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GLOBAL HEALTH FOCUS : b) BREAST CANCER |
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BREAST CANCER – THE MAJOR CANCER KILLER IN WOMEN 
Written by Nor ‘Azlah Mohamad Azhar'
It is not surprising to know that breast cancer is the commonest cancer in women in Malaysia, where 1 in 20 of Malaysian women suffers from it.
According to Professor Yip Cheng Har, an internationally renowned consultant breast surgeon in the University Malaya Medical Centre, ethnicity plays quite an important role here, where the incidence of breast cancer is highest in Chinese women (1 in 16 Chinese women), followed by Indian women (1 in 17 Indian women), and lowest in Malay women (1 in 28 Malay women). In terms of age, 33% or one-third of women with breast cancer are aged 40-49 years old, while approximately 14.1% of them are under the age of 40 years old.
Stage at presentation
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STAGE
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DESCRIPTION
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1
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Cancer is 2 cm or less, and it has not spread to the lymph nodes in the armpit.
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2
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Cancer is more than 2 cm, or when it has spread to the lymph nodes in the armpit.
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3
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Large tumours, more than 5 cm which has spread to the lymph nodes in the armpit.
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4
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Cancer has spread or metastasise to other organs such as the lungs, liver or bones.
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Looking at the percentage of women presenting with late breast cancer stage in UMMC, 40% of Malay women present with late breast cancer compared to only 15% of Chinese women and 20% of Indian women. The reasons for their late presentation were found to be three main reasons – which are fatalism (the belief that all events are predetermined and inevitable), belief in alternative therapy, and also inability of the woman to decide for treatment for themselves, i.e. the decision making was in the hands of significant others such as husband, parents or siblings. Other reasons were that they are afraid of surgery, and also financial and/or family problems.
Presentation of breast cancer
Formation of lumps is the most common sign presented by women in the clinic, where over 90% of them do so. Apart from that, it is worrying to know that a study in UMMC showed that women waited for a median of 3 months, before really seeing a doctor to find out what’s wrong with them.
Treatment of breast cancer
Treatment of breast cancer requires a multidisciplinary team comprising of the surgeon, pathologist, radiologist, oncologist, plastic surgeon, breast care nurse, and psych-oncologist to get the best outcome. Unfortunately, multidisciplinary teams are not available in most parts of Malaysia. In Malaysia, for early stage breast cancer, surgery is the primary treatment. Surgery is either a mastectomy and axillary clearance, or a lumpectomy and axillary clearance, followed by radiotherapy. Both these types of surgery give similar outcomes. However, breast conservation is only possible if the woman presents with a small breast lump which is localised.
If the woman is unable to accept losing a breast, immediate breast reconstruction is offered after mastectomy. However, this takes longer operating time and requires special training, and is not covered by insurance. Thus, the patient in Malaysia has to pay out-of-pocket if she wants a reconstruction. (Note that in the USA, reconstruction is considered essential and is covered by insurance!)
Apart from that, other option such as chemotherapy with anthracycline-based regimes is readily available. Taxane based regimes is also available in some centres, but it is more expensive.
Survival
Survival is dependent of the stage of presentation and timely effective treatment; hence to improve survival, it is important to detect cancer early and to give optimal treatment to the patient.
Early detection methods
Mammography screening is the only screening method proven to reduce mortality from breast cancer. However, there is no population based mammography screening programme in Malaysia, and screening is opportunistic, i.e. self-referred. In the absence of this nation-wide mammography screening programme, breast health awareness is promoted by the Ministry of Health. This awareness campaign encompasses education about the symptoms of breast cancer, and also teaches breast self examination.
Psychosocial support
Women with breast cancer experience anxiety related to their diagnosis, and also side-effects of their cancer treatment. Social support, whether tangible, informational or emotional, is essential for women to adjust to life with breast cancer.
In western societies, a patient navigation programme (where a patient is assigned to a navigator who helps her with logistics of transport, where to apply for social welfare, how to get appointments, and what to ask the doctors) has been shown to improve satisfaction and reduce the time from presentation to initial treatment. At present however, there is no patient navigation programme in Malaysia. It is unfortunate that here in Malaysia, there is a lack of psychological support for women with breast cancer. This is due to lack of trained clinical psychologists, lack of breast care nurse, and also lack of a patient navigation system.
All in all, it can’t be denied that breast cancer is the commonest cancer in women. Apart from timely and effective treatment, psychosocial support and psychoeducation programmes are important to reduce distress and anxiety, and to improve quality of life. It is also important for research to be done to learn more about why breast cancer occurs, what can be done to prevent it, and how the cancer can be best treated while maintaining a good quality of life.
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