancer, you
may need more than surgery
alone.
“To fully minimise the chance of
recurrence, some patients will
need chemotherapy or targeted
therapy, radiotherapy and
hormonal therapy.
“These treatment methods
complement each other to control
the disease locally and
systematically.
“There are two types of cancer
control – localised control, which is
controlling the cancer in the
breast, and systemic control for
preventing the cancer from
metastasising.
“Surgery is mainly done as part
of local control to remove the root
of the cancer, while chemotherapy
or radiotherapy is done to stop the
Stomping out the fear
by the pathology details the size,
grade, stage, subtype and
aggressiveness of the patient’s
cancer.
The subtype is determined by
the proteins present in the breast
cancer cells, such as oestrogen
receptors, progesterone receptors
and human epidermal growth
factor receptor 2.
“Every woman has to know
her cancer profile as it shows the
risks of relapse. If there is a high
risk of recurrence,
chemotherapy is
offered,” adds
Dr Yip.
She says
that there
are ways
patients can
calculate
their
estimated
years of
survival.
cancer from spreading elsewhere
in the body.”
However, not all cancer patients
need chemotherapy. The decision
to advise patients to undergo
chemotherapy usually depends on
the stage of the disease – for
patients with large tumours or
cancer that involves the lymph
nodes.
Young patients with
unfavourable tumour
characteristics may also be advised
to undergo chemotherapy to
minimise the risk of recurrence.
Dr Tan adds, “Breast cancer
surgery is done as part of curative
treatment, meaning we aim to
cure the cancer by removing the
cancerous tissue surgically.
“If the cancer has metastasised
to other parts of the body – in
For example, patients can use
Predict, an online tool, to calculate
their own profiles and risk of
recurrence by keying in the
diagnostic factors included in
the reports given by their
pathologists.
Depending on the type of breast
cancer, the calculator measures a
survivor’s risk of dying according
to the optional follow-up
treatments sought, such as
hormonal therapy, chemotherapy
or targeted therapy.
When a survivor has a high risk
of recurrence, she will tend to be
filled with fear, worry, anxiety and
depression. Many people will
assume that this higher chance of
recurrence is caused by stress
experienced by the body and
immune system.
However, Dr Yip disagrees with
this belief as there are no studies
that prove this situation and
instead advises people to focus on
leading a healthy lifestyle to reduce
the risk of recurrence.
She says, “Scientifically speaking,
we cannot measure stress, because
different people handle stress
differently. Some people take a
deep breath while some others
scream and shout.
“The only factor that has been
shown to reduce recurrence in
all scientific studies is exercise
and not putting on weight. If
you put on weight, it is not a good
prognostic factor. You must be at
an ideal weight.”
Nevertheless, Dr Yip
understands that cancer survivors
Surgery is mainly
done as part of
local control to
remove the root of
the cancer, while
chemotherapy or
radiotherapy is done
to stop the cancer
from spreading
elsewhere in the
body.
Dr Tan Gie Hooi
stage 4 of breast cancer, for
example – we may use surgery as
a palliative option to alleviate the
symptoms in the patient, but
surgery is no longer the mainstay
of treatment.”
Contrary to common
misconceptions, mastectomy is not
the only choice of breast cancer
surgery.
“There are mainly two kinds
of breast cancer surgery –
lumpectomy and mastectomy.
More commonly known as breast
conservation surgery, lumpectomy
is done by removing just the lump
with a margin of normal tissue
Psycho-
oncologists are
not medical doctors
like psychiatrists,
but psychologists
who specialise in
cancer patients.
They take you
through your fears
with planned
may live in fear of recurrence
when trying to move on in life.
activities and
She recommends that patients visit material to support
you throughout.
counsellors or psychologists if they
are struggling mentally.
