Breast cancer is the most common type of cancer among women in Singapore, and is fatal if left untreated. Early detection and diagnosis of breast cancer can improve the chances of survival and reduce the need for aggressive treatments.
Detecting breast cancer
As different types of breast tumours have different characteristics and behaviours, there is a multitude of evaluation methods that are used to detect early breast cancer. Imaging tests can see past the skin and deep into the breast tissue, helping doctors find small breast tumours that are invisible to the naked eye.
“The choice of imaging depends on several factors, such as the patient’s age, risk factors, breast density, symptoms and personal preference,” says Clinical Assistant Professor Goh Chin Kong, Senior Consultant, Department of Diagnostic Radiology, CGH. “In some cases, a combination of imaging tests may be needed to achieve a definitive diagnosis.”
Imaging tests include mammography (using low amounts of X-rays with negligible radiation risks), Magnetic Resonance Imaging (MRI — using magnetic waves) and ultrasound (using sound waves).
Mammography, which has been in use for around 30 years, remains the most utilised imaging test, especially with recent technical advancements. Newer mammographic techniques include 3D mammography — also known as tomosynthesis (where small areas of abnormality are made more obvious), and contrast-enhanced mammography.
Contrast-enhanced spectral mammography
As a smart hospital, CGH continually utilises new imaging technologies to address the challenging nature of breast cancer diagnosis. In 2018, CGH started providing contrast-enhanced spectral mammography (CESM). CESM combines traditional mammography with intravenous contrast to show signs of breast cancer that may not be visible on standard imaging methods. CESM uses an iodine-based medicine — acting as a contrast — that is injected into a vein in the arm. New or abnormal blood flow patterns, indicative of cancer growth, are then highlighted on X-ray. The entire imaging procedure takes about 15 minutes, and is performed by CGH’s radiology nurses and technologists.
Benefits of CESM:
Abnormal tissue from the breast is removed to check for the presence of cancer cells in a biopsy.
Determining the diagnosis
A biopsy is usually performed once an abnormality is detected on the imaging test(s). It involves removing a small piece of abnormal tissue from the breast using a special needle. The needle is guided by various tools and imaging methods (such as ultrasound) to ensure precise extraction of the target tissue. The tissue will then be sent to the laboratory to check for the presence of cancer cells.
CGH’s surgeons carrying out a minimally invasive breast surgery.
Once a patient is diagnosed with breast cancer, the next step would be to remove the cancerous tumour from the breast. As the aim of treatment is to eradicate the cancer from the body, surgery remains the quickest and most complete way to remove the cancerous tissue.
In the past, the standard surgery was to remove the entire breast (mastectomy). With improvements in surgical techniques, breast-conserving surgery has become another option available to patients. In instances where the cancerous tumour is small and confined to a limited area of the breast, only that portion of the breast needs to be surgically removed, allowing the rest of the breast to remain. Accompanying treatments such as chemotherapy, radiotherapy and endocrine therapy may also be administered to reduce the risks of cancer relapse. If the breast cancer is detected in its earliest stages, surgery may be the only treatment required.
Minimal incisions, big impact
Surgical techniques to remove cancerous tumours from the breast have developed rapidly, enhancing the surgeon’s vision during procedures and also enabling the surgery to be performed with smaller scars. This is known as minimally invasive breast surgery(MIBS). MIBS may be used for both benign and cancerous conditions.
Conventional breast surgery is done through a direct cut over the tumour, which can result in large defects or unsightly scars. For breast-conserving surgery, a partial reconstruction may be performed with tissues around the breast. For mastectomies, the breast may be reconstructed using tissue transplanted from the patient’s back, abdomen or thigh, or women may choose to wear an external breast prosthesis to achieve symmetry.
“MIBS can be performed for both breast-conserving surgery and mastectomy. Reconstruction can also be performed in the same sitting, through the use of small well-placed incision(s) in inconspicuous or hidden areas of the breast, leading to better aesthetic outcomes while not compromising on safety,” says Clinical Assistant Professor Mok Chi Wei, Consultant, Division of Breast Surgery, CGH. “This is made possible with the use of endoscopic instruments, allowing the removal of the cancerous tumour through these small incisions.”
As MIBS uses small incision(s) made in inconspicuous or hidden areas, certain conditions such as a large cancerous tumour requiring skin removal may not derive the full benefit of MIBS. “CGH’s MIBS surgical outcomes have been comparable to that of conventional surgery methods, with the added advantage of smaller scars and improved patient satisfaction and aesthetic outcomes,” says Clin Asst Prof Mok.
