Oncology | Breast Cancer | Pantai Hospital

Breast cancer is a cancer arising from the uncontrollable cell growth of cells in the breast. It refers to cancer originating from breast tissue, most commonly from the inner lining of milk-producing ducts (such cancers are known as “ductal carcinoma”) or the lobules that supply the ducts with milk (also known as “lobular carcinoma”).

What are the types of breast cancer?

Breast cancer is classified by its location of origin and whether it spreads from the origin.

1. Non-invasive breast cancer

Non-invasive breast cancer is cancer of the cells of the breast duct or lobule (milk glands), which does not spread from this location.

Ductal carcinoma in situ (DCIS)
DCIS is a precancerous condition where abnormal cells are found in the lining of the breast milk duct. This condition is non-invasive and thus, the abnormal cells have not spread to the surrounding tissue. DCIS is the earliest form of breast cancer and is commonly discovered during a mammogram. Although it is non-invasive, DCIS still requires treatment to ensure that it does not spread to surrounding breast tissue.
Lobular carcinoma in situ (LCIS)
LCIS is a condition where abnormal cells are found in the lobules (milk glands) of the breast, which have not spread to the surrounding tissue. While this condition is not yet cancer, it means you do have an increased risk of getting breast cancer.

2. Invasive breast cancer

Invasive breast cancer is cancer of the cells of the breast duct or lobule that spreads and invades surrounding tissue. It can also spread to other regions of the body through the blood and lymphatic systems.

Invasive ductal carcinoma (IDC)
Abnormal cells in this cancer started in the milk ducts and have spread to the surrounding tissue.
Invasive lobular carcinoma (ILC)
This cancer begins in the lobules, or milk-producing glands of a woman’s breast. The term invasive in its name means that the cancerous cells which started in the lobules of the breast have spread to the nearby lymph nodes and maybe to other parts of the body.

Can men get breast cancer?

Men can also get breast cancer, although it is rare. Although men’s breasts are not fully developed like women’s, men too have breast tissue. Cancerous cells can also form in male breast tissue and are more common in older men.

Below are the most common types of breast cancer in men:

Invasive ductal carcinoma (IDC)
Invasive lobular carcinoma (ILC)
Ductal carcinoma in situ (DCIS)

Men with breast cancer usually have a good prognosis if the disease is detected early.

What is triple negative breast cancer?

Triple negative breast cancer refers to cancers that test negative for oestrogen, progesterone and the HER2 protein. This type of cancer is usually more aggressive and as such, very likely to have spread to surrounding areas by the time it is detected.

Triple negative breast cancer presents with the usual breast cancer symptoms, such as a lump in the breast, redness or pain in the breast, and a nipple that has discharge or turns inward.

What are the stages of breast cancer?

Stage 0: Non-invasive Breast Cancer

In stage 0, cancer cells and abnormal non-cancerous cells are still contained in a specific spot. They have not invaded neighbouring tissue. Examples include Ductal Carcinoma-In-Situ (DCIS) which is a precancerous condition that is confined to the ducts and Lobular Carcinoma-In-Situ (LCIS) (lobules) which is a risk factor for invasive cancer.

Stage I

In stage I, there is a small tumour, and only in the breast tissue or it might be found in lymph nodes close to the breast (isolated cells).

Stage II

Stage II breast cancer means that the cancer is in the breast, nearby lymph nodes or both. It is still considered an early stage of breast cancer.

Stage III: Invasive Cancer

This is a condition whereby the cancer has from the breast to lymph nodes close to the breast or to the skin or to the breast or to the chest hall.

Stage IV: Metastatic Breast Cancer

This is when the cancer has spread to other parts of the body. It is also called secondary breast cancer, advanced cancer, or metastatic breast cancer.

What are the signs and symptoms of breast cancer?

