Breast cancer is perhaps one of the biggest fears of women everywhere. As cancer becomes an increasingly prevalent medical condition, some women are starting to think more along the lines of “when” instead of “if”. While cancer in general is indeed a complex medical issue, it shouldn’t be one that you distance yourself from. We sit down with Dr Lavina Bharwani of Johns Hopkins as she explains to us the ins and outs of breast cancer.
1. What are some of the common myths/misconceptions surrounding breast cancer?
There is generally a misconception surrounding all cancers; that is the fear of “if I have cancer, I’m going to die”. That prevents people from coming forward to seek treatment. Unfortunately, it’s very common for women when it comes to breast cancer.
A lot of women who find a lump and are subsequently fearful of the possible implications, will not come for treatment and instead neglect it. People need to know that when cancer is caught early, it’s treatable and curable. The fear of what cancer might bring should not be guiding you and determining your way forward.
2. What is the reason behind the stigma that surrounds breast cancer?
The breast is considered to be a hallmark feature of what it means to be a woman so there are a lot of emotional issues regarding appearance. If a woman is diagnosed with breast cancer, there is always the possibility of surgery which can result in the potential loss of the breast. That has ramifications for the woman and how she handles the discussion and decision when it comes to going forward with surgery. If there is a mastectomy, which is the full removal of the breast, it can result in a stigma carried by the woman due to her feeling different from everyone else.
I think that a lot has changed in breast cancer because as women move on to being survivors, the whole notion of “being different” dissolves. In most societies, there is a certain value attached to being a survivor. More and more women are finding it comfortable to come together and talk about breast cancer, resulting in them feeling more empowered.
3. Are there any lifestyle factors associated with breast cancer/cancer risk?
There are certain factors that you can and cannot control that put you at risk of developing breast cancer. One is the age of menarche (age where menstruation first begins) – if you start young, you have a higher risk. If you have late-onset menopause, you also have a higher risk of having breast cancer. Not breastfeeding and not having children also puts you at a slightly higher risk of getting breast cancer. The reason behind this is because you have a prolonged exposure to oestrogen, which makes your breast cells grow and subsequently increase the chances of developing cancer.
Exercise is also a key issue, as well as obesity. Alcohol consumption is a known to be a risk factor when it comes to breast cancer. The standard guidelines put consumption put it a one to two units per week. There are also certain drugs that may be implicated in causing breast cancer – one is hormone replacement therapy (HRT).
About 10 years ago, there was a push to portray HRT as being beneficial for menopausal women due to its effects on bone, brain and cardiac health. So there was a whole slew of women getting on HRT, even for the purpose of preventing menopausal symptoms from developing and they found that this resulted in a 30 percent increase of breast cancer. If women do intend to go on HRT, it should be for a very short duration.
Oral contraceptives that contain oestrogen can also result in complications, especially for women whose families have a history with breast cancer.
4. What do statistics have to say regarding the odds of being diagnosed with breast cancer?
It depends on which part of the world you’re residing at. In the US, the incidence rate sits at one in eight women. In Singapore, it’s more of one in 11. There are certain populations that exhibit a higher risk, such as Caucasians and African-Americans. The Ashkenazi Jews are also predisposed to a higher risk due to genetic mutation. Asian Pacific populations are at a lower risk, but it’s unclear if this is due to socioeconomic factors or anything else. What we have found in Singapore however, is that there has been an increase in incidence. This may be due to women not having children early, they’re opting for late pregnancies and not breastfeeding – there may be components in this that are driving incidence rates up.
5. What are the common signs/markers to look out for?
One thing that is very important for women is for them to know their breast. Women should be doing monthly self-exams and should be done about five to seven days after their menstrual cycle. The main thing is to look out for any sudden changes to the size of your breast, as well as lumps, significant nipple discharge and changes in skin colour such as persistent redness. If any of these symptoms present themselves, then you need to be seeking professional help.
6. Can breast cancer be hereditary?
Yes, and it is. In five to 10 percent of cases, the cancer is in fact hereditary.
7. Is there a way to identify the specific genes (BRCA) linked to cancer?
John Hopkins does offer a service where we send the sample out to a company in the US which performs the test.
BRCA is actually tested through the blood – it’s a gene test that is done with a blood test. There are certain models that can be used to predict the chance of developing breast cancer compared to the rest of the general population. We look at family history and based on that, we can assess the risk profile. If one does have multiple family members with different cancers (breast, ovarian, prostate, etc.), then that person would be a good candidate for BRCA testing.
The other scenario where one would consider BRCA testing is if a woman was young (around 40 years old) and has been diagnosed with cancer. The question here is then, why? Why did this woman get cancer at the age of 40? There must have been something genetic that made that cell defective. In such cases, even if there wasn’t a family history of cancer, we would recommend that they consider BRCA testing.
We don’t send everybody and we have to be careful, because there are implications of going through BRCA testing. So if you send someone, it’s actually a process – you’d get counselled on the implications that come with a positive identification of the BRCA1 gene. You would have to consider what it would mean for you, your family, your children and even your insurance plans. We don’t take it lightly, so we actually will go through the whole process of having a genetic counsellor talk to the patient and their family and have them understand what’s involved. In the end, some people just don’t want to know – they don’t want that sort of thing to determine their way of life.
8. Are certain demographics more predisposed to breast cancer?
In Singapore, we’ve seen a higher incidence rate amongst Chinese women, but this could be due to the fact that Chinese make up the ethnic majority of the local population. It’s not as established as to which demographics are at a higher risk of developing breast cancer, at least in Singapore.
9. What are some common mistakes made during self-examination?
The biggest mistake is when women perform self-examinations during their menstrual or pre-menstrual cycle. This can be result in inaccurate results due to the breast being a bit swollen. There are also different methods as to how to perform the self-examination, so it’s important that you choose the one that is the most comfortable for you and stick with it. It’s also important to follow through – if you find something and it persists, seek help and evaluation immediately.
10. Have there been any notable developments in the field of breast cancer treatment?
Chemotherapy is not what it used to be; treatment is not as miserable as it used to be. That is the key thing here when we talk about advancement in treatments. Breast cancer is not treated the same way for everybody; it is very personalised. We now know that there are three different types of breast cancer and based on that, there are tailored treatments for each. And because we have a better understanding of these cancers, the outcomes are much improved.
The biggest discovery we’ve made is that in 30 percent of breast cancer, the condition is driven by this protein known as HER2. This protein is expressed on the surface of the cells and it literally drives the growth of cancer. 15 years ago, it was considered a poor prognosis. A woman would be diagnosed with stage four breast cancer and chemotherapy would give her approximately 12 months to live. Because of that, a good deal of resources was invested in researching this pathway. Now, we have four drugs (trastuzumab [Herceptin], lapatinib [Tykerb], pertuzumab [Perjeta], and ado-trastuzumab emtansine [Kadcyla]) to address this issue. As such, the current average lifespan of a woman who’s tested positive for HER2 and is diagnosed with stage four breast cancer has been extended to five years. Quality of life has now become a key area of focus for us when it comes to treating patients.
As our understanding of cancer grows and advances in treatment continue, the fatalistic nature of breast cancer may soon become a thing of the past. As it stands, vigilance is still the first line of defence when it comes to fighting cancer. While it may be tempting to hedge all your bets on cutting-edge medication and technology, it’s a far safer choice to know how to recognise signs and symptoms, and taking immediate action should any of them emerge.