BreastcanceristhemostcommontypeofcanceramongwomeninSingaporetoday.1outofevery13womeninSingaporeislikelytobeafflictedbybreastcancer.
Normalcellsdivideandreproduceinanorderlymanner.Yourbodyreliesonthisorderlyactivitytorepairinjuriesandreplacewornouttissue.Sometimesthisorderlyprocessisdisrupted.Cellsgrowanddivideoutofcontrol,producingextratissuetoformamassorlumpcalledatumour.Atumourcanbebenignormalignant.
Benigntumoursarenotcancers.Theymaygrowslowlybutdonotspreadtootherpartsofthebody.
Malignanttumoursarecancerousgrowthsandhavethepotentialtospreadtootherpartsofthebody.
Breastcancerisamalignanttumourwhichoccurswhenbreastcellsbecomeabnormalanddividewithoutcontrolororder.
Themajorityofbreastcancersstartinthemilkducts.Asmallnumberstartinthemilksacsorlobules.Withinthesetwogroups,somegrowveryslowlywhileothersdevelopmorerapidly.
Breastcancercanspreadtothelymphnodesandtootherpartsofthebodysuchasthebones,liver,lungandsometimestothebrain.
Screeningsimplymeansperformingaprocedureortesttodetectanabnormalitybeforesymptomsappear.Thisallowsproblemstobedetectedearlier,investigatedandtreatedearly.
Breastscreeningmethodsinclude:
A.BreastSelf-ExaminationBreastSelf-Examination(BSE)isrecommendedonceamonthabout1weekfromthefirstdayofmenses.Forwomenwhonolongermenstruate,choosingadateeachmonthisaneasywaytoremember.Reporttothedoctoranybreastchangessuchasredness,swelling,presenceofalump,skinchangesordischargefromthenipple.
Self-awarenessofbreastchangesthroughregularBSEandbeingfamiliarwithwhatisnormalandstableisusefultodetectabnormalities.
B.ClinicalBreastExamination
Haveadoctororbreastspecialistnurseexamineyourbreastsonceeveryyearifyouare40yearsandabove.Thisincludesavisualexaminationandamanualcheckoftheentirebreastandunderarmareaforchanges.Changesinthebreastmaynotbeduetocanceranddiagnostictestsmaybeperformedtoassessthesechanges.
Mammographyisalow-poweredX-raytechniquethatgivesanimageoftheinternalstructureofthebreast.UsualscreeningmammogramsinvolvetakingX-rayimageswiththebreastcompressedbetweentwoplateswithtwoviewstaken—cranialcaudalorhorizontalandmediolateralobliqueordiagonal.
Mammogramstakeanimageoftheinternalstructureofthebreastandcanhelpdetectabnormalities.
Additionalanglesandmagnifiedviewsmaybetakenifthereareareasofconcern.Itcandetectthepresenceandpositionofabnormalitiesandhelpinthediagnosisofbreastproblems,includingcancer.
Theriskofdevelopingbreastcancerincreaseswithage.Womenwithriskfactorssuchasafamilyhistoryofbreastcancershoulddiscusswiththeirdoctorswhentogoforandtheintervalofregularscreening.
Thereareothertestssuchasbreastultrasound,tomosynthesisandMRI,availableforassessmentofthebreasts.
Thesearenotusedforregularscreeninginwellwomenandareusedforfurtherevaluationafterinitialscreeningmammogram,butmaybeconsideredforwomenwithhighriskofbreastcancer.
Ductalcarcinomainsitu(DCIS)generallydoesnotcausesymptoms,andismostcommonlydiscoveredinscreeningmammograms.Occasionally,womenwithDuctalcarcinomainsitu(DCIS)maypresentwithabreastlumporbloodynippledischarge.
Breastcancerisotherwiseusuallypainlessandtheremaybenosymptomsintheearlyphasewhenbreastcancerfirstdevelops.
Whenthecancergrows,signsandsymptomsmaydevelopandtheycaninclude:
Thereisnosurewaytopreventbreastcancer,buttheriskscanbelowered.Theseincludemodifyingtheriskfactorswhichwehavecontroloversuchas:
Inhigh-riskwomen,suchasthosewithaverystrongfamilyhistoryorhavegeneticmutationssuchastheBRCA,risk-reducingoptionsincludetakingdrugsorhavingsurgerythatcanreducetheirrisk.Risk-reducingsurgeriesincluderemovalofthebreast(mastectomy)andremovaloftheovaries.
Analternativemanagementstrategytorisk-reductionmethodsisclosesurveillance.Whilethisdoesnotreducetheriskofcancerdevelopment,itdoesimproveoutcomebydiscoveringthecancersinearlierstages,allowingearliertreatmentandhencebetteroutcomes.
About5to10percentofbreastcancerscanbeattributedtohereditarybreastandovariancancer(HBOC)syndrome.Geneticchange(mutation)intheBRCA1orBRCA2geneisthemostcommoncauseofHereditaryBreastandOvarianCancer(HBOC).
IndividualswithBRCA1orBRCA2mutationtendtodevelopcanceratanearlieragethanthegeneralpopulationandhavehigherriskforbilateralbreastcancer,asecondprimarytumourinadifferenttissue,andcancerrecurrence.
Mutationsinotherlesscommongeneshavealsobeenfoundtoincreasetheriskofdevelopingbreastandothercancers.