The symptoms of breast cancer vary widely. Some types of breast cancer may not show obvious symptoms. Some warning signs of breast cancer are:

1. Presence of a lump

The first noticeable symptom of breast cancer is typically a lump in the breast or underarm/armpit that feels different from the other breast tissue. More than 80% of breast cancer cases are discovered when the woman feels a lump which sometimes can be found in the armpit as well. Most patients discover the presence of a lump due to an abnormal mammogram screening result.

2. Skin changes

Skin changes such as redness, discolouration, scaliness or mild flaking of the nipple skin could be due to Paget’s disease of the breast, one of the many variants of breast cancer.

Irritation or dimpling of the breast skin may occur as well while in inflammatory breast cancer; the skin may have ridges or appear pitted, akin to the skin of an orange (called peau d’orange).

Signs and symptoms also include thickening or swelling of a part of the breast and change in breast size, shape, or appearance.

3. Nipple changes

Some changes with the nipple are trivial, such as structural (retracted or inverted), while others may occur due to the presence of discharge (clear or bloody discharge) that is not breast milk.

Note that the above symptoms can arise with other conditions that are not cancer. If you feel concerned over certain signs or symptoms, see a doctor right away.

In advance stages, symptoms related to distant spread of the cancer may occur, such as:

Bone pain (bone metastases)
Shortness of breath (lung metastases)
Drop in appetite (liver metastases)
Involuntary weight loss (liver metastases)
Headaches
Neurological pain or weakness

What are the risk factors of developing breast cancer?

There are certain risk factors that you should be aware of when it comes to breast cancer causes. These include:

Female gender (breast cancer is far more common in females)
Family history of breast cancer
Carrier of BRCA gene mutations (BRCA 1 and BRCA 2)
Previous history of breast cancer
Presence of breast lumps
Having a first child at an older age
Never having been pregnant (never conceived)
Use of hormonal replacement therapy
Alcohol and cigarette use
Older age
Radiation exposure (from radiation therapy treatments)
Started menstruation at a younger age (before 12 years old)
Menopause at an older age (after 55 years old)
Being overweight or obese

How do doctors diagnose breast cancer?

Breast cancer is generally diagnosed either through pre-empted screening or diagnostic test prompted by its symptoms (e.g., breast pain, nipple discharge or presence of mass). Regular health screenings are important as they allow early detection of tumours. When cancers are detected early, they tend to have better treatment outcomes.

Patients who present breast cancer symptoms will undergo a set of assessments known as ‘Assessment’. The Triple Assessment test is used to accurately diagnose all palpable breast lumps and can yield a sensitivity of 99%.

Triple Assessment consists of:

1. Doctor’s assessments

Doctor’s assessments include findings from clinical breast examination (CBE). A doctor will conduct CBE to notice any change involving the size, shape, and texture of any lump.

Benign lumps are soft, smooth, round, and movable. A malignant lump feels hard, is oddly shaped, and feels firmly attached.

2. Radiological imaging of the breast (mammography or breast ultrasound)

A mammogram is an x-ray of the breast. Mammograms can detect breast cancer years before the tumour can be felt by you or your doctor. A mammogram should be scheduled every year after age 40.

How does mammography screening help detect breast cancer?

Mammograms can detect breast lesions smaller than 1 cm in size.
A smaller lesion increases the possibility of having breast-conserving surgery.
Survival rate is also generally better.

A breast ultrasound looks inside of the breast using sound waves and their echoes. It can detect certain features that may be difficult to observe on mammograms, such as fluid-filled cysts.

How does an ultrasound help detect breast cancer?

Ultrasounds are useful to distinguish solid tumours from fluid-filled masses such as cysts, which are very unlikely to be cancer.
Ultrasounds are also used to guide a biopsy needle into the breast tissue to extract cells and examine them for cancer.

3. Biopsy of breast tissue for laboratory tests

A breast biopsy may be performed if symptoms or an imaging test (such a mammogram) indicate the possibility of breast cancer. A small amount of breast tissue is taken from the suspected lesion so they may be tested in a lab.

