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The term “cancer” often triggers fear, as it is known as the silent killer. The survival rate of patients with end-stage cancer is very low, and even in early stages, the risk of cancer recurrence remains high. In Malaysia, breast cancer is the most common cancer among women.
Statistics show roughly 1 in every 19 women in our country may develop breast cancer at some point in their lives. In recent years, many young patients have been diagnosed with breast cancer, which has raised growing concern.
Malaysian breast cancer patients often seek treatment only when the condition has progressed. More than half of the patients are diagnosed at a late stage, and some even missed the golden period of optimal treatment.
Delay from the onset of symptoms to the initiation of treatment may reduce the chance of curing breast cancer. The delay could be caused by several factors, including insufficient public awareness towards breast cancer, concerns about the side effects of cancer treatment, and even fertility concerns in young patients. Most patients are also influenced by the myth that “cancer is incurable,” believing that treatment may create more problems instead of eliminating cancer.
Over the past decade, the advancement in technology has brought numerous breakthroughs in breast cancer treatment, leading to a reduction in mortality rate and significant improvement in patients’ quality of life. Before discussing treatment options, we should first understand how breast cancer is diagnosed and staged.
The diagnosis of breast cancer usually begins with examination. Imaging can detect abnormalities in the breast tissues. To further confirm whether it is cancer, doctors will obtain tissue samples from the patients’ breasts for analysis. During clinical breast examination, the healthcare team will check the breast for any abnormalities, such as lumps, nipple discharge or bleeding, skin dimpling or swelling, and the presence of lumps under the armpit or below the collarbone.
Mammography is an X-ray examination of the breast. It is commonly used to screen for breast cancer. If abnormality is detected during screening, the patient may be requested to undergo another mammogram for a more detailed evaluation. This is known as the diagnostic mammogram and is usually performed on both breasts.
Ultrasounds use waves to create images of the internal body structure. Breast ultrasound can help the healthcare team by providing further information about a breast lump. For example, it can help to determine whether a lump is solid or a fluid-filled cyst. The healthcare team can determine the next step in evaluation from the provided information. In current practice, mammography and ultrasound are usually used together in breast assessment. This is because each method provides different information, and combining them improves the accuracy of breast cancer detection.
A MRI device uses magnetic field and radio waves to create detailed images of the structure of the internal body. Breast MRI provides more detailed images of the breast. Sometimes, it is used to check more closely at the affected breast to identify other areas of cancer, and it may also be used to examine the cancer of the opposite side of the breast. A contrast medium is commonly given before breast MRI to help produce clear images of the tissues.
A biopsy is a medical procedure in which a sample of tissue is taken and examined in the laboratory. To obtain the tissue sample, a healthcare professional will insert a needle through the skin into the breast tissue. Imaging techniques such as X-ray or ultrasound will be used to guide the needle to the area of concern. The collected tissue is then sent to the laboratory to determine whether there is any presence of canceration. Additional tests on the sample can provide information about the cancer type, how quickly it is growing, and the presence of hormone receptors such as ER/PR and HER2. These findings help the healthcare team to plan the most appropriate treatment.
Once breast cancer has been diagnosed, further tests may be required in order to determine the extent of the cancer, which is known as staging. The stage of cancer helps the healthcare team to discuss the treatment plan.
Tests and procedures used for staging may include:
Not every patient will require undergoing all of these tests. The healthcare team will decide which tests are appropriate based on the patients’ condition.
Breast cancer is staged from 1 to 4. A lower number indicates earlier-stage cancer and a better chance of cure. Stage 1 breast cancer indicates the cancer is still confined in the breast tissues. As the cancer spreads to nearby lymph nodes and progresses to the later stages, the number increases. Stage 4 breast cancer means that it has spread to other parts of the body.
There is more than one treatment option to cure breast cancer. Treatment usually involves a combination of operation and other therapies. The healthcare team and the patients will develop the most appropriate treatment plan together. In current medical practice, breast cancer treatment may be local therapy, systemic therapy, or a combination of both.
Local therapy targets the breast, chest wall, and the lymph node area, and includes the following:
A breast cancer operation typically involves removing the tumor along with its surrounding healthy tissues, as well as nearby lymph nodes. Patients may choose to undergo breast reconstruction after the operation. The breast reconstruction is a procedure to restore the shape of the breast, either using the patient’s own tissue or implants.