While Malaysia is still lacking in
resources for mental health, she Emeritus Prof Datuk Dr Yip Cheng Har
presents hope for breast cancer
survivors as there is a new form of
psychologists called psycho- sometimes, what they are going
oncologists, who are slowly through can be stressful to the
increasing their presence in other family as well,” she says.
countries. For patients who prefer help
“Psycho-oncologists are not within a community, aftercare
medical doctors like psychiatrists, support is provided by hospitals or
but psychologists who specialise in non-governmental organisations.
cancer patients. They take you With adequate education,
through your fears with planned mental support and connection
activities and material to support with peers who share similar
you throughout. experiences, there is no need for
“In this country, people don’t like breast cancer survivors to live in
to see psychiatrists or psychologists fear.
because it is a stigma. They do not
see the need for that because they n For more information, call
have family support, but 03-5639 1212.
while preserving the breast,” she always discuss about the different
explains.
Nevertheless, the kind of
options of surgery with their
doctors.
surgery a patient needs to “For patients who have
undergo depends on the stage of undergone mastectomy but do not
cancer because in some cases, wish for reconstruction surgery,
mastectomy is warranted to
achieve oncologic clearance.
there are breast prostheses
available in the market that they
Dr Tan clarifies, “If the lump is can use to achieve symmetry of
too big and lumpectomy does breast contour.”
not seem feasible, we may Breast cancer, like every
try to shrink
the lump with the
other cancer, comes with a
chance of recurrence.
help of chemotherapy
first.
According to Dr Tan, the
possibility of a relapse
“If this is for breast cancer
successful, we can
go for the breast
depends on many
factors, including
conservation
surgery.
completion of
treatment the first
“However, in time around, the type
instances such as of breast cancer the
when the cancer has patient has and the
too many foci, the only stage of cancer the
option is mastectomy. patient is in.
“For patients who Do not let the thought of
have to undergo losing your breast stop you
mastectomy, there is from getting treated for
always a choice of this killer disease.
breast reconstruction, Always discuss your
either immediately concern and options
(in the same with a doctor.
setting of Seeking a second
mastectomy) or opinion is
delayed (after advisable when
completion of in doubt.
cancer
treatment). n For more
“Therefore, information, call
patients should 03-5639 1212.
2 Breast Cancer Awareness
Early detection and prompt treatment
BREAST cancer is one of the scariest and
most frequently diagnosed cancers among
women worldwide. Therefore, there is a
need to spread awareness of how risk
factors, regular screenings, early detection
and prompt treatment come into play in the
survival rates of breast cancer patients.
Risk factors are factors that increase your
chance of developing breast cancer. Dr Kiran
Kaur Amer Singh, consultant general
surgeon with special interest in breast
surgery at Columbia Asia Hospital – Klang,
divides risk factors into two types: non-
modifiable and modifiable risk factors.
Non-modifiable risk factors are factors
that cannot be changed, which include
gender, family history of breast cancer and
being a carrier of the BRCA1 and BRCA2
gene mutation. Hitting puberty early (below
12 years old) and menopause later in life
(after 55 years old) increase one's risk of
Debunking misconceptions on mammogram screening
IN conjunction with Breast Cancer
Awareness Month, various activities are
being held across the world to highlight the
seriousness of this disease and importance of
early detection.
Among women, breast cancer is the most
prevalent form of cancer and causes the
greatest number of cancer-related deaths. In
some cases, early detection of breast cancer
is a matter of life or death.
Women can easily perform breast
examinations at home and clinical breast
examinations are widely available, but
mammogram remains the main test for
detection of breast cancer.
It is recommended that women above the
age of 45 get mammograms regularly or as
advised by their respective doctors.
Despite the extensive clinical use of
mammogram machines the world over,
there are countless articles circulating online
that claim these machines emit harmful
radiation, working against their intended
purpose as detection tools. Furthermore,
there are other speculative articles that
suggest mammogram machines provide a
high probability of misdiagnosis.
