Keeping Abreast Of The Signs

Breast screening and early detection are keys to successful breast cancer detection and treatment, Dr. Harjit Kaur tells Mariel Chow.

February 19, 03:45 PM

Breast cancer predominantly affects women, but can sometimes occur in men. The disease – as stated by the American Cancer Society – begins when cells in the breast grow out of control. Once these processes commence, cells normally form a tumour, which can be detected via screening or clinical breast examination as a lump.
 While breast cancers can form in different parts of the breast, most begin at the milk ducts (ductal cancer). Others however, are activated in the glands that make breast milk (lobular cancer). Although many breast cancers show up as breast lumps, not all do. Early breast cancers are often detected via a screening mammography, or ultrasound of the breasts. In both screenings the anomaly is usually seen  as calcification or solid tumours. Approximately 85-90 percent of breast lumps are not malignant or cancerous. However, it is still important to see your doctor to get assessed, and ensure the lumps are not suspicious.
 In Malaysia, recent information notes that one in 20 women are at risk of breast cancer. Unfortunately, these statistics have not been updated, according to Consultant Breast and Endocrine Surgeon, Dr. Harjit Kaur. “Current statistics by neighbouring countries like Singapore probably are the same as in Malaysia — numbers are much greater, at one in ten or 11 women.” Although the numbers are high, Dr. Harjit is happy to note that women are becoming more aware about the disease. More young women are coming forward and undergoing breast examinations at regular intervals. By doing so, it allows for early detection and successful treatment.
Consultant Breast and Endocrine Surgeon, Dr. Harjit Kaur
Time Of Examinations
 As reported by Dr. Harjit, breast cancer is unique because it can affect women of all ages. “I’m not advocating screening at very early ages, but I do recommend that women above the age of 21 practise some self-vigilance,” she explains. If they are unsure of how to do self-breast examinations, they must see a breast physician for advice and learn the technique. Young women with a high-risk family history should get themselves screened at a younger age. Ultrasound examination of the breasts is safe and reasonably accurate. “Young women are not exempt from the disease. We are seeing increasing numbers of young breast cancer patients these days. Therefore, young women should not ignore any signs of changes in their breasts.”
 While Dr. Harjit may not have the exact number of women choosing to undergo breast screening, she has noted that more young patients are coming forward and putting their health first by undergoing thorough breast checks.
 Self-Breast Examination At Home
 The most important thing patients need to recognise is their normal breast. Dr. Harjit points out, “The misconception most women have about self breast examination is the need to look for lumps. Self breast examination is actually about understanding and recognising what your normal breasts feel and look like.” The preferred time to examine your breasts is a week after the monthly menses, as this is when the breasts are least congested. During this time, women must ensure that the breasts are felt from top to bottom, and even behind the nipple. Once women regularly practise home examinations from an early age, they’ll come to know their breasts well, and in the event something peculiar crops up, patients will be quick to pick it up. Following this, individuals must of course consult with specialists and undergo thorough checks, including physical examinations, mammograms and ultrasounds.
 Time To Get Checked
 Examinations should typically be done once annually. If patients are 40 years and above, doctors recommend a baseline mammogram and ultrasound. If patients are below 40, an ultrasound alone should suffice. Dr. Harjit says that some women choose not to undergo breast examinations because of fear. Some procrastinate or practise the belief that ‘ignorance is bliss’, which is obviously very wrong.
 Many are often embarrassed to undergo check-ups due to cultural or religious sensitivities. Finally, cost may also play a role as annual examinations and consultations can cost a few hundred ringgit. Dr. Harjit laments, “Women often place strong emphasis on female empowerment in the household and workplace. Breast examination is a form of self-empowerment as well, and should be practised.”
This patient is two years post surgery and underwent biilateral mastectomy and immediate implant reconstruction
Early Signs of Cancer
 There are no early signs of breast cancer, which is precisely why Dr. Harjit stresses the importance of early screening. Early cancers are almost always picked up through imaging and scans. When a lump is clinically felt, it is often about one cm in size or more. Breast lumps below two cm are still considered early disease. 
 There are four stages of breast cancer, with the difference being the extent of disease spread. Stage 1 cancers are localised to the breast. Once lymph nodes are involved, patients are automatically classified as Stage 2. If many lymph nodes are affected, or the tumour is large, the cancer has progressed into Stage 3. Stage 4 means the disease has spread to other organs in the body, such as the liver, lungs and bones, making cures difficult. However, with modern medicine and therapy, many are able to prolong life with good quality. 
 Breast cancer is a systemic disease and can spread via the bloodstream and lymphatic system. Even if cells are small or caught early, cancers have the capability of migrating to other regions. As a result, some individuals may relapse despite having completed treatment.
 Causes and Genetic Markers