Ice-cold precision
Aside from aiding in breast cancer diagnosis, CGH’s radiologists also perform minimally invasive procedures using various imaging techniques.
Dr Shi Haiyuan, Consultant, Department of Diagnostic Radiology, CGH (right), and the CGH care team carrying out a cryoablation procedure.
One such procedure for the treatment of breast cancer is cryoablation — therapy that involves freezing and killing cancer cells with extreme cold temperatures. “The best results are seen when the treatment is carried out on early-stage low-risk cancers that are less than 1.5cm in size,” says Dr Shi Haiyuan, Consultant, Department of Diagnostic Radiology, CGH.
The cryoablation needle creates an ice-ball around its tip, freezing and destroying the tumour with lethal cold.
The innovative procedure is similar to the commonly performed bedside breast biopsy, which involves removing a small piece of tissue for laboratory tests with the use of a specialised needle. Anaesthesia is injected into the skin and breast tissue, following which, the operating doctor makes a 2mm skin cut and inserts a special “freeze” needle through the tumour. The precise needle placement is guided by real-time ultrasound scanning. Ice forms around the tumour, leading to the destruction of the tumour cells, while preserving normal breast tissue.
The entire process takes around an hour, during which the patient is awake and virtually free from pain. Recovery time is minimal and the patient can return to near-normal activities on the same day following treatment. Some self-resolving swelling or redness of the breast may be experienced two to four weeks after the cryoablation treatment.
While cryoablation is relatively new in the treatment of breast cancers, it is a mature technology that has been in use for many years in the treatment of other tumours. Encouraged by promising results from international clinical trials, CGH started offering breast cryoablation for selected cancer patients, with the first case successfully carried out in 2020. To ensure that patients receive the most appropriate treatment, the decision for cryoablation is only made following discussion with the patient and CGH’s various medical specialists, including the oncologists and breast surgeons.
CGH is currently one of the few centres in Singapore offering breast cryoablation for selected breast cancer patients who are too frail medically to undergo definitive surgery safely. Similar to breast cancer surgery, cryoablation treatment may be combined with radiation therapy and chemotherapy, to reduce the risks of cancer relapse or recurrence.
Typically, a breast surgery patient at CGH undergoing a routine mastectomy or breast-conserving surgery will be admitted on the day of surgery, observed overnight and discharged the following morning. To enhance patient recovery, the CGH Breast Centre introduced the same-day discharge day surgery option for patients in 2021.
Being discharged on the same day of their surgery allows patients to recover in a familiar home environment, enabling them to rest better and feel more comfortable. This empowers patients in their self-care and encourages them to move about instead of lying in bed, thus facilitating faster recovery. In addition, this reduces the risk of hospital-acquired infections. Most patients who undergo breast cancer surgical treatment options are suitable for same day discharge if they are fit and healthy, and are able to reliably perform self-care independently or have reliable caregiver(s).
Multi-disciplinary care
Multi-disciplinary care team collaborations are crucial to the holistic recovery of a breast cancer patient. At CGH, the surgeons and anaesthetists work together to achieve the best pain control levels and expedite post-operative recovery for the patients, while the breast care nurses play an important role in patient care.
Preoperatively, breast care nurses provide information and support to patients and their families, and clarify information on the surgery.
After the surgery, they provide postoperative counselling for patients in the ward, and educate them on wound care and arm exercises.
“In caring for our patients, we are vital points of contact between the patient, family and care team after the diagnosis of breast cancer to ensure that they receive the best dedicated care and support,” says Ms Sophia Chua, Nurse Clinician (Advanced Practice Nurse), CGH.
With the use of technology, CGH’s breast care nurses communicate seamlessly with the patients following their discharge from hospital back to home through video consultations on wound care follow-ups where required. The surgeons also conduct a video consultation with the patient the day after they go home to ensure that they are well.
While some breast cancer patients who have undergone treatment recover well to pre-treatment levels, there are others who might experience symptoms of nerve-related pains, such as nerve-related dysfunction, numbness, muscle and joint aches and pains.
These issues arise as the body’s cells are affected by chemotherapy. “Our nerves are very sensitive to chemotherapy agents and can become damaged as a side effect of treating the cancer,” says Dr Edmund Neo, Associate Consultant, Department of Rehabilitation Medicine, CGH. “Some of the damaged nerves might not recover well even after completing chemotherapy, and many patients suffer in silence without completely understanding how they can manage these problems or get help to do so.”
