Dr Lim SiewKuan is a general surgeon at Mount Elizabeth Novena Hospital, Singapore where she specializes in breast surgery. She was in Manila recently to talkabout the rising incidence of breast cancer among Asian women.  In the Philippines, breast cancer is the leading cause of cancer deaths among women.  Majority of these cases are women diagnosed at the advanced stages of the disease where, despite the advances in treatment, survival is low.

There is also an alarming increase in breast cancer patients aged below 50. Medical professionals like Dr. Lim have been advocating breast cancer screening for all women aged 30 and up because at its early stages, breast cancer is highly treatable.

Here are the highlights of the interview with Dr Lim.

Q: Is there a particular type of woman or class of women who are prone to breast cancer?

Breast cancer risk is actually high across the female population. Among all the breast cancer patients, about 10 to 15 percent (of women) are with inherited genetic mutations, the most common of which is the BRCA gene.

A famous actress, Angeline Jolie, has this gene. For women like her, having this gene mutation will increase their risk or chances of having breast cancer by up to 70 to 80 percent. Not only that, the chances of them having ovarian cancer are about 40 percent.

Because this is a genetic mutation, it may be passed down to the future generations of a family. If an index patient is tested positive, we should then test the family members, because even the males in the family are prone to breast cancer and other types of cancer, like prostate cancer and other intra-abdominal cancers.

We will then advise patients with this gene about the risk and the available disease prevention strategies, which includes surgery (removal of the breasts with immediate reconstruction) and hormonal therapy.

Q: Men can also have breast cancer?

Yes. Actually one to two percent of all breast cancers happen in males.

Q: At what age should one have a test to determine the presence of the BRCA gene?

We do not recommend testing before a person reaches the legal age (18 or 21 years old depending on the country), as he or she should have the right to decide whether to or when to undergo testing. We want them to know exactly what they will be going through and fully understand the implications of genetic testing. For this reason, a pre-testing genetic counselling session is required. Besides, the cancers do not occur early in life. For a woman who is BRCA positive, we start tight surveillance at age 25, so genetic testing is best done between age 21 to 25. The test is very easy to do – a blood test or a saliva test.

Q: It is advisable for women to undergo screening for breast cancer at age 30?

In Singapore, screening for breast cancer for normal women without any symptoms, is advised when they reach age 40. In some countries, they advise screening at age 50.

However, because of many factors like unhealthy diet and changes in our lifestyle, we are seeing younger cases.  So we advise ladies after age 18 to do breast self- examination. If they find a lump or any other symptom like nipple discharge at any age, they need to have breast cancer screening immediately.

Q: Is surgery the best treatment for breast cancer?

Surgery is the main form of treatment for breast cancer unless the patient for a valid reason cannot undergo surgery. We have to remove the cancer cells, and also frequently use additional therapy (hormonal therapy, chemotherapy, radiotherapy, targeted therapy) to decrease the risk of recurrence.

Q: Why do women hesitate to undergo breast cancer screening?

I do know that many women are afraid to even go to a breast doctor or OB gynecologist. Cancer strikes fear in many women. We did a study of 1,000 women in Singapore about their perceptions of breast screening, and we asked why they do not go (for screening). Women in Singapore generally feel that if they do not have symptoms, they do not need breast screening. But the message we, in the medical community, want to get across, is breast screening is for all women, before symptoms are noted.

We highly recommend women to undergo breast cancer screening when they reach the age of 40 because breast cancer is very curable at the early stages. The 5-year relative survival rate of a person with stage 1 cancer is at 100 percent. However, if a patient is diagnosed with stage 3 or stage 4 cancer, the survival rate is significantly lower.

Q: Is there a correlation between breast implants and breast cancer?

Breast implants do not cause breast cancer that is commonly found in women. Implants have been linked to a very rare cancer that occurs in the capsule around the implant.  The cancer may develop several years (8-10 years) after the patient has the breast implant. The patient will initially feel breast swelling, tightening of the skin, and there may be a build-up of fluid around the implant.

This type of lymphoma is treated by removing the whole implant and the capsule. If detected early, it can be treated easily. However, if it has spread to other areas, chemotherapy will be recommended.

There are however, other problems (with implants) that may arise, and require further surgery in the future. For example, if the implant leaks or hardens with scar tissue, the body shape changes and the breasts are no longer symmetrical, or if the implant is displaced, we have to change or remove the implants. So we have to inform the patient of that.

Nowadays, younger patients tend to choose to use their own (body) tissue for breast reconstruction. This is a longer, more complex procedure because it involves taking tissue from the back, the tummy, or thigh. These would require surgery that would take an extra 8-10 hours.

We have to discuss all the pros and cons of each type of reconstruction with each patient. The decision for reconstruction is personal, and the final decision lies with the patient.

Q: When can a woman have breast reconstruction?

Most of the time, we do breast reconstruction immediately after mastectomy. If we plan a full breast reconstruction, we do not do the conventional mastectomy.

We would do a skin-sparing mastectomy:  we make a small incision, remove the underlying breast tissue while keeping the skin envelope (for the reconstructed breast). One of my patients describes it as ‘taking the pillow out of the pillow case and putting another one back in’. The best scenario is when the tumor is away from the nipple. In that case, we can actually keep the nipple and (the result) still looks very natural.

However, we do not advise patients who are frail, who are diabetic or who are smokers to have breast reconstruction because of the long hours needed for the procedure.

Q: For patients recovering from surgery, do you recommend any lifestyle changes?

I advise them to keep to a healthy diet, with more fruits and vegetables. Take adequate rest. And because we have a lot of data showing how exercise can decrease the morbidity of the treatment and the side effects of chemotherapy and hormone therapy, we advise them to continue to exercise throughout the treatment.

The treatment period is long, and patients may get depressed due to the physical and emotional stress they undergo. It is important to have a strong network of social support (family and friends) during this time. We also have a Breast Cancer Foundation with a hotline that patients can call for advice and trained volunteers, who are survivors themselves, are available to support them.

Q: What are the factors behind the increasing incidence of women with breast cancer?

Actually it is lifestyle changes. Singapore, for instance, has grown rapidly into a developed country over the last few decades and we have seen cases of breast cancer increase threefold. Interestingly, countries like the Philippines, China, India, have the same pattern. The rate of breast cancer in the cities is also much higher compared to the rural areas.

There are now significant changes in how women make reproductive decisions. In cities, women have children later in their life, and they have fewer children. Also, they don’t breastfeed for too long. Data shows that having a child before age 35, having more children or breastfeeding for more than a year, are factors that decrease the risk of having breast cancer.

The increased use of external estrogen or oral contraceptive pills to delay pregnancy also increases women’s risk of breast cancer occurrence.

We now know that exercise and healthy (low-fat and high-fiber) diets minimize the chances of having breast cancer.

Obesity is also a risk factor. After menopause, female hormones levels (which can cause cancer) are supposed to drop but the presence of fatty tissue keeps the hormonal levels higher than normal. This is why we see a higher breast cancer incidence among post-menopausal obese women.

Q:  As a female medical practitioner in Asia, have you ever felt at a disadvantage in your career?

No, I have been quite fortunate in Singapore, and I did not experience any discrimination because of my gender. When I decided to specialize in breast surgery, being a female doctor became a significant advantage instead, because female patients are more comfortable with women surgeons. I also feel that being a woman myself, I can empathize more with the psycho-social needs of my female patients and their families.

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