Breast screening through mammography makes it possible to detect breast cancer at a very early stage, before it can be felt. This has shown to provide better survival rates if cancer is detected and treated at an early stage. (Bundred. ANZ Journal of Surgery 2007)
The American Cancer Society recommends that it be done once a year for women aged 40 and above. A study is Singapore has also been published which concludes that “locally an optimal screening interval may be close to one year”. (Gao F. et al. Int J Cancer 2002)
Breast imaging provides us with pictures and images of the breast tissue. This does not give a diagnosis, but presents us with clues as to whether there is a major problem or not. The characteristics of the abnormality seen on the images can indicate the likelihood of being benign (not cancer) or malignant (cancer). To be absolutely sure about the nature of the abnormality, a biopsy might be needed.
A biopsy is the removal of a sample of breast tissue for its study under a microscope. This may be in terms of removal of cells, or tissue sections depending on the nature of the images seen and the findings on physical examination.
The majority of women with abnormalities within the breast may not need to undergo a biopsy. The need for a biopsy depends on the clues that are left by the clinical, mammographic and ultrasound examinations. In some instances, a biopsy may be needed to establish a diagnosis and ensure that the abnormality is not cancer..
In the majority (80-90%) of cases, a woman will NOT need to lose her breast when she is diagnosed with breast cancer. This is Dr Tan’s particular interest and skill. If a mastectomy (removal of the breast) has been suggested for the treatment of your problem, you may wish to see Dr Tan for an evaluation with regards to the suitability for breast conservation surgery. (treatment that allows a woman with breast cancer to keep her natural breast, rather than undergo reconstruction)
The objective of Breast Conservation Surgery is to provide effective treatment for breast cancer with preservation of a woman’s natural breast in as close to its original shape as possible. In other words, the aim is to preserve breast symmetry. If care is not taken to perform certain manoeuvres during surgery, chances are that distortion, sometimes severe, will result. Dr Tan has written about these special techniques that she uses during surgery to prevent distortion or denting of the breast after surgery, restoring the breast to its original shape as much as possible.
Ultimately, Dr Tan’s goal is to allow a woman to be effectively treated for breast cancer while preserving her natural self and returning to life again after treatment is completed.
In most cases, doctors who are familiar with the treatment of a particular condition will give the same opinion on the management plans. However, in a few instances, opinions may vary depending on philosophy, technical ability and threshold for risk of missing a major problem.
With regards to biopsy, Dr Tan believes in providing as accurate a diagnosis as possible through non-invasive or minimally invasive techniques where appropriate.
With regards to breast cancer, Dr Tan’s philosophy is to attempt as much as possible to give every woman diagnosed with breast cancer a fighting chance to preserve her natural breast in a form as symmetrical as possible to the other breast.
Breast cancer treatment involves not only a breast surgeon like Dr Tan. Medical oncologists (doctors who treat cancer using medication) and radiation oncologists (doctors who treat cancer using x-ray therapy, sometimes also known as Radiotherapists) also participate in the care of breast cancer patients.
To give an idea of the role of these specialists, the staff of MammoCare interviewed Dr LS, a senior consultant medical oncologist and Dr LK, a senior consultant radiation oncologist. Excerpts of the interview are reproduced here. Please note that these are not a substitute for a formal consultation, and it would be best to consult an appropriate specialist for more information regarding your unique situation.
Should you wish to be referred to these doctors, kindly apply in person at MammoCare. Thank you.
Dr LS: Chemotherapy is an administration of drugs through intravenous injection or orally at times. This is done to try to kill the microscopic tumour that may be left in the body to reduce the chance of tumour recurrence. Radiotherapy is using radiation to kill any tumour cells that may be left behind in the chest wall. Chemotherapy is to reduce the risk of systemic relapse whereas radiotherapy is to reduce the risk of local relapse.