The radiation therapy uses high-energy X-rays to treat cancer. In breast cancer treatment, it is commonly delivered as external beam radiation therapy. It is often given after surgery or chemotherapy, as it can destroy any remaining cancer cells. The radiation therapy can reduce the risk of cancer recurrence. Besides, it may be used in end-staged breast cancer to relieve pain or control bleeding. With the advancement of technology, newer radiation techniques such as SRS, SBRT, and IORT are now available. These techniques can control cancer more effectively while reducing side effects.
Systemic therapy treats cancer throughout the body and includes the following:
Chemotherapy uses drugs to stop or destroy the growth of the cancer cells. These drugs may be given orally or through intravenous (IV) infusion. The limitation of chemotherapy is that it is not highly selective; while it targets cancer cells, it may also affect other normal cells, causing fatigue, vomiting, fluid retention, allergic reactions, and hair loss. However, most of the side effects can now be managed with supporting medications.
Hormonal therapy is suitable for hormone receptor-positive breast cancer, which there is the presence of ER or PR receptors on the surface of cancer cells. This treatment works by lowering the hormone levels in the body or blocking the interaction between hormones and their receptors, thereby slowing or stopping cancer cells’ growth. Most of them are oral medications, but some are given by intramuscular (IM) or subcutaneous (SC) injection.
Targeted therapy uses drugs that specifically attack cancer cells with certain markers. For this approach to work, the “target” must first be identified for the drugs to lock on and take effect. Hence, only cancers with specific markers are suitable for targeted therapy. For example, HER2-positive breast cancer can be treated with drugs that target HER2. Hormone receptor-positive cancers can be treated with CDK4/6 inhibitors or PIK3CA inhibitors. Breast cancers associated with the BRCA gene may also benefit from its targeted therapy. Since targeted therapy focuses on cancer cells with specific markers, it is typically more selective than chemotherapy, not affecting surrounding normal cells and causing fewer side effects. However, it is often more costly. These treatments may be administered orally or via intravenous (IV) infusion.
Immunotherapy strengthens patients’ immune systems to help fight cancer cells through drugs. It is commonly used in triple-negative breast cancer. Unlike chemotherapy, this treatment brings fewer side effects.
An antibody-drug conjugate combines targeted therapy and chemotherapy to selectively suppress the growth of breast cancer cells and destroy them. This treatment can be more effective than conventional chemotherapy in suppressing cancer cells.
Many hospitals in Malaysia are currently undergoing international clinical trials. Breast cancer clinical trials are designed to evaluate new treatments, interventions, and diagnostic methods that are aimed at preventing, detecting, treating, or controlling the disease. These provide more treatment options to the breast cancer patients. Patients who are interested in joining the clinical trials may consult their oncologist for more information.
Besides breast self-examination, all women are encouraged to undergo regular screening with mammography and breast ultrasound. It is generally recommended by doctors that women aged 40 and above should have these examinations every two years.
If one belongs to a high-risk population, the screening should begin earlier and more frequently. High-risk populations include those with a history of breast conditions (even benign ones, such as cysts), a family history of breast cancer, or carrying a BRCA gene mutation. It is recommended to start screening about 10 years earlier than the age at which a family member was diagnosed.
Particular attention should be given to individuals with a BRCA gene mutation. This type of cancer tends to be malignant, occurs at a younger age, and is often more challenging to manage. If a family member is found to carry a BRCA gene mutation, other family members are recommended to do genetic examinations and follow-ups regularly.
Compared to end-stage breast cancer, which has only a 30% cure rate, early-stage breast cancer has a cure rate up to 90%. Thus, this highlights the importance of early detection and timely treatment.
Breast cancer may progress rapidly, sometimes advancing from an early stage to end stage within a short period, which reduces the chance of cure. Many breast cancer patients’ conditions deteriorate over time, making them less able to tolerate treatment and potentially losing the chance of recovery. Hence, early screening, early diagnosis, and early treatment remain the most effective approach.
Patients may find it helpful to connect with other breast cancer patients. Everyone can share opinions or their journey with breast cancer. It also allows patients to encourage and care for each other, making the journey of fighting breast cancer less lonely.
Breast cancer treatment varies from person to person, and the journey can be long. It is important for patients to communicate with their oncologist and build a trusting relationship. This can make the treatment journey smoother.
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