HereditaryBreastandOvarianCancer(HBOC)isanadult-onset,cancerpredispositionsyndromewhichcanbepasseddownthroughgenerations.
ThehistoryofcancerinyourcloserelativesisaclueaboutthechanceofHBOCsyndromeinyourfamily.Itismorelikelyifoneormoreofthefollowingfeaturescanbeconfirmedinyourfamily:
GenetictestingforHereditaryBreastandOvarianCancer(HBOC)syndromeisabloodtestthatisavailableattheCancerGeneticsServiceatNCCSwhenspecificcriteriaaremet.Genetictestingiscomplex,thusitdoesnottakeplacewithoutgeneticcounsellingandtheprocessofinformedconsent.
Cancergeneticcounsellingisaprocesstoassessaperson'sriskofhavinganinheritedsusceptibilitytocancer.Itisusuallyprovidedbyageneticcounsellorand/orcancergeneticisttohelppeopleunderstandandadapttothemedical,psychologicalandfamilialimplicationsofgeneticcontributionstocancer.
GeneticcounsellingcanhelpyoubetterunderstandtheoutcomesandimpactsofgenetictestingandthepossibleimplicationswhenfindingageneticmutationofHereditaryBreastandOvarianCancer(HBOC)syndrome.
Increasedsurveillance(clinicalbreastexam,mammogramandMRI)andconsiderationofrisk-reducinginterventions(suchaschemopreventionandpreventivemastectomyoroophorectomy)arerecommended.
IfyourfamilyhistoryofcancersuggestsHereditaryBreastandOvarianCancer(HBOC)syndrome,pleasetalktoyourdoctorregardingyourconcernsandtheywillmakethenecessaryarrangementsifageneticriskassessmentisneeded.
FindingageneticmutationofHereditaryBreastandOvarianCancer(HBOC)syndromemayhelpto:
Thecausesofbreastcancerarenotexactlyknownbutthereareriskfactorsthatincreasethechanceofdevelopingbreastcancer.
Havingriskfactorsdonotmeanawomanwilldefinitelydevelopbreastcancer,asmanywomenwhohavehadbreastcancerdidnothaveanyapparentriskfactors.
Someriskfactorssuchasgenderandage,orthoserelatedtoourenvironmentcannotbechanged(non-modifiable),whileothersaremodifiableastheyarerelatedtoourlifestylechoices.
Beingawomanisariskfactorfordevelopingbreastcancer.Womenhaveamuchhigherchanceofdevelopingbreastcancerthanmenduetothefemalehormonesoestrogenandprogesterone.
Thisriskisincreasedwithlongerhormonalexposureinwomenwithearlymenarche(onsetofmenstruation)beforetheageof12andlatemenopause(aftertheageof55).
Otherhormonal-relatedfactorsincludeneverhavingchildren,latechildbearing(aftertheageof30),andobesity,especiallyexcessiveweightgaininpost-menopausalwomen.Thisriskalsoincreaseswithage.
Geneticfactorsandfamilyhistoryofbreastcancer,especiallyinafirst-degreerelative(mother,sisterordaughter),ortwoormorecloserelativessuchascousinsandthepresenceofgeneticalterationsincertaingenessuchasBRCA1andBRCA2whichareassociatedwithsignificantlifetimerisksofbreastcancer.
Apasthistoryofbreastcancer,radiationexposureformedicalreasonsandcertainbenignconditionssuchasatypicalductalhyperplasia,atypicallobularhyperplasiaorlobularcarcinomain-situdiagnosedonbreastbiopsyalsoincreasetherisk.
However,mostwomenwhohavebreastcancerhavenoneoftheaboveriskfactors.Likewise,notpossessinganyoftheseriskfactorsdoesnotmeanthatonewillnotgetbreastcancer.Thereisongoingresearchtolearnmoreaboutthesefactors,aswellaswaystopreventbreastcancer.
Breastcancercanbeclassifiedbythestageofcanceratdiagnosisandtheirbiologicalcharacteristics.Thesewilldeterminetreatmentrecommendationsasithasprognostic(mostlikelyoutcomeofthedisease)implicationsandtreatmentimplications.
Understandingthestageofthecancerisimportanttounderstandtheprognosisandthetreatmentrecommendation.
Cancerstreatedinearlierstageshavebetteroutcomes,moreadvancedcancerswillneedmoreaggressivetreatment.
Cancerstageisbasedon:
TheTNMstagingsystemisbasedon:T:SizeofthetumourN:LymphnodeinvolvementM:Metastasiswhencancerhasspreadtootherorganslikethelung,liverandbones.DifferentT,NandMincombinationwilldeterminethestageofthecancer.
Stage0orDuctalCarcinomainSitu(DCIS)isacommonnon-invasivebreastcancer,wherecancercellsarestillwithintheductsandhavenotgrownouttobreachtheductliningsintothesurroundingnormalbreasttissue.
DCIS,alsoknownasStage0breastcancer,unlikeinvasivebreastcancer,isnotlife-threatening,butitcanincreasetheriskofdevelopinganinvasivebreastcancer.
lnvasivebreastcanceroccurswhencancercellsspreadbeyondtheductsorlobulesresultingininvasiveductalandinvasivelobularbreastcancer,thetwomostcommonsubtypesofbreastcancer.
