ESG Virtual Wellness Series
- All About Breast Cancer

Women’s Health (Part : 3 of 3)
- All About Breast Cancer

Wed 31 March 2021 | 12pm - 1:30pm ​

Speaker

Dr Lynette Ngo is a medical oncologist at Mount Elizabeth Novena Hospital, Singapore. Her areas of interest include breast and gynaecologic cancers, hereditary cancers and genetic counselling, psychosocial oncology and palliative medicine, as well as general medical oncology.

She received her postgraduate diploma in palliative medicine from Edith Cowan University, Australia, and obtained her specialist accreditation in medical oncology from the Academy of Medicine, Singapore. She also completed the Intensive Course in Cancer Risk Assessment at City of Hope Hospital, California.
In pursuing her subspecialty interest in gynaecologic cancers, Dr Ngo was awarded the Health Manpower Development Programme Award to spend a year at the Gillette Center for Gynecologic Oncology at Massachusetts General Hospital (MGH), USA.

Dr Ngo spent 7 years practising at the National Cancer Centre, Singapore (NCCS) from 2005 – 2012.

Dr. Lynette Ngo

Medical Oncologist

Breast and Gynecologic Cancers

Synopsis

In this talk, Dr. Lynette Ngo provides a comprehensive summary of the technical side of breast cancer, helping us understand how and when breast cancer develops as well as some risk factors, preventive and eradicative treatments and screening measures.

She begins by going through some of the demographics of breast cancer around the world, some trends between high-risk countries and what to look out for to lower the risk of developing it. Dr. Ngo also walks through some cancer signs to look out for, diagnosing breast cancer as well as treatments for this disease.

Transcript

Dr. Lynette Ngo: Thank you very much Fadyl for the very kind introduction and hello everybody. I think we reached the more technical aspect of the talk today. So I’ll be giving an overview of breast cancer; looking at what are some of the risks of breast cancer, seeing if you can prevent breast cancer, or if breast cancer develops, what we can do to improve our outcome. So as everybody probably knows, breast cancer is the most common cancer in women all over the world. Singapore is no different. Breast cancer is ranked the number one top cancer in women. It comprises almost one third of all cancers diagnosed every year in women. The second most common cancer, colorectal cancer, is less than half the incidents of breast cancer. This is a map of countries in Asia, as you can see the countries that are colored darker blue are the countries with the highest incidence of breast cancers. These include countries like Japan, Korea, the Middle Eastern countries, Kazakhstan, Saudi Arabia, and Pakistan. And in Southeast Asia over here, Singapore is colored the darkest blue. 

So what do these countries have in common? Well, in general, these countries are the more affluent countries, the more developed countries, we tend to adopt a more westernized sort of lifestyle. We tend to eat diets that are higher in fats, processed food, processed meat, as well as red meat. Women tend to work so they have fewer children and less breastfeeding as well. So this is the incidence of breast cancer in Singapore over the years, as represented by the red line from the 1960s, the incidence of breast cancer has slowly been rising, but thankfully the death rates from breast cancer represented by the brown line at the bottom has remained flat. And this is thanks to the increased uptake of breast cancer screening, as well as advances in medical treatment for breast cancer.

So today I’ll be giving an overview of what exactly is breast cancer. What are some of the red flags that alert us to the possibility of breast cancer, how we diagnose breast cancer, if we can prevent breast cancer and what are some of the treatment modalities for breast cancer. So this front part overlaps a little bit with Tharasini’s talk: what is breast cancer? So, as she mentioned earlier, this is an anatomical representation of the female breast. So breast milk is produced in the breast mammary glands. And this is represented by the lobules over here as represented in fig. B when breast milk is produced, it is then secreted into the ducts of the breast and then externally to the nipple. 90% of all breast cancers develop in the ducts of the breasts. This is a cross-section of the ducts of the breast.

