Managing Breast Cancer with a ‘Less is More’ Approach

  • 11 Jun 2020

Breast cancer is one of the most common cancers among women in the world today. In Singapore, the incidence of breast cancer continues to climb, where an estimated of 1 in 11 women will be diagnosed with the condition in their lifetime. 

However, it is certainly not all doom and gloom. Through the twin effects of heightened public awareness of breast cancer as well as the advancement in medical treatment, we have been able to improve the cure rates by at least 50 per cent in the last 30 years.
 
In our latest article we speak to General Surgeon Dr Ong Kong Wee to learn more about how early breast cancer can be detected and managed with a ‘less is more’ approach. 


Screening and early detection 

One of the best ways to detect early stage breast cancer is regular screening. Women above 40 years old are encouraged to go for annual breast screening while those aged above 50 years old should do it every two years. 

According to Dr Ong, the preferred screening method is the mammogram, a process that use low-dose X-rays to create images of the breast. In most Asian women, however, the breast tissue tends to be so dense that conventional mammogram may miss small lesions. 

“Through the use of 3-D mammogram, also known as digital breast tomosynthesis, we can improve the screening accuracy by as much as 50 per cent. Furthermore, ultrasound of the breasts can be added on to mammogram to further improve the detection rate,” Dr Ong emphasised. 
 

The era of de-escalation – ‘Less is more’ 

The detection of early stage breast cancers has led experts around the world to re-think the way patients are treated. While the traditional methods still work well, they often come at a heavy price in terms of side effects and complications, some of which may be long lasting or permanent. More recently, newer alternatives have emerged and has proven to be just as effective as conventional methods, but are far more convenient and carry less morbidities for the patients. 

Indeed, we are now firmly in the era of de-escalation of treatment, where doing less treatment translates to more benefits for the patient. 

Breast conservation therapy Surgery is considered the primary treatment for breast cancer, especially in its early stages. For many years, mastectomy or removal of the whole breast was deemed as necessary in order to cure breast cancer. 

However, we now have over 40 years of strong supporting evidence that a lumpectomy, i.e. removing the tumour together with a margin of healthy breast tissue, is as effective as a mastectomy. Following lumpectomy, most patients will require a course of radiation therapy to the affected breast. This treatment combination process is known as breast conservation therapy. 

Being able to keep the breast goes beyond just cosmetic considerations. It is just as important to look after a patient’s psychological well-being while we cure them of a physical illness like breast cancer. To Dr Ong, preserving a good body image for patients can help ease their treatment process and allow them to adapt back to life as a cancer survivor.


Sentinel Lymph Node Biopsy (SLNB) 

Cancer surgery involves not only the complete removal of the tumour, but also the surrounding lymph nodes. This is because cancer can spread via the lymphatic system to these lymph nodes. In breast cancer surgery, this procedure is known as an axillary clearance, in which most of the lymph 

nodes in the armpit are removed. However, there is a risk of lymphedema or swelling of the arm which is permanent and potentially disabling. Other side effects include shoulder stiffness, numbness and pain. 

As only 1 in 5 patients with early breast cancer will have lymph node involvement, majority of patients will not require an axillary clearance as part of their treatment. 

Recently, sentinel lymph node biopsy has emerged as an alternative for checking if the lymph nodes are involved. Following an injection of a small volume of blue dye or radioactive substance into the breast, the surgeon is able to identify the lymph nodes which are the first ones to encounter cancer cells spreading from the tumour. These lymph nodes are known as sentinel lymph nodes. Typically, two or three sentinel lymph nodes will be removed and checked to see if cancer cells are present. The patient will be spared from an axillary clearance once it is confirmed that there is no cancer spread.


Avoiding chemotherapy 

The greatest fear among most patients diagnosed with cancer is having to undergo chemotherapy, mainly due to the significant side effects. These include suppression of the immune system, as well as damage to the heart and nerves. Nevertheless, chemotherapy is often still recommended for many breast cancer patients, especially those with more aggressive forms of the disease. 

Sharing his insights on alternative tests to check for breast cancer cells, Dr Ong said: “A major development has been the discovery of genomic tests such as Oncotype DX and MammaPrint. These tests check for specific genes in cancer cells, and are able to accurately predict the chance of the cancer recurrence. Patients who are deemed at low risk of recurrence will not benefit significantly from the addition of chemotherapy in their treatment plans.” 

“These tests are generally most applicable to patients with early stage cancer which have not spread to the lymph nodes or other distant organs,” Dr Ong added.


Less or no radiotherapy 

Radiotherapy is often used to minimise the risk of locoregional recurrence, that is, the chance of cancer coming back to the breast, chest wall or armpit. For early stage breast cancer, the most common indicators appear after a lumpectomy, or when the lymph nodes are affected. Radiotherapy is carried out in small, daily fractions over several weeks. While side effects such as skin burn is generally well tolerated, patients often feel that the treatment is too long. 

In recent years, several methods of radiotherapy collectively known as accelerated partial breast irraditation (APBI) have emerged, shortening the treatment period significantly ranging from under an hour to one week. In carefully selected patients, these newer modalities are able to provide effective disease control which is similar to conventional radiotherapy. 

Today, there is an even better news for older patients above the age of 65. It has been shown that for this group of patients, radiotherapy may be completely omitted if the cancer is of a slow growing nature and has not spread to the lymph nodes.


Early detection is key 

The outlook for patients diagnosed with early breast cancers is very favourable. While it is still necessary to undergo one or more types of treatment to get the best outcome, patients may be suitable for treatment options which are much more convenient and well tolerated. Indeed, being diagnosed with cancer does not mean having to bear with the scars of the disease nor the treatment. 

Concluding his take on breast cancer, Dr Ong said: “As one of my patients puts it, “This (cancer) is not a roadblock, but a small speed bump in my life.” 

Contributed by

Dr Ong Kong Wee
General Surgeon
K W Ong Breast and General Surgery Clinic
Farrer Park Hospital