Such articles, though inaccurate,
discourage women from getting screened,
some even avoiding mammogram
screenings out of fear of being exposed to
radiation.
Should women proceed with regular
mammogram screenings? What should be
the right course of action to detect breast
cancer early?
A baseless concern
According to Dr Kiran Kaur Amer Singh,
consultant general surgeon with special
interest in breast surgery at Columbia
Asia Hospital – Klang, women must continue
to undergo regular mammogram screenings.
She stresses that mammogram is still the
recommended procedure for early detection
of breast cancer, and studies have proven
that its benefits outweigh its risks. She also
developing breast cancer as well.
“Early menarche and late menopause
cause prolonged lifetime exposure to
endogenous ovarian hormones, that is,
oestrogens. The longer the exposure, the
higher the breast cancer risk,” says Dr Kiran.
Modifiable risks come down to lifestyle
choices such as sedentary habits, alcohol
consumption, smoking and even long-term
intake of exogenous hormones in the form of
oral contraceptive pills or hormone
replacement therapy after hitting
menopause. Not bearing children, full-term
pregnancy after the age of 30 as well as not
breastfeeding increase the risk further.
According to Dr Kiran, “Non-modifiable
risks cannot be changed. However, risks may
be lowered for some patients. For example,
prophylactic mastectomy can be performed
to lower breast cancer risks in BRCA gene
mutation carriers.
“In terms of modifiable risk factors,
leading a healthy lifestyle, regular exercise
and maintaining a healthy weight will not
only reduce risks of breast cancer but also its
recurrence in survivors.
“Limiting the amount of alcohol consumed
and cessation of smoking are also
important.”
She shares that although family history of
breast cancer is a significant risk factor, only
5% to 10% of breast cancer cases are
inherited. The remaining 90% to 95% of
cases are sporadic. This means that
individuals who do not have a family
member with breast cancer are not spared
from the disease.
Therefore, it is essential for women to
participate in breast cancer screening
programmes and undergo mammogram or
ultrasound if recommended so that
immediate action may be taken should they
be diagnosed.
Dr Kiran adds, “Thanks to breast cancer
research over the years, treatment has come
The benefits of detecting breast cancer early outweighs the risks associated with mammography.
says that radiation emitted by mammogram
machines is quite low compared to other
devices such as computed tomography
scanners.
Emeritus Prof Datuk Dr Yip Cheng Har,
consultant breast surgeon at Subang Jaya
Medical Centre, supports this view, saying
that humans are exposed to radiation in
other scenarios such as when flying in
aeroplanes.
“The radiation dose for a mammogram
screening is very low. It is equivalent to you
taking a flight from Kuala Lumpur to
London because you are also exposed to
radiation up in the air.
“The radiation emitted by mammogram
machines does not cause cancer and the
American Cancer Society recommends
undergoing mammogram screenings once
every two years,” says Dr Yip.
Besides the fear of radiation, there is also
a long way, significantly improving the
survival rate and prognosis especially for
patients with early-stage breast cancer.
“There has been advancement in surgical
techniques as well as adjuvant treatments,
which are now widely available.
“We have moved towards breast-
conserving surgery (lumpectomy) and
sentinel lymph node biopsies for suitable
patients with early-stage breast cancer.
“This means that it may no longer be
necessary to remove the entire breast as
lumpectomy can be offered with equally
good outcome. The idea of surgery is to
completely resect the tumour with negative
margins, followed by appropriate adjuvant
therapy.”
Adjuvant therapy helps to reduce risk of
recurrence after surgery. Types of adjuvant
therapy available include chemotherapy,
radiotherapy, hormonal therapy and
targeted therapy.
However, not all patients will benefit from
these treatment modalities. Treatment
offered is based on stage of disease, type and
grade of tumour, patient’s general health
condition, hormone receptor status and
other factors.
Addressing the issue of patients seeking
treatment only during the later stages of
cancer, Dr Kiran believes that education and
awareness are the best course to take to
alleviate patients’ fears.