As you can see the cells lining the ducts of the breast are all regular, very well well-placed. Now, if the cells lining the walls of the doubts become abnormal, they start to grow uncontrollably, and cancer starts to develop. Now if the abnormal growth of the cells are confined within the wall of the ducts, we call this ductal carcinoma in situ, or DCIS. So this is not quite cancer yet. It is pre-cancer, one stage before it develops into cancer and this is when we want to catch cancer. If the abnormal growth of cells breach the wall of the duct, they go out of the wall, we call this invasive ductal carcinoma or what we commonly know as breast cancer. The problem with breast cancer is that these abnormal cells have the potential to travel to the surrounding structures and worse,

If they enter the bloodstream or the lymphatic drainage of the breast, they can possibly also spread to other organs, such as the brain, the lungs, the bone, and this is what we want to prevent. So what are some of the signs and symptoms of breast cancer? This brings us to our first poll question, I guess most of you probably know the answer. So here’s a statement, if you think it’s true or false. “If a breast lump is painful, it is more likely to be cancer.” Do you think it’s true, false or not sure.

So enter this into the poll and while we get the answers, let’s move on with talk. So the most common sign and symptom of breast cancer is a breast lump. It can occur in the breast itself or in the drainage system of the breast, which is the lymph node. And the axillary lymph node is usually under the armpit. But not all breast cancers present as a breast lump, even though it’s the most common presentation, it can also present as  nipple discharge or bleeding, a change in the shape or contour of the breast. If the cancer is hiding beneath the nipple, it may pull into the nipple and cause inversion or what we called nipple retraction. It can cause a change in color or appearance of the areola, which is the region around the nipple, or it can simply the whole breast can simply look very red, swollen, and pitted like the skin of an orange.

We call this medically (inaudible). So that brings us back to our poll. If the breast lump is painful, is it more likely to be cancer or not? Well it is less likely to be cancer. Generally pain is not caused by cancer. Usually it’s caused by hormonal changes in the breasts. And some women actually do experience breast pain in the pre-menstrual part of the cycle. However, it’s never a hundred percent. Breast cancer can still present as breast breast pain, but it’s less likely. Conversely, if a woman tells me that because the breast lump is not painful it is not cancer, that is not true. Most breast lumps are painless. They are usually hard and painless. So if any woman presents with a hard, painless breast lump, she should seek medical attention as soon as possible. Here are some of the other presentations, it could even present just as a rash.

This is a condition called Paget’s disease of the breast, where the rash actually eats into the entire nipple and it is cancer. And similar to what Tharasini mentioned just now, some women think only older women can get breast cancer. Some women tell me that they are too young to have breast cancer, it can’t be. But breast cancer can occur at any age. In fact, the incidents of women with breast cancer at a younger age is slowly rising and even men can get breast cancer. So how do we diagnose breast cancer? We call it the triple diagnostic method with the mammogram, the breast ultrasound and a biopsy. So this is what the mammogram machine looks like, it’s basically an x-ray machine. So a woman’s breast will compress and spread out by a plastic pedal. X-rays are then emitted from the diode above the breast, enters through the breast, and are captured by the x-ray graph underneath the breast.

This has been converted into computer images where we can see a breast tumor, so it can appear as a mass, a nodule, or it can appear as tiny white spots in the mammogram. We call these microcalcifications and these calcifications are what we see in precancer of very, very early stage cancer. And this is what we want to pick up on a mammogram when it’s at the very, very early stage, when it is still entirely curable, some women have what we call dense breasts. If you notice the entire breast is totally white. This occurs when a woman has less fatty tissue in the breast, and there is a lot of memory glands. And if there is a microcalcification or nodule, it might be totally obscured by the breast itself.

As a woman grows older, the breast will then accumulate more fatty tissue and less glands and then the mammogram becomes a little bit more transparent, and this is when we can pick up any abnormalities. So if a woman has dense breasts, we might need to add on a breast ultrasound, which is basically a machine that emits sound waves. It is reflected from the breast and then we can pick up any cysts, nodules, and so on. And if we do see any abnormalities, the mammogram or breast ultrasound, we will need to confirm this with a biopsy, which is basically a needle that is inserted into the area of abnormality. And the cells are then removed, viewed under the microscope. And the pathologist will tell us whether or not it is confirmed to be cancer or not. So what causes breast cancer? This brings us to our next poll question. Some women say underarm antiperspirant causes cancer, is that true or false?