Metastaticbreastcancerreferstothestagewhenthecancerhasspreadbeyondthebreasttodistantorganssuchasthelungs,liverorbones.
Breastcancersarealsodifferentiatedbythepresenceofspecialreceptorsonthesurfaceofthecancercells,suchasthe:
Thisisassociatedwiththeaggressivenessofthecancerandaffectstheprognosisofthepatient.
Moreimportantly,therearedrugstotargetthesechanges,andhencedirectedtreatmentforthemwillimprovetheoutcome.
Thehistopathological(microscopicappearance)subtypeofthecanceralsohelpstodeterminetheprognosis,andnatureofbreastcanceroverall.
Thegrade(assessmentofhowabnormalthecancercellslook)alsodeterminestheaggressivenessandhence,treatmentrecommendations.
Themostcommonsubtypeistheinvasivecarcinomaofnospecialtype(NST).Specificsubtypesincludeinvasivelobular,tubular,cribriform,metaplastic,apocrine,mucinous,papillaryandmicropapillarycarcinoma,aswellascarcinomawithmedullaryandneuroendocrine(WHOclassification2012).
Ifthereisanunusuallumporchangesinthebreasts,seekmedicalattention.Trytopinpointtheareaaccuratelyasthiswillassistthedoctorwiththeexamination.Testswillberecommendedtoobtainadefinitediagnosis.
TeststodiagnoseBreastCancerinclude:
Mammographyisalow-poweredX-raytechniquethatgivesapictureoftheinternalstructureofthebreast.UsualscreeningmammogramsinvolvetakingX-rayimagesofthebreastcompressedbetweentwoplateswithtwoviewstaken—cranialcaudalorhorizontalandmediolateralobliqueordiagonal.
Additionalanglesandmagnifiedviewsmaybetakenifthereareareasofconcern.Itcandetectthepresenceandpositionoftheabnormalitiesandhelpinthediagnosisofbreastproblems,includingcancer.
Anypreviousmammograms(andreportsifavailable)shouldbebroughtalongwhenseeingadoctor.
Sometimesalumpthatcanbefeltisnotseenonamammogram.Othertestsmaybenecessarytodetermineifthelumpiscancerous.
Breastultrasoundistheuseofhigh-frequencysoundwavestoproduceanimageofbreasttissue.
Thesoundwavesaretransmittedfromtheprobethroughthegelintothebody.Thetransducercollectsthesoundsthatbouncebackandacomputerthenusesthosesoundwavestocreateanimage.
Thisusesacombinationofmagnetismandradiowavestobuildupapictureconsistingofdetailedcross-sectionsofpicturesofthebreasts.
Thetestinvolveslyingonthestomachonapaddedplatform,withcushionedopeningsforthebreasts,thatpassesthroughatunnel-likestructure(whichformsaverylargemagnet).Itmaytakeuptoonehourtocomplete,butiscompletelypainless.
MagneticResonancelmaging(MRI)isusefulwhenmammogramsarenotsuitable,e.g.inyoungwomenwithdensebreasttissueorwhenfindingsonmammogramsandultrasoundarenotconclusivetoachieveadiagnosis.
Itisusedasascreeningtoolforyoungwomenwithhigh-riskfactorslikeBRCAgenecarriersorthosewithaverystrongfamilyhistoryofbreastcancer.
ThisinvolvestakingmultipleX-raysofeachbreastfrommanyangles.Thebreastispositionedthesamewayasinaconventionalmammogram,butonlyalittlepressureisapplied,justenoughtokeepthebreastinastablepositionduringtheprocedure.
AnX-raytubemovesinanarcaroundthebreastwhileimagesaretaken.Informationissenttoacomputer,whereitisassembledtoproduceclear,highly-focussed3-dimensionalimagesthroughoutthebreast.
Thisisaminimallyinvasivemethodthatobtainsafewtinystripsoftissuefromanareaofabnormalitywithawideboreneedle.Localanaestheticisinjectedtonumbthebreastarea,followedbyasmallincisionintheskintoalloweasyinsertionoftheneedle.
Iftheabnormalityisnon-palpable(notdetectablebyclinicalexamination)andvisibleontheultrasound,ultrasoundguidanceisusedtoobtainthetissue.Usually2to6coresoftissuewillbeobtainedforexamination.
Anursewillapplycompressiontothebreasttostopanybleeding.Thewoundisclosedbyasteristripandthedressingapplied.Strenuousactivityistobeavoidedfor2daysafterthebiopsy.
Vacuum-assistedbiopsy(VAB)devicesusealargerboreneedlewithavacuumcomponenttoobtaintissuesamplesfromnon-palpablelesions.
Liketheusualcorebiopsy,thisminimallyinvasiveprocedureisalsoperformedunderlocalanaesthesia,whichisinjectedtonumbthebreastarea,followedbyasmallincisionintheskintoalloweasyinsertionoftheneedle.Itisusedforlesionsseenbymammography(stereotactic-guidedbiopsy),ultrasoundorMRI.
Thesurgeonorradiologistplacestheprobeintothesuspiciousareaofthebreastaccurately.Avacuumthendrawsthetissueintotheprobe,acuttingdeviceremovesthetissuesampleandthencarriesitthroughtheprobeintoacollectionarea.