How does a biopsy screen for breast cancer?

A biopsy allows for tissue samples from the breast to be examined for the presence of cancer cells.
It is performed to confirm a cancer diagnosis.

Biopsy of breast tissues can be obtained either through fine needle aspiration cytology (FNAC) or core needle biopsy (CNB):

FNAC is the least invasive method of breast biopsy which involves the insertion of a thin, hollow needle into the breast to withdraw cells from the suspected area.
CNB uses a larger needle and instead of cells, it removes a small cylinder of tissue (a core) about the size of a rice grain, from the breast.

From the breast biopsy, pathologists can determine the appearance of cells, grading and cancer stage.

Learn more about the different types of screening and diagnostic procedures performed to diagnose breast cancer.

How is breast cancer treated?

Management of breast cancer depends on several factors such as the stage of the cancer, tumour-to-breast ratio, and the patient’s condition.

After the diagnosis has been established, the doctor will provide a comprehensive counselling on the treatment options based on their respective outcomes. Patients would then be able to make an informed decision regarding the best treatment for themselves.

Treatment for breast cancer depends on the size of the tumour and the extent of its spread in the body. These may include:

1. Breast Conservation Surgery (BCS)

Breast Conservation Surgery (BCS) followed by radiotherapy is the main treatment for women with stage I or II breast cancer. This treatment provides a survival rate equivalent to that of a total mastectomy and axillary clearance while preserving the breast. In BCS, only the tumour and a small margin of normal tissue surrounding it are removed.

2. Mastectomy

Mastectomy involves the complete removal of the breast, and it is performed under the following considerations:

Factors that increase the risk of local recurrence (e.g., diffuse visible calcifications on mammogram, multiple primary tumours, or failure to obtain tumour-free margins).
Physical disabilities that preclude lying flat or abducting the arm, preventing the use of radiotherapy.
Absolute contraindications to radiotherapy such as pregnancy, previous irradiation of the breast or relative contraindications such as systemic lupus erythematosus or scleroderma.
Tumour of 4 cm or more in size, or larger tumours with sizes in proportion to the breast. Neoadjuvant (i.e., pre-surgery) chemotherapy has the potential to downstage large tumours and improve the chances of successful breast conserving surgery.
The patient’s clear preference for mastectomy.

3. Radiotherapy

Radiotherapy involves the use of high energy radiation to destroy cancer cells. It is effective in reducing the risk of local or regional recurrence of breast cancer. As such, it can be used following breast conservation surgery or total mastectomy.

4. Chemotherapy

Chemotherapy is a systemic therapy that can either be performed as an adjuvant or neoadjuvant therapy (before a surgical procedure). Neoadjuvant chemotherapy is usually provided for locally advanced breast cancer.

As breast cancer is recognised as a systemic disease even in its early stage, adjuvant chemotherapy should be considered, especially in pre-menopausal women who have the following:

One or more positive axillary lymph nodes
Oestrogen receptor (ER) negative disease
HER2, 3+ disease
Tumour larger than 2 cm in size
Grade 3 disease

Neoadjuvant chemotherapy is also increasingly being used for certain patients with earlier stage disease (in particular, patients with triple negative disease or HER2-positive disease).

5. Monoclonal antibodies

Monoclonal antibodies can also be used to treat breast cancer. Normally, the body creates antibodies in response to an antigen (the receptor on the surface of bacteria). Antibody attaches to the antigen in order to mark it for destruction by the body’s immune system. Trastuzumab (a monoclonal antibody) works by targeting receptors on cancer cells.

Under regular conditions, the human epidermal growth factor receptor 2 (HER2) gene stimulates normal cell growth by instructing the cell to divide and multiply in a controlled manner. However, some cancerous breast tissues contain too much HER2, triggering the cells to divide and multiply rapidly. Trastuzumab attaches to the HER2 receptors and marks the cell for the immune system to destroy.