And our third poll question, my daughter herself tells me wearing a bra to sleep at night increases your chance of getting breast cancer. Do you think there’s a true false, or if you’re not sure, just put under C. So this is a study looking at thousands of women with breast cancer, and they looked at all the possible risk factors and they found that the number one risk factor for breast cancer is actually age: an older woman is more likely to have breast cancer than a younger woman, a woman aged, 70 years, and above has an 18 times more likely to have breast cancer than a woman 30 years of age.

This is the rate of breast cancer over the years, as you noticed the incidence of breast cancer, sharply rises from the age of 40 years onwards, it peaks at 60 years of age, and then it slowly comes down. So this gives rise to the recommendation that women aged 40 years and above should go for screening mammograms. And the recommendations are yearly screening mammograms from the age of 40, 2 yearly mammograms from the age of 50. And if there is a strong family history of breast cancer, we may need to add on other types of tests. Unfortunately in Singapore, only 20% of all breast cancers are picked up through a screening mammogram, whereas in some other countries, 40% of breast cancers are not palpable, meaning that we can’t feel any lumps at all. They are actually found on screening mammograms, and we hope to one day achieve this.

So the number one risk factor is age. Number two risk factor is a gene mutation in BRCA1 and 2. This has been touched on in great detail by Tharasini. So yes, she showed this picture. So in 1984, scientists started to study families, Ashkenazi Jew families with very, very high incidents of breast and ovary cancer. And they discovered that these families carried an abnormal gene. They called it the breast cancer gene or the BRCA gene. So anyone with a strong family history of breast cancer, or even an unusual presentation of breast cancer, such as two breast cancers or breast and ovary cancer should seek genetic testing. And you need to see Tharasini or a genetic counselor for genetic testing. So age and genetic mutations are probably not reversible, but what can we prevent? So these are some of the more preventable risk factors for breast cancer.

And these include smoking, excessive body weight, alcohol intake, which Claudia has touched on just now, poor diet and physical inactivity. In June last year, American Cancer Society looked at all the studies, looking at the risk factors for breast cancer. And they gave some guidelines. They recommend that all women should engage in 150 to 300 minutes of moderate intensity exercise per week. We should follow a healthy diet, which includes reduction in red and processed meats, less sugar, sweetened beverages, and less highly processed foods. And again, alcohol has been recommended to be totally avoided. Now, this is very difficult, especially for me. So alcohol is a very social activity. So women who cannot avoid alcohol should limit their consumption to no more than one drink per day for women.

So that brings us to our poll question, does underarm antiperspirant cause breast cancer? It is not in our list of risk factors so there’s no scientific evidence at this point and does wearing a bra to sleep cause breast cancer? Also no scientific evidence at this point. So if breast cancer does develop what happens? There are many, many different modalities of treatment for breast cancer. It could be local treatment surgery to remove the breast cancer, radiation therapy at the area of the breast cancer or systemic therapy, which includes medicine that is administered into the bloodstream to kill cancer cells anywhere in the body. And this includes chemotherapy, hormone therapy, targeted therapy and immunotherapy. So which one is the most important of them all? Like any superhero story, not one of them is the hero. Everybody works together in tandem to kill breast cancer. So breast cancer treatment is multidisciplinary, but a lot of the time what we choose and what is more important, depends on the stage of breast cancer.

So we generally can divide breast cancer into two stages – early and advanced breast cancer. So early breast cancer basically means stages one, two, and three, where the breast cancer is still confined to the breast and the regional lymph nodes. It has not spread out of the breast. The goal of treatment here is cure. If the cancer has spread to other areas of the body, like the brain, the lungs, the liver, this is stage four cancer in general is considered incurable. But nowadays we don’t really need to give women survival time of six months or less to live with advances in breast cancer treatment. Women can live many, many years with stage four breast cancer. And now we consider it more of a chronic disease where they learn to live with the cancer rather than just trying to survive it. So the paradigm of treatment of early breast cancer stages, one, two, and three are, if the cancer is operable, we want to remove it.