MoretissueisusuallyobtainedusingtheVacuum-assistedbiopsy(VAB)thantheusualcoreneedlebiopsyandthenumberofstripsremovedisdependentontheareathatneedstobeexamined.
Asmalltitaniumclip(microclip)maybeplacedatthebiopsysiteasalocationmarkerforfuturetreatment.Thisclipisverysmall(2mm),isharmless,andwillnotcauseanyproblemswhenleftinsidethebreast.AnX-rayistakenpost-biopsytoensureproperclipplacement.Newbiodegradablemarkersarealsoavailablenow.
Anursewillapplycompressiontothebreasttostopanybleeding,thewoundisclosedbyasteristripandthedressingapplied.Strenuousactivityistobeavoidedfor2daysafterthebiopsy.
Thisprocedureisminimallyinvasiveascomparedtoanopensurgicalbiopsy.Itisperformedasadaysurgeryprocedure.lthastheabilitytosampletinyabnormalitiescalledmicrocalcifications,makingearlydiagnosisofbreastcancerpossible.
Underlocalanaesthesia,ittakesabout30to45minutestocomplete.Theprocedureisusuallynotpainfulbutyoumayexperiencesomediscomfort.
Asyringewithaveryfineneedleisusedtowithdrawfluidorcellsfromabreastlump.Thisisasimpleprocedureandcanbeuncomfortablebutisusuallytolerableenoughforittobedoneintheclinic.
Ifthelumpisjustacyst,withdrawingfluidinthismannerwillusuallymakethecystdisappear.
However,ifthelumpissolid,yourdoctormayusethisproceduretowithdrawsomecellsfromit.Thecellswillthenbesenttoalaboratoryforexamination.
Anexcisionbiopsyistheremovalofalumporsampleofsuspicioustissuebysurgeryforexaminationunderamicroscopetogiveadefinitediagnosis.
Forlesionsthataresmallornotpalpable,accuratemarkingoftheareaforsurgeryisnecessary.Theseincludeusingultrasoundduringsurgery,orwithproceduresdonejustbeforesurgerytomarktheareatobeoperated.
Ultrasound,mammogramorMRIcanbeusedtoinsertasmallthinwiretotheabnormalspotinthebreast.
Thiswireisusedtoguidethesurgeontoremovetheareaaccurately.ThistechniqueisknownasHookWireLocalisation(HWL)Biopsy.
Excisionbiopsiesareoftenperformedundergeneralanaesthesia,dependingonthesizeandpositionofthelump,butlocalanaesthesiamaybeusedforsmalllesionsclosetotheskin.
Asaminordaysurgeryprocedure,patientscanreturnhomeaftersurgery.Strenuousactivityistobeavoidedforthefirstfewdays;immediateabilityforusuallightactivitiesofdailylivingisexpected.
Post-operativeadvicemaydifferbetweenindividualsdependingontheirneedsandcircumstances.Ingeneral,mostwillbeabletoreturntoworkinaweek.
Treatmentofbreastcancerofteninvolvesmorethanonetherapy,andmaybeacombinationoftherapies.
Treatmentrecommendationsdependonfactorssuchasthecancertype,stageofthecancer,sizeofthetumourinrelationtothebreastsize,whetherbreastpreservationisdesiredandthepatient’sgeneralhealth.
Personalpreferencesdeterminecertainchoices,iftheoptionisavailable,suchastheoptionsforthetypeofsurgery.Beingdiagnosedwithbreastcancerandhavingtodecideonthetreatmentoptionsmaybedifficult.Thesupportoffriendsandfamilyduringtheconsultanddiscussionontheresultsoftestsandtreatmentisrecommended.
Inearlybreastcancer,surgeryisthefirsttreatmentofchoice.Chemotherapy,targetedandhormonaltherapymaybeusedbeforesurgery(neoadjuvanttherapy),oraftersurgery(adjuvanttherapy).Radiotherapyisusuallygivenaftersurgery.
InstageIVcancer,thegoalistostabilisethediseasewithsystemictherapy.However,localtreatmentoftumourswithradiationtherapyorsurgerymayberecommendedwhensymptomsneedtobealleviated.
Image-GuidedLocalisationforSurgery
Fornon-palpabletumoursthatneedtoberemovedwithsurgery,localisationwithahookwireoralocalisingsubstanceunderimageguidancedonepriortothesurgeryisneeded.
Thisprocedureisperformedunderlocalanaesthesia,priortosurgery.Mammogram,ultrasoundorMRIguidanceisusedtoaccuratelylocatethesiteforsurgery.
Afinewire(hookwire)isinsertedoraradioactivesubstanceisinjectedintothebreast,withinorincloseproximitytothelesionofinterest,whichwillberemovedduringthesurgery.
Mastectomyistheremovalofthewholebreast(incorporatingthebreasttumour).Ingeneral,therearetwotypesofmastectomy:
Skin,fatandsometimesmuscle(aflap)fromanotherpartofyourbodymaybeusedtomakeintoabreastshape.Thisoperationtakesabout6to8hoursandrequiresahospitalstayofbetween1to2weeks.Severaldrainsareusedandremovedafter1to2weeks.Flapsmaybefromthefollowingareas:
Additionalprocedurestoimprovethelookofthebreastaftertheinitialsurgerymayincludeaddinganipple,surgerytotheoppositebreasttocreateagoodmatch,orrefiningtheshapeoftherecreatedbreast.
