Stigma Around Breast Screening and Breast Cancer Treatment for older women Breast cancer is one of the most prevalent cancers among women in Singapore, and early detection through screening and treatment are essential to improve outcomes. However, despite the importance of breast cancer screening and treatment, there remains a significant stigma surrounding these topics particularly among older women. This stigma can result in older women avoiding screenings and seeking treatment early, which can negatively impact their health outcomes.  In this article, we will explore the stigma surrounding breast cancer screening for older women and suggest ways to overcome it.  Factors Contributing to Stigma While breast cancer is the number one cancer among women in Singapore, only two in five women have kept up with their regular screening mammogram, according to the National Population Health Survey 2020. Some factors for the low screening rate and stigma on breast cancer screening among older women include:  Perceived costs versus the benefits of breast cancer screening Perceived high breast cancer screening costs versus the benefits of breast cancer screening among women in Singapore was identified as the most common obstacle to breast cancer screening in Singapore. Fear of breast cancer screening Another common factor is the fear of the screening procedure itself, such as the potential of pain during a mammogram, or exposure to radiation from mammograms, as well as the fear of potential outcomes arising from the breast cancer screening[1]. These outcomes include the fear of being diagnosed with breast cancer and the resulting financial burden of the treatment, the fear of a diminished quality of life, the fear of treatment side effects and of having to take medication for life.  Personal priorities Women may not place priority on breast cancer screening as there are many other commitments that are deemed as more important. Common reasons include having “no time” due to personal or professional responsibilities and the “inconvenience”[1] in having to personally attend the screening that may or may not be nearby. Modesty, embarrassment and distrust of breast cancer screening Modesty and embarrassment related to cultural beliefs[1] were frequently cited as reasons for women not undergoing breast cancer screening, as seen in several studies. The presence of male staff during the procedure, as well as previous negative screening experiences (either personal or witnessed in others) were identified as significant barriers to breast cancer screening.  Perceived susceptibility to breast cancer “I’m healthy” was commonly cited as a reason for avoiding breast cancer screening among women who have not undergone a mammogram before. Malay women were found to indicate this more often as a reason to avoid screening[1] compared with their Chinese and Indian counterparts. Another common reason cited for avoiding breast cancer screening was the perception of not being at risk. Women often cited a lack of family history, feeling healthy, and having undergone a prior mammogram with normal results as reasons for exemption from regular screening. Some women also believed that actively seeking cancer screening would increase their risk of getting breast cancer1 and that getting regular screening meant that something was wrong with them. Perceived severity of breast cancer False beliefs, where women believe their health outcomes were beyond their control, were also identified as a significant barrier to breast screening uptake. Women aged 60 years and above were more likely to cite these false beliefs compared to younger women. [1] Benefits of regular breast cancer screening Mammography lowers a woman’s risk of dying from breast cancer. It’s recommended for women aged 50 to 69 years old to have mammograms on a regular basis[2]. A meta-analysis that combined the results from six randomised controlled trials[2] found that: Women aged 50-59 who got mammograms on a regular basis had a 14 percent lower risk of dying from breast cancer than women who didn’t get mammograms. Women aged 60-69 who got mammograms on a regular basis had a 33 percent lower risk of dying from breast cancer than women who didn’t get mammograms. For women aged 50 and above, they are encouraged to go for a mammogram screening once every two yearsunless the doctor advises otherwise.  For women aged 40 to 49, a yearly mammogram is recommended.  Do consult a doctor on the benefits and limitations of doing a mammogram at this age. How to address breast cancer screening stigma Understand the importance of going for a mammogram It’s important to know that going for regular breast cancer screening is the right thing to do. In Singapore, Breast cancer is the most common cancer among women, accounting for all female cancers between 2015 and 2019. However, the good news is that early detection significantly increases the chances of surviving breast cancer. Mammograms are one of the most reliable screening tools for breast cancer, as they can detect suspicious areas before they can be felt by hand. Mammograms are also particularly effective for women aged between 50 and 70 years old.  