6. Endocrine therapy

Endocrine therapy is beneficial for patients who suffer from oestrogen receptor (ER) positive diseases. Treatments under this group of therapy include the use of systemic drugs such as tamoxifen and aromatase inhibitors, and ovarian suppression or ablation therapy.

Learn more about the different types of treatment technologies to treat breast cancer.

What can I do to reduce the risk of developing breast cancer?

We recommend following these healthy lifestyle practices to reduce the risk of breast cancer:

Maintaining a healthy body weight
Exercise regularly
Eat a well-balanced, healthy diet
Avoid or stop smoking
Avoid or limit alcohol
Do breast self-examination (breast check) frequently
Limit postmenopausal hormone therapy

Frequently asked questions (FAQs)

Risk factors

1. Does family history of breast cancer put someone at higher risk?

Statistically only 5-10% of individuals diagnosed with breast cancer are thought to be hereditary.

2. How does menstrual and reproductive history affect breast cancer risks?

Women who began their menstrual cycles before age 12, have no biological children, or had their first child at 30 or older, or began menopause after 55 are at a higher risk. Research has proven that the number of menstrual cycles a woman has over time influences risk.

3. Does breast size affect breast cancer risk?

There has been no conclusive evidence that breast size is related to breast cancer risk. However, dense breast tissue makes it harder for radiologists to read the mammogram.

4. Can breastfeeding reduce the risk of breast cancer?

Yes, breastfeeding can reduce the risk of developing breast cancer. Hormonal changes after giving birth pause a woman’s period. Breastfeeding extends these changes, reducing exposure to hormones such as oestrogen over her lifetime. Since these hormones are linked to breast cancer, breastfeeding reduces the risk of breast cancer.

Besides this, women who breastfeed shed breast tissue as they do so. This process can help remove cells with DNA damage and thus, reduce the chances of contracting breast cancer.

5. Does smoking cause breast cancer?

Multiple studies suggest that there is a moderately increased risk of breast cancer in smokers. Most importantly, smoking also directly contributes to heart and other lung diseases, too.

Signs & symptoms

6. How does a breast lump feel like?

Cancerous lumps are usually:

Painless
Feels like a hard mass
Immobile - does not move around when pushed
Irregular in shape
Located at the outer part of your breast
Grows over time

However, not all cancerous lumps feel this way. They may also be soft, tender, rounded and painful. As such, it is imperative that you see a doctor right away if you feel any lump.

7. What are the signs that breast cancer has spread?

Metastatic breast cancer is a secondary cancer – the cancerous cells originate in breast tissue and then travel to other parts of the body. The most common areas of breast cancer metastasis are the bones, lungs and liver.

8. How fast does breast cancer spread?

It is hard to tell how fast breast cancer spreads. The disease affects people differently and cancerous cells do not adhere to normal patterns of cell division. The type of breast cancer and personal factors such as age, and medical history can also affect how quickly it grows.

Treatment

9. How do I manage the side effects of breast cancer treatment?

It is important to liaise closely with your oncologist so that side effects from treatment such as radiation and chemotherapy can be managed effectively throughout the course of treatment. In most instances, side effects tend to be mild to moderate or generally tolerable and manageable.

Early detection & prevention

10. How often should I do breast self-examination? How is it done?

Women should perform a breast self-examination (BSE) regularly starting from age 20. Conduct a breast self-exam once a month and look for any changes in breast tissue, such as changes in size.

If you notice any palpable lumps, dimpling or puckering of the breast, inversion of the nipple, redness or scaliness of the breast skin, nipple/areola area, or discharge of secretions from the nipple, consult your doctor without delay.

How to do breast self-examination (breast check)

1. Stand in front of a mirror and look at your breasts closely. Look for changes in size, shape, colour and texture of your skin and nipple.