Siliconeimplantsmaybeusedtocreateanewbreastandtheoperationtakesabout4to5hours.Thereareusually2to3drainsinsertedandthehospitalstayis2to5days.
A1-stageprocedureiswhenthepermanentimplantisinsertedatthetimeofmastectomy.A2-stageprocedureiswhenatemporaryexpanderisplacedatthetimeofmastectomyandgraduallyexpandedtostretchtheskin.Theexpanderwillbeexchangedforapermanentimplantatalatersurgery.
SentinelLymphNodeBiopsy(SLNB)isrecommendedforearly-stagebreastcancerwhenthelymphnodesinthearmpitdonotappeartohavecancer.
Sentinellymphnodes(SLN)arethefirstfewlymphnodesinthearmpitwherethelymphaticvesselsfromthebreastdrainto.Thesewillberemovedduringsurgeryandexaminedunderthemicroscope(frozensection)todetermineifcancerhasspreadtotheSLN.
Thisisdoneundergeneralanaesthesia(GA).AbluedyeoraradioactivesubstanceisinjectedaroundthecancersiteoratthenipplepriortosurgerytolocatetheSLN.Theradioactivesubstancewillbeinjectedbeforetheoperation.Thebluedyewillbeinjectedduringtheoperation.
IfcancerisdetectedintheSLN,lymphnodesintheaxillawillberemoved.IfnocancerisdetectedintheSLN,nofurthersurgeryisneeded.
Thefinalhistology(microscopicassessment)willbereviewedabout1weekaftersurgery.Inupto5percentofcases,thefinalassessmentoftheSLNmaybedifferentfromtheinitialfrozensectionresultandasecondoperationmayberecommended.
IfthedyeorradioactivesubstanceisnotabletoidentifytheSLN,removalofallthelymphnodes(axillaryclearance)willbedone.
AxillaryClearanceistheremovalofalllymphnodesfromtheunderarmwhenthelymphnodesarefoundtohavecancercells.
Sideeffectsofaxillaryclearanceincludeshoulderstiffnessandnumbnessoftheinnerpartofyourupperarm.Lymphoedema(swellingofthearm)mayoccurin10to15percentofwomen.Thisisbecauselymphnodesdrainfluidfromthearmandtheirremovalmaycausefluidtoaccumulateinthearmontheoperatedside.
Aseparateaxillaryincisionisoftenneededforpatientsundergoingbreastconservingsurgery.
Aswithallsurgicalprocedures,complicationscanoccur.Risksofgeneralanaesthesiaincludeallergytoanaestheticagents,heartattack,strokeanddeepveinthrombosis,especiallyforlongersurgeries.
Ouranaesthetistswillassessallpatientsbeforesurgerytoensuretheyareoptimisedandpreparedforsurgerytominimisetheserisks.
Surgicalcomplicationsinclude:
Aftersurgeryisplanned,referraltotheBreastCareNurse(BCN)Serviceisnecessary.OurBreastSpecialistNursewillexplainandexploreconcernsandissuespertainingtobreastcancerandthetreatmentoptions,andplanpre-operative,operativeandpost-operativemanagementtoensuresuccessfultreatmentandrecovery.
Consulttimeforindividualpatientsvaryfrom30to75minutes.ApersonalcontactnumberwillbeprovidedforconvenienceandtheBCNwillbearesourcepersonforpatientsandtheirfamiliesinthecoordinationofthevariousappointmentsbeforeandaftersurgeryinthetreatmentjourney.
Post-operativeservicesincludewoundanddraincare,rehabilitation,educationprogrammesandprosthesis-fitting.
Radiotherapyisalmostalwaysrecommendedafterbreast-conservingsurgeryandofteninpatientswithhighrisksdiseaseaftermastectomy.Thisincludepatientswithlargetumoursandthosewherethecancerhasspreadtoinvolvemultiplelymphnodes.Almostalways,radiotherapyisperformedaftersurgeryandchemotherapy,whenneeded.
Radiotherapyisperformedoveraperiodoftime,whichmayvaryindurationbetween1to6weeks.Theactualtreatmentdurationwillbedeterminedfollowingaconsultationwithyourspecialistbasedonanassessmentofyourneeds.
Followingthisconsultation,anappointmentwillbemadeforscanstobeperformedofthepartofthebodytobeirradiated.ThisprocessiscalledCT-Simulation.Duringthissession,youwillmeetwithourteamofRadiationTherapistswhowilldeterminethebesttreatmentpositionforyouandobtainaCTscanoftheareatobetreated.
Yourdoctorandteamofspecialistswillthenperformapersonalizedplanningforradiotherapyaccordingtoyourneeds.Computerizedtreatmentplanningisusedtooptimisethedeliveryofhighradiationdosetothetreatmentarea,whilereducingradiationdosetovitalorganslikeyourheartandlungs.
Radiotherapyisdeliveredeveryday,5daysaweekforthedurationofthetreatment.Dailytreatmentlastsbetween30to60minutesandisperformedonanoutpatientbasis.Treatmentisentirelypainlessandwithoutanyperceptiblesensation.