Manage the anxiety about going for a mammogram Be prepared for the breast cancer screening by managing anxiety and obtaining all the necessary information, including what to expect and what to wear etc. The imaging centre will be able to provide a preparation list for you.   Talking to someone who has undergone breast screening previously, or consulting with a doctor[5], or breast cancer specialist, can also help to alleviate any fears or uncertainties that an older woman may have on breast cancer screening. It’s natural to feel some discomfort during the screening procedure as breast compression is required to obtain a clear image. However, the level of pain can vary among individuals. Women can share their pain concerns with the radiographer conducting the screening, who will then make adjustments for better comfort  Go with a friend for the mammogram Having someone to accompany a woman for her mammogram can help lighten the mood and keep her relaxed. Women can encourage their girlfriends, especially those who have never undergone breast cancer screening before, to get screened together with them.  Women can use this opportunity to meet up and help promote good health for everyone.  Stay calm after going for a mammogram Waiting for the screening results can be agonising for some women but instead of dwelling on the outcome, try to keep calm and keep themselves busy with activities they enjoy.  It’s also helpful to keep in mind the following facts: No screening test is entirely accurate, and women may be asked to undergo further tests, such as a repeat mammogram or ultrasound scan. In most cases, these additional tests will show that everything is clear. Only one in 10 breast lumps are cancerous5 so there’s no need to worry too much.  There are various effective breast cancer treatment options available today, and survival rates have significantly improved.  By taking the time to get regular screening, women can catch any potential issues early, which can increase their chances of successful treatment and recovery. Breast cancer screening is a quick and mostly painless process and it could save lives. Women should not let fear keep them from taking care of their health.  This Mother’s Day, women can give the gift of health to their mother by encouraging her to get a mammogram. Show love and appreciation by scheduling a mammogram for mum and joining her for the appointment. Together, let’s make women’s health and well-being a priority.  References Academy of Medicine Singapore, “Barriers to breast cancer screening in Singapore: A literature review”, https://annals.edu.sg/barriers-to-breast-cancer-screening-in-singapore-a-literature-review/ Susan G.Komen, “Breast Cancer Screening for Women at Average Risk, https://www.komen.org/breast-cancer/screening/when-to-screen/average-risk-women/ Singapore Cancer Society, “Mammogram”, https://www.singaporecancersociety.org.sg/get-screened/breast-cancer/mammogram.html Health Promotion Board, “Singapore Cancer Registry Annual Report 2019”, https://www.nrdo.gov.sg/docs/librariesprovider3/default-document-library/scr-2019_annual-report_final.pdf Healthub, “5 Ways to Psych Yourself for a Mammogram”, https://www.healthhub.sg/live-healthy/1839/5-ways-to-psych-yourself-for-a-mammogram

Breast cancer is the most common cancer among women in Singapore with over 2,000 women diagnosed each year. According to the Singapore Cancer Registry Annual Report 2018, the incidences of breast cancer are highest in women aged between 40 and 69 years old. What are some of the symptoms and risk factors, and how can we prevent breast cancer? The most common type of breast cancer originates from the cells lining the milk ducts and glands[1]. When abnormal cells are detected in the milk ducts and have not spread to other parts of the breast or the rest of the body, this is termed as Ductal Carcinoma In-Situ (DCIS). Patients with DCIS have a greater chance of recovering. Breast cancer may also begin in the glandular tissue called lobules or in other cells or tissue within the breast. The importance of early detection and regular breast cancer screening Going for regular breast cancer screening is important because it catches breast changes early before symptoms (such as a lump that can be felt) develop. Breast cancer is most treatable when it is detected and diagnosed at an early stage. Identifying the disease during its initial growth can mean that the required treatments are simpler and more effective. The earlier the breast cancer is detected, the smaller the tumour may be and the less likely it