 There is no definitive known cause of breast cancer. “It is probably multifactorial; and poor lifestyle choices contribute,” Dr. Harjit says. “Stress, poor diet, lack of exercise, excessive nicotine and alcohol consumption coupled with poor genetics are contributory factors,” Dr. Harjit warns. 
 Even if patients aren't genetically predisposed, mutations can still occur. Doctors cannot explain why some patients are more prone to cellular mutation than others. There are some who practice all the world’s known bad habits and do not have any issues, while others who live straight-edged lives get struck with the disease. Dr. Harjit says, “It’s very tricky and to this day, we don't know the exact cause of the disease.” She does however add, “Everyone should do the best they can to keep their immune systems strong. This can be done with optimal lifestyle habits like healthy diets, regular exercise, good rest and a reduction or cessation of nicotine and alcohol.” 
 The genetic markers associated with breast cancer are BRCA1 and BRCA2. BRCA1 is connected to breast and ovarian cancer, while BRCA2 is associated with breast and prostate cancer among men. If patients present with these gene profiles, the risk of breast cancer is elevated to 85 to 90 percent. “Some patients with these genetic profiles often choose to undergo prophylactic mastectomies. As their risks are very high, they opt to remove their breasts before cancer strikes.”
 Genetic testing is still as its infancy in Malaysia. There are a few centres where it can be done. Not many patients opt to do the tests, as they are not well protected as yet in terms of insurance coverage here in Malaysia. In other counties such as Australia and the United States of America, patients are protected and not discriminated against despite genetic predispositions. The breast chapter of the College of Surgeons is making efforts to speak out about these issues, but there are no positive outcomes from the discussions and lobbies to date. Although genetic testing isn't routinely carried out, doctors are able to categorise patients as ‘high risk’ by good history taking. They then advocate more vigilance and screening in this group of patients. 
 Breast Cancer Surgery
 Breast cancer surgery is divided into mastectomies (removal of the entire breast) and lumpectomies (breast conserving surgery). The decision on the type of surgery is made with safety and cosmesis in mind.  In other words, the amount of tissue removed must be adequate while maintaining the preservation of breast cosmesis. Dr. Harjit shares that it is pointless to remove large chunks of breast tissue and have the breast look unappealing. Therefore, patients should opt for mastectomies instead. 
 In the event individuals desire to attempt breast conservation, if suitable, they may undergo neo-adjuvant chemotherapy, which reduces the tumour size for more acceptable surgical options. All factors are discussed during in-depth consultations and only via thorough discussions can safe and informed decisions be made.
 Breast Reconstructive Surgery
 Breast reconstructive surgery is the reconstruction of the breasts following mastectomies. It can be done as an immediate or delayed procedure. There are various types of breast reconstruction surgery, and making the right choice for yourself is best done after clear discussion with your surgeon. All options are usually discussed, detailing the risks and benefits of each procedure, allowing the patient to make informed choices.
 There are two popular forms of reconstruction: simple reconstruction with implants, and autologous reconstruction (flap surgery) utilising one’s own tissues and muscles. Although personal desires count, other factors like co-morbidities, breast size, surgical duration and nicotine intake do play a role in the choice of procedure. 
 Implant reconstruction is probably the simplest of the types of reconstruction options available. It does not take long and is relatively straightforward. Modern implants are generally safe. Nevertheless, it is still a foreign material in your body, which may give rise to problems in some patients, like capsular contracture and infection. These issues are not life threatening and should they arise, these implants can be removed or replaced. 
 Autologous reconstruction uses the body fat and muscle. They may look and feel more similar to the natural breasts. However, flap procedures require more surgical time and are more complex, hence making them more expensive. Dr. Harjit says, “Surgeries are tailored according to the needs, patient expectations and the type of tumour or disease the patient presents with. If cancers are large or involve the skin, we may not even recommend immediate reconstructions, as quick recovery and adjuvant treatment takes precedence.” 
 Immediate Reconstruction and Acceptance
 If there are no contraindications, Dr. Harjit considers immediate reconstruction to be the best choice. Not only are cosmetic outcomes upheld, but there are better chances of saving a patient’s original fat, skin and nipple areolar complex. Delayed reconstruction, although always possible, will pose higher risks of nipple and skin loss, resulting in decreased aesthetic outcomes and less natural results.
 There are many physical and emotional advantages linked to breast reconstruction surgery. It must be noted that the reconstructed breasts will never look the same as the original.   “What it does give is a fairly similar size mound and the closest possible to the patient’s natural breast.”   Dr. Harjit points out. She continues, “They will look normal in clothing and bathing suits, but nipple sensation may be lost occasionally due to disruption of the  nerve supply.” Depending on the type of oncoplastic surgery chosen, the feel and appearance of one’s new breast may be dissimilar as well. In short, individuals must accept that reconstructed breasts will never look or feel the same. Once patients have realistic expectations, satisfaction and a good quality of life will be achieved. 
 

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