Radiationaffectsbothcancerandtheirsurroundingnormalcells.Cancercellsaretypicallymoresensitivetoradiationthannormalcells,andarelessabletorepairthemselvesafterbeingdamagedbyX-rays.Hence,theydieoffafterradiation.Eventhoughthesurroundingnormalcellscanbeaffectedbyradiation,theyoftenrecoverwithtime.Thiscanmanifestassideeffectsthatoriginatefromthesiteoftreatment,manyofwhichareshort-termandtemporary,althoughtherearesomecaseswherelong-termcomplicationsmayalsooccur.
Earlysideeffectscanoccurduringradiotherapy,typically2weeksintothetreatment.Suchsideeffectsareusuallytemporaryandshowgradualimprovementin8weeksuponcompletionoftreatment.However,somemaytakealongertimetoresolve.Examplesofsuchearlysideeffectsincludefatigue,skinchangessuchasredness,pigmentation,drynessanditching,ordiscomfortfromtemporarybreastswelling.
Latesideeffectsareuncommonandmayoccuronlymanymonthsoryearsaftertreatment.Asmallproportionofpatientsmayexperienceprogressivehardeningofthebreastandtheoverlyingskinwhichmayleadtoashrinkingordistortionofthebreastorchestwall.Otherlatecomplicationstotheheartandlungsaremuchrarerandyourdoctorwilladviseyoufurtherastherisksvarybetweenpatients.
IntraoperativeRadiotherapy(IORT)isaspecializedformofradiotherapyusedinthetreatmentofbreastcancer.Likeallradiotherapy,highenergyradiationisusedtodamageandkillcancercells,soastoreducetheamountofcancerinyourbodyandincreasesthechanceofyoustayingcancerfree.
IORTisperformedonlyinpatientsundergoingbreast-conservingsurgery.Additionally,IORTissuitableonlyforpatientswithearlystagecancersandmeetconditionsthatyourradiationoncologistswilladviseyouon.
Insuitablepatients,IORTisperformedduringthecancersurgeryimmediatelyuponremovalofthetumour.Aspecializedapplicatorwillbeplacedintotheexcisioncavitytoirradiatetheimmediatebreasttissuefrominsideouthencelimitingthedosetotherestoftheinvolvedbreastandnormalorgans.Aspatientswillremainunderanesthesia,IORTiscompletelypainless.
Formostpatients,thissinglefractionIORTwillbetheonlyradiotherapytheyrequire,hencethetreatmentburdeninwellselectedpatientscanbereduced.Occasionally,thesurgeryandsubsequentexaminationofthecancermayrevealadditionalinformationaboutthecancerwhichmayleadtoyourdoctorrecommendingfortheuseofadditionalexternalbeamRTafterIORT.
Patientswillexperiencetheusualsymptomsrelatingtobreastcancersurgery.Inaddition,somepatientsmayexperienceaslowerresolutionoftheseromaassociatedwiththesurgicalcavity.Asmallergroupofpatientsmayfindlocalizedhardeningofthebreasttissueandskinintheregionoftheoperation.Rarely,thismayleadtoadistortionofthebreastinthelongterm.
Thistreatmentusesanti-cancerdrugstopreventcancercellsfromgrowingandreproducingthemselves.Thesedrugsareusuallygivenbyinjectionthroughveinsintothebloodstreamtoallpartsofthebody.
Itisusuallygivenover3to6monthsandmaybeusedalone,beforesurgery(neoadjuvant)oraftersurgery(adjuvant)therapy,ortogetherwithtargetedtherapytoincreasetheeffectivenessofthetreatment,dependingonthetypeandstageofcancer.
Chemotherapyisgivenincycles.Eachcycleconsistsofatreatmentperiodfollowedbyaresting(recovery)period.Ascancerdrugsalsoaffectnormalcells,therestingperiodistoallowthebodytorecoverbeforethenexttreatmentcyclestarts.
Breastcancersarealsotestedforspecialreceptors.OnesuchreceptoristheHumanEpidermalGrowthFactor2(HER2)receptor.Thisreceptorisover-expressedinabout25percentofallbreastcancers;thepresenceneedstobeconfirmedbylaboratorytestsperformedonthebiopsyspecimenbeforethetreatmentisgiven.
Theaimofthetreatmentistoreduceandhopefullyeliminateexistingcancercellsinthehumanbodywhileminimisingsideeffectsonnormalcells.
Trastuzumab,alsoknownasHerceptin,targetstheHER2(HumanEpidermalGrowthFactor2)receptorsoncancercellstopreventcellgrowthanddivision.
Herceptinhasbeenshowntoprolongsurvivalinbreastcancerpatientswithearlyandadvanceddisease(StageIV)whenusedincombinationwithchemotherapy.
Anincreasingnumberoftargeteddrugsarebecomingavailableforthetreatmentofbreastcancer,includingLapatinib(whichtargetsHER2andEGFR)andBevacizumab(whichtargetsafactorassociatedwithnewbloodvesselformationintumours.
Breastcancersaretestedforoestrogenreceptors(ER)andprogesteronereceptors(PR)ontheirsurfacesassuchcancerscanbestimulatedbyoestrogenorprogesteronetogrow.
Hormonaltherapyisaimedatblockingthiseffect.Thedrugrecommendedisdependentonthemenopausalstatusofthewomen.
Hormonaltherapycancausesomesideeffects,andtheyaredependentonthetypeofdrugtakenandcanvaryfromonepatienttoanother.