would have spread to other parts of your body or the lymph nodes. Breast cancer symptoms Symptoms may vary for different people and some of these symptoms may be related to other conditions that are not due to cancer. It is best to speak to your doctor or breast cancer specialist if you have any of these symptoms. Some symptoms of breast cancer may include: Lump in the breast or underarm area Thickening or swelling of part of the breast Irritation or dimpling of the skin on the breast A rash or flaky skin in the nipple area or the breast Pain or discomfort around the nipple or in the surrounding area; or the nipple being pulled inward Nipple discharge other than breast milk, including blood Change in the size or the shape of the breast Pain or discomfort in the breast How is breast cancer diagnosed? Your healthcare professional or breast cancer specialist may conduct one or more of the following test(s) or procedure(s) to diagnose breast cancer: Physical examination. Your doctor or breast cancer specialist will examine both of your breasts and lymph nodes in your armpit to detect any lumps or other abnormalities. Breast mammogram. Mammograms, which is an X-ray of the breast are commonly used to screen for breast cancer. Your breast cancer specialist may recommend a diagnostic mammogram to evaluate any abnormality that is detected on a screening mammogram. Breast ultrasound. Breast ultrasound, which is more commonly used in younger women can be used to determine whether a new breast lump is a solid mass or a fluid-filled cyst. Breast magnetic resonance imaging (MRI). A breast MRI is a contrast-enhanced machine that uses strong magnets to create cross-sectional images of the breast. Confirmation of breast cancer Removing a sample of breast cells for testing (biopsy). A biopsy, where a sample of breast cells is removed for testing, is the definitive way to make a diagnosis of breast cancer. During a biopsy[2], your breast cancer specialist will use a specialised needle device to extract a core tissue from the suspicious area. Biopsy samples will be sent to a laboratory for analysis to determine whether the cells are cancerous. The pathologist will also analyse the biopsy sample to determine the type of cells involved in the breast cancer, the aggressiveness of the cancer, and whether the cancer cells have hormone receptors or other receptors that may influence your treatment options. Risk factors for Breast Cancer Leading a sedentary lifestyle or being overweight after menopause can increase your risk of getting breast cancer. Some hormone replacement therapy[3] especially those that include both estrogen and progesterone taken during menopause may also increase the risk for breast cancer if taken for more than five years. Drinking excessive alcohol and having your pregnancy after age 30 may also increase a woman’s risk of breast cancer3. The risk for breast cancer also increases with age. Most breast cancers are diagnosed after age 40[4]. A woman’s risk for breast cancer is also higher if a first-degree relative or multiple family members on the parents’ side[5] have had breast or ovarian cancer. How to prevent breast cancer Apart from regular breast screening, research shows that lifestyle changes can decrease the risk of breast cancer, even among women who are at high risk. Here are some lifestyle strategies that you can use to reduce your risk[6]: Cut down on your consumption of alcohol as this can reduce your risk of developing breast cancer. The general recommendation is to limit yourself to no more than one drink a day. Maintain a healthy body weight. Cut down on your daily calorie intake and try to incorporate some daily physical activity such as taking a walk, alighting one stop before your destination, doing housework or climbing the stairs. Breast-feeding may also play a role in breast cancer prevention. The protective effect is enhanced if you breast feed for a longer period. Limit postmenopausal hormone therapy.  Talk to your doctor about the risks and benefits of hormone therapy as you might be able to manage your symptoms with nonhormonal therapies and medications. Eating a healthy diet might decrease your risk of some types of cancer including breast cancer. Try to consume more plant-based foods, such as fruits and vegetables, whole grains, legumes, and nuts. Cut down on red meat and choose healthy fats, such as olive oil and eat more oily fish such as tuna, salmon and mackerel. References: [1]Singapore Cancer Society, Breast Cancer [2]American Cancer Society, Breast Cancer Early Detection and Diagnosis [3]Centre for Disease Control & Prevention, What Are the Risk Factors for Breast Cancer? [4]Singapore Cancer Registry Annual Report 2020 [5]Centre for Disease Control & Prevention, What Can I Do to Reduce My Risk of Breast Cancer? [6]Mayo Clinic, Breast cancer prevention: How to reduce your risk