2. Next, lift your arms above your head and check your breasts again.

3. Then, place your hands on your hips and press inwards to tense the muscle under your breasts.

4. Look closely for any visible changes in the breasts.

5. Begin palpation from your underarm and examine your breast in concentric circles, starting from the outer region of the nipple.

6. Your breasts can also be palpated in vertical strips.

7. Gently squeeze your nipples to look for abnormal discharge.

8. With your arm placed at the side, examine for lumps under your armpit again using your free hand.

11. How often should you get a mammogram?

12. Are mammograms painful?

The mammography procedure does involve compressing the breasts and this can sometimes cause slight discomfort for a very brief period of time. Sensitive patients should schedule their mammograms a week after their menstrual cycle so that the breasts are less tender.

13. How to prevent breast cancer?

Changes in your lifestyle can help decrease the risk of breast cancer. You can do the following:

Consult your doctor about breast screening
Be familiar with your breasts and inspect for changes, lumps, or other signs. While this can’t prevent breast cancer, it will help you to catch it early on
Limit alcohol intake
Exercise 30 minutes a day
Be aware of what you eat. A healthy diet can reduce your risk of breast cancer
Maintain a healthy weight
Be aware of the risks of postmenopausal hormone therapy

14. Can a healthy diet help to prevent breast cancer?

Eating plenty of fruits, green and orange vegetables, and a nutritious, low-fat diet can reduce your risk of developing breast cancer, whilst a high-fat diet increases the risk because fat triggers oestrogen production that can spur tumour growth.

15. Can physical activity reduce the risk of breast cancer?

Exercise boosts the immune system and helps keep your weight in check. A woman can begin to lower her risk of breast cancer with just three hours of exercise per week, or about 30 minutes a day, without even hitting the gym because power walking can get the job done!

16. When is Breast Cancer Awareness month?

October is Breast Cancer Awareness month.

Myths & facts

17. Myth: Breast cancer only happens to middle-aged and older women.

Fact: Younger women can and do get breast cancer, as do men.

18. Myth: Breast cancer always causes a lump you can feel.

Fact: Breast cancer might not cause a lump, especially when it first develops.

19. Myth: Early-stage breast cancer rarely recurs.

Fact: Even with early-stage breast cancer, there is always some risk the cancer will return.

20. Myth: If I don’t have a family history of breast cancer, I won’t get it.

Fact: Most people diagnosed with breast cancer have no known family history.

21. Myth: Wearing a bra can cause breast cancer.

Fact: There is no evidence that bras cause breast cancer.

22. Myth: Using underarm antiperspirant can cause breast cancer.

Fact: There is no evidence of a connection between underarm antiperspirant and breast cancer, but the safety of antiperspirants is still being studied.

23. Myth: Annual mammograms guarantee that breast cancer will be found early.

Fact: Although mammography is the best early-detection tool we have, it doesn’t always find breast cancer at an early stage.

24. Myth: If you maintain a healthy weight, exercise regularly, eat healthy, and limit alcohol, you don’t have to worry about breast cancer.

Fact: Although these behaviours can help lower breast cancer risk, they can’t eliminate it completely.

Make an appointment at Pantai Hospitals

Early detection is important for the best outcomes. Performing regular breast self-examinations and scheduling regular mammograms can help detect breast cancer in its early stages. Early-stage detection gives you the best chance of fighting breast cancer.

Early detection of breast cancer makes it easier to treat the disease with effective and appropriate treatment. A dedicated multidisciplinary team of specialists and oncologists at Pantai Hospitals is available for consultation to provide the best care and assistance to patients through screening, diagnosis, and treatment.

Get in touch with us to book an appointment today if you have any concerns or questions about breast cancer treatment options.

Learn more about cancer care and Oncology services at Pantai Hospitals.

Pantai Hospitals have been accredited by the Malaysian Society for Quality in Health (MSQH) for its commitment to patient safety and service quality.