Regularfollowupbythedoctoraftertreatmentisrecommendedduetotheriskofdevelopingbreastcanceragain.
Thiswillincludephysicalexaminationofthechest,underarms,neck,andtheotherbreastwithperiodicmammograms.
Changestolookoutforinclude:
Woundsareoftenclosedwithabsorbablestitches,hencestitchremovalisnotneeded.
Woundcareissimpleandpatientswillbetaughtandgivenspecificinstructionsinthemanagementofvarioustypesofwoundcoverage.
Patientsarerecommendedtoshower2daysaftermostsurgeriessuchasbreast-conservingsurgeryandsimplemastectomies.
Softflexibletubedrainsareplacedundertheskinatthetimeofsurgery.Thesehelptoremovebloodandotherfluidsthataccumulateatthesiteofsurgery.Patientswithoutbreastreconstructionsurgeryareusuallydischargedfromthehospitalwiththetubedrainonthedayaftersurgery.
Thenurseinthewardwillteachthedraincareandprovideacharttokeeparecordofthedrainage,tobereportedtotheBreastCareNurse(BCN)daily.Thedrainwillberemovedintheclinicwhenthedrainageisminimalandthisusuallytakes1to2weeks.
Patientsarerecommendedtoseeadoctorifthereis:
Routinemedicationsprescribedbydoctorsareusuallyresumedimmediatelyaftersurgeryandtherearedietrestrictionsunlessotherwiseadvisedbythedoctor.
Patientsareencouragedtoresumenormalmobilityandfunctionassoonasitissuitableaftersurgery.
Mostpatientswithbreast-conservingsurgery(BCS)andsimplemastectomieswillbeabletoresumeusualdailyactivitiesimmediatelyaftersurgery,withspecialprecautionsforthosewithbreastreconstructionsurgery,wheremanagementwilldifferaccordingtotheirsurgeries.
OurArmExerciseProgrammeconductedbyourOccupationalTherapistsorPhysiotherapistsonthedayaftersurgeryaimstopreventshoulderandarmstiffness.Thiswillenableyoutousethearmasyouhadbeforesurgeryinactivitiesathome,workandinrecreation.
Theexercisesalsopromotecirculationofthelymphaticsystem,thuspreventingswellingoftheaffectedarm.Over-strenuousactivitiesaretobeavoidedinthefirstfewweeksafterdischarge.
Theseexercisesaretobedoneoncedaily,andeachsetofexercisesistoberepeated5times.InstructionsfromtheOccupationalTherapistorBreastCareNurseonthelimitationswillbeadvisedasneeded.
Followingaxillarysurgery,lymphoedemaandincreasedriskofinfectionofthearmmayoccuraslymphnodesalsocontaincellswhichfightinfection.
Therefore,extracaretoprotectthehandandarmontheoperatedsidefrominjuryisrecommended.
Patientswillbereferredtoaphysiotherapistoroccupationaltherapistspecially-trainedintreatinglymphoedema.Theywillrecommendprogrammeswhichincludeskincare,exercise,manuallymphaticdrainage(aspecialmassagetechnique),andcompressiongarmentstohelpreducetheswelling.
Preventivemeasuresinclude:Youwillbereferredtoanoccupationalorphysiotherapistforrehabilitationadviceandarmexercise.Exercisesmaybeginasearlyasthefirstpost-operativeday.Thefollowingbasicstepscangreatlyreducetheriskofarmswelling:
Goodskincareisessentialinpreventinganinfectionandsubsequentswelling
Avoidextremeheatonaffectedarmpathway
Careforwounds,cutsorburns,andrecognizingthesymptomsofinfection
Avoidanyconstrictionstothearmasthismightrestricttheflowoflymphfluid
Ontheoperatedside,
Maintainexercisetomaximizelymphflow
Avoidoveruseorfatigueofyourarmmuscles
Withamastectomy,physicalappearancecanbemaintainedbywearingaprosthesis(calledabreastform),orbyundergoingbreastreconstruction.
Therearewomenwhochoosenottohavebreastreconstructionaftermastectomy.Somemakethisdecisionbecausetheywanttoavoidextrasurgery.Forothers,itisbecausetheyarecomfortablewiththeirappearanceandbodyimage.
Breastformsorprosthesesareusedtomaintainappearanceandasenseofbalance,aswellastorelievethestrainonposturethatmayoccurafteramastectomy.Theyareavailableinavarietyofsizes,shapesandcolours.Somearedesignedtofitintoaspecialbra.Otherscanbeattachedsecurelytoyourchestusingaspecialadhesive.
Nineoutof10womenwhogototheirdoctorswithbreastlumpshaveabenigndisorder,notcancer.Normalchangesassociatedwiththemenstrualcyclecanmakebreastsfeellumpy.
Thebeliefisthatchanginglevelsoffemalehormonesduringpregnancycouldencouragetherecurrenceofbreastcancer.However,thereisnodatatoshowthatthisisso.Somedoctorswilladviseyoutowaitoneortwoyearsaftercompletionoftreatmentbeforeattemptingtoconceive.Nevertheless,dodiscusswithyourdoctorbeforeplanningtoconceive.