“Fear of losing one’s breast is common.
Therefore, patients should be made aware
that if they undergo mastectomy for breast
cancer, there are options for creating a new
breast.
“Breast reconstruction generally falls into
two categories: implant-based reconstruction
and flap (autologous) reconstruction using
the patient’s own tissues.
“In this region, the challenge that we face
is beliefs. Many patients strongly believe in
alternative medicine as the mainstay for
the misconception that mammograms
are inaccurate, hence not worth the
risk.
Dr Kiran debunks this misconception,
saying, “No test has 100% specificity.
However, mammography has been proven
to be sensitive enough and that is why it is
recommended worldwide.
“There may be drawbacks to
mammograms, especially for women who
have dense breasts as images from their
mammograms will appear opaque (white).
This can be confusing because calcifications
and tumours appear white as well.
“This can be resolved by performing
adjunct ultrasound screenings with
increased sensitivity for young women who
generally have denser breasts. Mammogram
is still the main recommendation for women
above 45 years old who have less dense
breast tissue.”
SUNDAY STAR, 14 OCTOBER 2018
Dr Kiran Kaur Amer Singh.
cure of breast cancer, and that causes the
delay in coming forward for treatment.
“The problem of stigma is also common,
which creates a significant barrier to
medical care. Some don’t even tell their
family members about the disease,” she
explains.
She adds that other factors that may
contribute to the reluctance in coming
forward for screening programmes and
treatment are the potential cost and
misconceptions surrounding breast
cancer.
“One common misconception is that the
radiation of mammogram causes more harm
than benefit. This is not true. Mammogram
exposes patients to low-dose radiation and
the benefit definitely outweighs the harm,”
says Dr Kiran.
It is only with the eradication of such
beliefs that we can see an increase in early
detection and survival rate of breast cancer.
Early detection saves lives.
n For more information, call 03-3346 7999.
The radiation emitted
by mammogram machines
does not cause cancer
and the American Cancer
Society recommends
undergoing mammogram
screenings once every
two years.
Emeritus Prof Datuk Dr Yip Cheng Har
Maintain the commitment
As for women who are breast cancer
survivors, annual follow-up screenings
become all the more crucial as the risk of
recurrence is never null.
Annual mammogram and ultrasound
tests must be done as there is a 5%
chance of cancer developing in the other
breast.
Dr Yip stresses, “If patients have a
lumpectomy (where the breast is not
removed), yearly screenings for both breasts
are recommended as 10 out of 100 cancer
survivors tend to relapse.”
She also highlights that breast cancer
survivors must be aware of changes to their
bodies as there may be warning signs.
“A relapse could happen in between
screenings. Backaches, coughing, difficulty
breathing, poor appetite or weight loss
could be signs of a relapse, so breast cancer
survivors may need to check in earlier than
their scheduled yearly examinations.”
Granted, undergoing a mammogram can
get a little uncomfortable, but when weighed
against the possibility of only detecting the
disease when it is already in an advanced
stage, a little discomfort is a small price to
pay for the gift of life.
SUNDAY STAR, 14 OCTOBER 2018 3
4 Breast Cancer Awareness SUNDAY STAR, 14 OCTOBER 2018

Know the disease For better support

IT is hoped that advancements in
the medical field will help increase
her own, hence the need for
medical practitioners to properly
BREAST cancer is a condition in breast cancer survival rates in educate patients’ families as
which cells begin to grow out of
control, usually forming a tumour
Breast cancer future, but until new developments
come around, non-governmental
well.

that can be felt as a lump or seen is a condition in organisations, hospitals and other
Solidarity as a unit
via imaging. It can arise from cells
that produce (lobular) or transport which cells begin non-profit establishments must
work diligently towards the same Another important aspect that
(ductal) milk. to grow out of cause.