So surgery is the mainstay of treatment. We want to remove it by surgery, followed by adjuvant therapy, which is medicine given to prevent a relapse. If the cancer is too big to be removed by surgery, we will administer neoadjuvant systemic therapy. This is treatment designed to shrink the cancer cells, such that it can be removed by surgery, followed by adjuvant driven therapy, given to prevent a cancer relapse. This is what we used to do in the past, but nowadays things have changed. Not everybody wants to go for surgery. First, the different types of surgical techniques, we can have a mastectomy where the entire breast, including the cancer is removed, or just a lumpectomy where the cancer cells is removed. But the breast remains also the lymph nodes that are possible areas of spread of the cancer is removed. So some women who want to have a lumpectomy rather than mastectomy, they will undergo new adjuvant chemotherapy, where chemotherapy is given to shrink the tumor from a large tumor to a very, very small tumor where lumpectomy can then be performed to remove the tumor through a lumpectomy scar.

Not only that, we now also understand that breast cancer is not just one cancer. There actually many different subtypes of breast cancer and we don’t treat it just the same. It’s not one size fits all. So when they looked at breast cancer under the microscope, they found that there are actually three main subtypes of breast cancers. Some breast cancers stay positive for hormone receptors. We call this ER positive breast cancers. Some cancers stay positive for a protein called Her2. We call this Her2 positive breast cancers. And if they are negative for ER or Her2 or PR, we call these triple negative breast cancers. Majority of breast cancers are hormone receptor positive, but 20% are her two positive and 15% are triple negative. And in general it has been found that triple negative and Her2 positive breast cancers are the more aggressive types of breast cancers, they tend to relapse more easily.

And so generally we find that we administer new adjuvant chemotherapy that is treatment given before surgery to kill the cancer cells and improve survival before we actually embark on surgery. And if cancer is stage four, if it is advanced, the main treatment would be chemotherapy. This is medicine administered into the veins where it can treat the cancer cells in any part of the body. Again, there have been more advances in terms of treatment for stage four breast cancers. So we no longer just use chemotherapy. There are now targeted therapies, immunotherapies available for stage four breast cancers. So immunotherapy is a very, very big advancement in treatment for breast cancer, where it’s been found that drugs administered into the system to harness the immune system of the patients to produce enough immune cells, to kill the cancer cells, rather than just using drugs to kill the cancer cells.

And that has led to these two individuals winning the Nobel prize for treatment using immunotherapy in cancer treatment. So this brings me to the end of my talk in summary breast cancer is the top cancer in women worldwide. In Singapore, one in 13, women will be diagnosed with breast cancer. If we know what our risk factors are for breast cancer, we can try to prevent it. We can also screen ourselves more appropriately if we know what our risk is like, but even if breast cancer develops early detection is the key to cure by detecting breast cancer early. We can prevent it from coming back again. So if we understand what breast cancer types you have, you will then be able to get the best treatment for the best outcome. Thank you, everybody. And this is our team. So this is Curie Oncology. There are four medical oncologists, each of us specializing in a different type of cancer. And this is my email over here. So I specialize in women’s cancers. So if you have any questions, please feel free to drop me a line. Thank you.

Key Takeaway

Around the world, breast cancer is more prevalent in developed countries as people who live there tend to consume more processed foods, red meat, and have less children who breastfeed. There are two non modifiable risk factors, age and family history. With age, increased routine screening is advised in order to catch cancer, if present, at an early stage to increase the chances of complete recovery. With family history, genetic counselling that advises on treatments are vital in preventing and managing breast cancer in an individual as well. Some risk factors of cancer that are changeable include a person’s diet, smoking, alcohol, and more.

Can we prevent breast cancer? By being aware of these risk factors as well as catching the disease in its early, precancerous stages are vital to this. When breast cancer does develop, there are three ways to diagnose it – mammograms, a breast ultrasound and a biopsy. There are several different treatment options such as surgery, chemotherapy or immunotherapies to combat the three subtypes of breast cancer.

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