Somewomendobettercosmeticallywithamastectomythanwiththeremovalofjustthelump,sincebreastreconstructionisnowavailableusingtissueexpandersorskinflaps.Yoursurgeonwillbeabletoadviseifyouaresuitableforbreastreconstruction.TheSingaporeCancerSocietyhasaReachtoRecoveryProgrammethatprovidesphysical,cosmetic,post-operativeandpsychologicalsupport.Thevolunteerisusuallyafemalewhohasundergoneamastectomy.
Radiationexposurefrommodernmammogramequipmentisbelievedtobesafe.
Althoughyourworryisunderstandable,youshouldseeyourfamilydoctorassoonaspossible.Thegreatmajorityofbreastlumpsarenotcancerous.
Asmallproportionofbreastcancerislinkedtofactorsthatcanbeinheritedfromonegenerationtothenext.Dependinguponthenumberofcloserelativesaffected,youmayhaveagreaterchancethanawomanwhodoesnothaveafamilyhistoryofbreastcancer.Mostfamilydoctorsorhospitalswillprovideinformationonbreastself-examinationandmammogramscreenings.
Manywomenwhohavehadbreastcancerliveanormallifespan.Feelfreetodiscussyourownprognosiswithyourdoctor.
Thisdependsonthesize,positionandtypeofyourbreastcanceraswellasthesizeofyourbreast.
Itisuncommonforwomentoexperiencelastingdamagefrommodernradiotherapytechniques.Mostchemotherapyside-effectsareshort-term.Nauseaandvomitingarecontrolledinmostpatients.Hairlossisstillcommon,andyoumayrequireatemporarywig.Yourperiodsmaydisappearduringchemotherapybutmayreturnwhenyoucompletechemotherapy.However,forwomenintheirlate30sand40s,menopausemayoccurearly,perhapsincreasingtheriskofosteoporosisandheartdisease.Ifafeveroccurswhileyouareonchemotherapy,seeyourdoctorimmediatelyincaseantibioticsareneeded.
Normalfemalehormoneslikeoestrogenmaypromotegrowthofnormalhealthybreasttissue,butmayalsoacceleratethegrowthandrecurrenceofcertainbreastcancers.Drugsthatslowbreastcancergrowthbyinterferingwithnormalfemalehormoneactionaregenericallycalledhormonetherapy.Somebreastcancersneedthehormone,oestrogen,togrow.Hormonetherapycanpreventyourbody’snaturalhormonesfromactivatinggrowthorspreadofcancercells.
Themostcommondrugusedforhormonetherapyforbreastcanceristheoraltablet,tamoxifen,whichstopstheactionofoestrogen.
Youmayexperienceanyofthefollowingcommonsideeffects:
Whenusedtotreatearlybreastcancer,tamoxifenismostoftenprescribedfor5years.Patientswithadvanceddiseasemaytakeitforvaryinglengthsoftimedependingontheirresponsetotreatment.
Manybreastcancershave‘receptors’foroestrogenandprogesterone.Receptorsareproteinsonthesurfaceofthecancercellstowhichspecifichormones(e.g.oestrogenorprogesterone)attachthemselves.Ifthecancerhasoestrogenorprogesteronereceptors,itislikelythathormonaltreatmentwouldbenefitthisgroupofwomen.
Thereisawiderangeavailable.Thetypeofbreastformyourequirewilldependonyourneeds.Itshouldcloselysimulatetheweightandshapeofanaturalbreastandyourotherbreast.Ifyouneedadvice,speakwithyourBreastCareNurse.
Yes,theprosthesiscanbewashed.Instructionsonthecareoftheprosthesiscanbefoundintheboxwhenyoupurchaseone.Youshouldalsoplacetheprosthesisintheboxwhenyouarenotusingit.
Itwillbehelpfultostayactiveandtoexerciseregularlyifyoucan.Lightexercise,suchaswalkingaftersurgery,canassistintherecoveryprocess.Theamountandtypeofexercisewilldependonwhatyouareusedtoandhowwellyoufeel.Itisbesttodiscussyourconcernswithyourdoctor.
Itisimportanttohaveregularscheduledmammogramsontheoppositebreast.Breastselfexaminationshouldcontinue.Checkboththeremainingandthereconstructedbreastatthesametimeeachmonth.Youwilllearnwhatisnormalforyousincethebreastreconstruction.Thereconstructedbreastwillfeeldifferentandtheotherbreastmayhavechangedtoo.
Youcanstillbreastfeedyourbabyfromtheunaffectedbreast.Itisnotadvisabletobreastfeedyourbabyonthebreastthatisaffectedbycancer,asitwillnotbeabletoproduceadequatemilk.
Yes,youcan.Lumpectomyisnotsoextensivethatitwillaffectyourbreastfeedingcapacity,butradiationtherapywill.Thebreasttreatedwithradiationmaygothroughthesamechangesasthenormaloneduringpregnancy,butitwillproducelittleornomilk.Youcan,however,breastfeedyourbabywiththeotherbreast.
Yes,youcanstillbreastfeedyourbabywiththeotherbreast.Frequentnursingwillbenecessaryatfirstsoastobuildupagoodsupplyofmilk.
Yes.Abiopsywillnotinterferewithyourabilitytobreastfeed.Evenifyouneedabiopsywhileyouarebreastfeeding,youcanstillcontinuetobreast-feed.However,youwillneedtodiscussthiswithyourdoctor.