Breast cancer survivorship
needs more attention is the
delivery of support systems for
Symptoms control, usually comprises various aspects such survivors as well as family

Below are some symptoms of forming a tumour as diagnosis, necessary medical

this abnormal growth.
l Usually painless lumps
l Blood-stained nipple discharge
l Unilateral rash on the nipple
areola that worsens over time
l Sudden onset of inverted
nipple
l Sudden change in size or
shape of breast
Stages
The stages of breast cancer
are:
l Stage 0 – Known as ductal
carcinoma, the cell growth is
limited to the area within a duct
or lobule and has not invaded
surrounding tissues.
l Stage 1 – The tumour is up
to 2cm across and has not affected
the lymph nodes.
l Stage 2 – The tumour is 2cm
to 5cm across and may have
spread to nearby nodes.
l Stage 3 – The tumour is
more than 5cm across and may
have spread to some lymph
nodes.
l Stage 4 – The cancer has
spread to distant organs, usually
the bones, liver, brain and
lungs.
Dr Sujatha Narayanan.
Prevention
There are no definite
preventative methods for breast
cancer. However, simple steps
can be taken to reduce the risks:
l Early detection via
mammogram or ultrasound,
depending on your age
l Practising a healthy diet and
exercising as being overweight
increases the risk of breast cancer,
especially after menopause
l Breastfeeding may lower
the risk of breast cancer
l Avoiding smoking and
reducing alcohol consumption as
these may increase the risk of
breast cancer in women
KPJ Selangor Specialist
Hospital in Seksyen 20, Shah Alam,
uses digital breast tomosynthesis
(DBT) for all mammographic
examinations.
DBT reduces compression
discomfort, increases detection
that can be felt
as a lump or seen
via imaging. It
can arise from
cells that produce
(lobular) or
transport (ductal)
milk.
rates, emits less radiation and
provides greater clarity.
Associated stereotactic biopsy
can increase the rate of detection
of abnormal microcalcifications in
the breast.
Interested in our digital 3D
mammogram? Call our radiology
services at 03-5543 1111 for an
appointment. – By Dr Sujatha
Narayanan, consultant general
and breast surgeon at KPJ
Selangor Specialist Hospital
n For details, visit
www.kpjselangor.com
KKLIU No.2161/2018
treatment, evaluation of prognosis
markers, follow-up sessions to
identify response to treatment and
preventative steps against
recurrence.
Alarmingly, there is still a
need to raise awareness regarding
breast cancer and convince women
who have been diagnosed to seek
immediate medical treatment.
Cases of women opting to
undergo alternative medicine are
not unusual in Malaysia, which is a
fact that must change.
The rise of social media and
ease of access to information on
the Internet is both a blessing and
curse as while information can be
easily disseminated to the masses,
many people are unable to
separate myth from truth.
It is dangerous for anyone
living with breast cancer to be
relying purely on information
available online as patient
education needs to be tailored
to her needs, condition, cancer
subtype, education level, cultural
sensitivity and language
preference.
Information found online
can be overwhelming, easily
misinterpreted or hard to digest
when a patient accesses it on
members or caregivers.
Due to the nature of the
disease, patients and family
members are likely to struggle to
come to terms with reality, thus
needing emotional and mental
support.
Cancer can affect mental and
emotional health in addition to
physical health, causing stress not
only to patients but everyone
around them.
Those affected must realise
that they are not alone in this
battle.
Helplines run by the National
Cancer Council Malaysia, National
Cancer Society Malaysia and Breast
Cancer Welfare Association
Malaysia enable callers to share
their struggles, be they directly or
indirectly affected by breast
cancer.
As Malaysia does not currently
have a comprehensive, nationwide
aftercare programme, the onus
falls on patients and family
members to reach out to helplines
or support groups.
The message is thus clear for all
those affected by breast cancer –
having open dialogue and safe
spaces to share their feelings and
thoughts can help them cope with
the disease.