Putting patients first at CGH
Recognising the needs of this group of patients, CGH started cancer rehabilitation services, complementing the existing cancer prehabilitation service which optimises the pre-operative status of patients going for cancer surgery, so as to reduce the complication rates, hospitalisation periods and physical recovery of these patients. The cancer rehabilitation clinic aims to care for patients managing their longer-term and post-treatment-related functional challenges.
In providing multi-disciplinary rehabilitative care for breast cancer patients, in addition to the breast surgeons, oncologists and breast care nurses, allied health professionals such as occupational therapists, physiotherapists, dietitians and psychologists also play a part. With this service available at CGH, patients with breast cancer have access to a one-stop solution centre, from diagnosis and treatment to rehabilitation.
Rehabilitation Medicine interventions
Breast cancer rehabilitation consists of a range of interventions intended to address and overcome the challenges a patient experiences with their movements and daily life, which could have arisen from physical or mental issues stemming from their cancer and cancer treatment. A holistic approach covers areas such as exercise, nutrition and psychological support, with the objective of helping patients return to their pre-illness health levels, and aiding them to recover sufficiently to move about safely at home and in the community.
Exercises
Physical exercise has multiple significant and proven benefits for patients recovering from cancer, including reducing their fatigue and pain, and improving their balance. The clinicians prescribe suitable exercises based on the condition of the individual patients. For example, a patient with post-operative arm-swelling must be careful not to overstrain their arm when exercising with weights, while a patient with cancer that had spread to the spine may need to avoid aggressive twisting motions. If needed, CGH’s occupational therapists and physiotherapists also supervise the patients’ rehabilitation exercises.
Injections
Some degenerative joint conditions can flare up when a patient is on hormonal medications, resulting in knee osteoarthritis, frozen shoulder or trigger finger. If conservative treatments are unable to sufficiently control the pain, steroid injections can be used to reduce the swelling and inflammation.
Medications
Depending on the patient’s condition, medications may be prescribed to help with the pain, stiffness, poor sleep, poor appetite, excessive tiredness or other conditions that they experience after their treatment.
Rehabilitation repairs
The cancer rehabilitation exercises have helped Mdm Engku in her recovery from chemotherapy- induced nerve pains.
As a breast cancer survivor who had undergone chemotherapy for her treatment, 65-year-old Mdm Engku Zubaidah was one of many patients who developed chemotherapy-induced peripheral neuropathy (CIPN). She had experienced a persistent numbness in her hands and legs, and her symptoms had been gradually worsening and did not feel like typical pains. “It was like the wind kept blowing through my body,” Mdm Engku described.
Many patients with CIPN find themselves at risk of falling or unable to walk properly because of the poor balance, poor sensation, and even distressing pain (from nerve damage) that come with the condition. It was with cancer-specific rehabilitation exercises, first supervised at the CGH Day Rehabilitation Centre, that led to a breakthrough in her condition. With a focus on balance and strengthening, Mdm Engku found herself rapidly regaining the confidence to move around at home and even in the community.
While another fall due to a viral infection led to challenges in her recovery journey, Mdm Engku persevered in her outpatient rehabilitation. “The exercises have helped me with my movement, I have been able to walk more and not feel tired so quickly. Also, the exercises have given me a better appetite!” says Mdm Engku. “I recommend going for these rehabilitation exercises, they provide me with a direction in my recovery, are helpful, and improve my stamina.”
More than a third of patients experience anxiety and depression at any one point of time in their journey with breast cancer.
Art therapy provides a form of emotional support, encouraging patients to express themselves through engagements in various art forms. In the process, they can formulate their own coping strategies when faced with complex emotional situations. This creative form of therapy encourages patients to release their “bottled up” emotions and find new meaning and perspectives through guided activities.
At CGH, art therapy is available for breast cancer patients as a support group activity. This is part of a pilot study led by Dr Melissa Seet, Consultant, Division of Breast Surgery, CGH, to study its safety and efficacy in helping breast cancer patients cope with the emotional challenges associated with breast cancer diagnosis and treatment.
At these sessions, under the guidance of a qualified art therapist, patients can express themselves freely using simple techniques in various art forms like sculpture, drawing, scrapbooking and more. “At the end of the day, every artwork’s unique beauty comes from the deeper personal stories and meanings that the patient attaches to it,” says Dr Seet.
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