Dr LK: Chemotherapy is mainly for decreasing the risk of distant relapse such as in the liver, lung, bones, and brain. Radiation may be required mainly for local control. For those who require chemotherapy, the control rate can still be improved for local metastasis where radiation is tentative.
Dr LS: Chemotherapy is dependant on the actual size of the tumor and how many lymph nodes are involved. Whether the patient has lumpectomy or mastectomy, it probably does not make a difference to their need for chemotherapy. Radiotherapy may make a difference. For example, if a patient has a small tumor less than 5cm and that it does not spread to the lymph node. If they choose mastectomy, they can omit radiotherapy. However, for patient whose tumors are larger, for example, more than 5cm or even if the tumor is small, say 2cm, but they have 5 lymph nodes involved, even though they may have had mastectomy, they would need radiation.
Radiation-Oncologist: The requirement for chemotherapy depends very much on tumor size, nodule status that is also used to address decreasing the risk of distant relapse. When we talk about radiation, it is more for local relapse. Therefore classically, if mastectomy has been offered and if the tumor is small, supposing at the end of surgery, the pathology result comes back, the lymph nodes are negative or only 1 to 3 lymph nodes are involved, the patient will not require radiation. If one elects for mastectomy, it does not guarantee the patient will not require radiation after surgery.
Dr LS: If you are talking about survival, there is no difference between mastectomy and lumpectomy. First of all, lumpectomy has to follow by radiation. If the patient chooses not to have radiotherapy after that, then they must have mastectomy. You can only do lumpectomy if the tumour is small enough relative through the breast size. So this is nothing to do with the absolute tumour but rather the size of the tumour in relation to the size of the patient’s breast. So, you can even do breast conservation surgery for tumor that is 5cm if patient has a large breast. On the other hand, you could have a patient who has only 3cm tumor and the breast is very small, then it is better to do mastectomy. Secondly, the location of the tumor is very important. Even if the tumor is very small and is right underneath the nipple, then it becomes difficult to conserve. (please note that Dr Mona Tan does not agree with this comment) With all these provisions, then mastectomy and breast conservation plus radiotherapy has the same outcome in terms of survival that has been proven by randomized study.
Dr LK: For tumor less than 3cm or 4cm, despite the absolute size concern, it doesn’t really matter breast conserving surgery versus mastectomy, studies has shown there is no overall survival for patient electing one way or other.
Radiation-Oncologist: It must be multifactor, not just the surgeon’s point of view, in terms of offering mastectomy, the surgeon will look at the disease itself, patient’s preference and the surgeon’s skills. Each time a patient has a breast cancer small enough tumors that is possible to be operated with breast conserving in mind, I think this option should be offered and discussed with the patient.
Radiation-Oncologist: I would like certainly say so in terms of electing breast conserving surgery, patient would really want to see a very good cosmetic outcome. Therefore, sometimes it can be very challenging for surgeons. Having said that, from our clinical experience, patient either gone through mastectomy or breast conserving surgery, I find that we clinicians are setting ourselves a much higher standard in terms of cosmetic outcome compared to patient’s satisfaction of breast conserving surgery.
Consultant Oncologist: The final cosmetic result is of course the concern. For example, I think it would be wrong to try to do lumpectomy if the patient has very small breast and the results are very poor anyway. It’s no point for me doing a lumpectomy and get a lot of scarring or the breast itself looks very lopsided. Sometimes, mastectomy does not necessarily give worst cosmetic result.
Radiation-Oncologist: The absolute indication is still 3 to 4 cm. (This is another comment that Dr Tan does not agree with – she has done breast conservation successfully with tumours that are more than 4 cm) Women with small breast sizes, a lot of them still qualify for breast conserving surgery. We have seen that their cosmetic outcome can be quite remarkable. Studies have shown that if you do breast conserving surgery followed by radiation, it is as good as part of mastectomy in terms of survival.
Mount Elizabeth Novena Hospital
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Mount Elizabeth Novena Hospital
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Mount Elizabeth Medical Centre
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