Do Scars really matter in Breast Cancer Treatment?
For many women undergoing breast cancer treatment, one of the most significant concerns is the impact of surgery on their appearance, particularly when it comes to the visibility of scars. While the primary goal of breast cancer surgery is to effectively remove cancerous tissue, aesthetic considerations cannot be overlooked in a patient’s emotional and psychological recovery. So, do scars really matter for breast cancer patients? The answer is complex and deeply personal, as it encompasses both physical healing and emotional well-being.The Emotional and Psychological Impact of ScarsThe idea of scars can evoke strong emotional responses. For some, they symbolise survival and strength after a life-altering experience, while for others, they may bring feelings of loss, fear, or diminished self-worth. ‘Correspondingly, the first group of patients may be ambivalent about their scars or even embrace them; whereas a second group of patients prioritise reconstruction options that minimise visible reminders’, says Dr Wong Manzhi, Senior Consultant Plastic Surgeon at The Aesthetic & Plastic Surgery Clinic. Physical changes, including scars, can lead to feelings of anxiety, depression, and a reduced quality of life. Many women report that scars on their chest can be a constant reminder of their cancer diagnosis, affecting their self-esteem and sexual identity [1].Importantly, emotional recovery is just as crucial as physical recovery. For many patients, the ability to feel “whole” again is tied not only to the success of the surgery but also to the way they perceive their bodies after the procedure. Scars, even when minimal, may alter how women feel about their body image and their sense of femininity.Scar Minimisation: The Role of Surgical TechniqueNot all scars are created equal. Advances in surgical techniques, such as nipple-sparing mastectomies (NSM) and keyhole surgeries, aim to reduce the visibility of scars while maintaining effective cancer treatment. Nipple-sparing mastectomies, for instance, have become increasingly popular, as they preserve the nipple-areolar complex (NAC) during surgery, resulting in a more natural post-operative appearance. For many women, the preservation of the NAC is a powerful tool in preserving their body image and reducing the emotional impact of the surgery.Additionally, keyhole surgeries—also known as minimal access surgeries—are another option that reduces scar size by using smaller incisions and specialised instruments like endoscopes and robotic systems. These procedures are gaining traction in breast cancer treatment, with studies showing that keyhole surgeries leave smaller scars (usually about 4 cm in length compared to 9 cm for traditional mastectomies) and promote faster healing [4].Beyond these techniques, oncoplastic surgery – which combines cancer removal with reconstructive techniques – also plays a key role in minimising scarring while preserving or even enhancing the breast contour. Skilled oncoplastic surgeons strategically place incisions and use tissue rearrangement methods to achieve better cosmetic outcomes with less visible scarring.However, it’s important to note that these options aren’t universally applicable. Some patients may not be candidates for nipple-sparing, keyhole, or oncoplastic surgeries due to the size of their tumours or other medical considerations. In these cases, conventional mastectomy may still be the best option for ensuring complete cancer removal.Aesthetic and Functional Considerations: Why They MatterWhen considering mastectomy options, both aesthetic and functional outcomes play a crucial role in the decision-making process. For many patients, immediate breast reconstruction after mastectomy can help restore a sense of normalcy, offering both psychological and physical benefits.The location and size of surgical scars can play a significant role in the reconstruction process. For instance, a larger incision may provide more flexibility for more complex reconstruction procedures. It is essential to discuss your options with your breast surgeon to determine the best approach for your specific condition.The Global Perspective: Mastectomy Rates and Cultural AttitudesMastectomy rates and cultural attitudes toward breast cancer surgery vary widely around the world. In countries like the United States, mastectomy rates have been rising, especially with the trend of preventive double mastectomies among women with a higher genetic risk, such as those with BRCA mutations. A 2017 study found that mastectomy rates in the U.S. have increased to 31% overall, with some regions seeing rates as high as 49% for double mastectomies [5].In countries like Singapore, mastectomy rates have remained consistently high. A review conducted over a decade found mastectomy rates ranging from 43% to 59%. These numbers may reflect cultural attitudes toward breast cancer, where mastectomy is seen as a necessary and life-saving procedure. Despite the availability of equivalent alternatives like breast-conserving surgery, many women opt for mastectomies due to the perceived greater oncologic safety and the desire for peace of mind [3].Looking Ahead: The Future of Scar MinimisationAs technology continues to advance, it’s likely that breast cancer surgeries may become even less invasive, with smaller incisions and better healing outcomes. Robotic surgery, for example, holds the promise of greater precision, leading to even smaller scars and potentially faster recovery times. Additionally, the use of tissue engineering and regenerative medicine may offer new ways to minimise the appearance of scars and even restore lost tissue [2].Furthermore, psychological support for breast cancer patients is gaining recognition as an integral part of treatment. Many hospitals now provide counselling and support groups specifically focused on body image, helping women navigate the emotional challenges that come with scarring and physical changes. These resources are critical for empowering patients to accept their bodies and find ways to heal emotionally and physically.Conclusion: Scars and the Journey of RecoveryWhile scars may be a visible reminder of a challenging chapter in a patient’s life, they also represent survival and the strength it takes to overcome cancer. However, minimising the impact of scars, both physically and emotionally, is an important consideration in breast cancer treatment. With advances in surgical techniques, increased awareness of emotional support, and a growing focus on personalised care, the future looks promising for breast cancer patients seeking to heal not only their bodies but also their spirits.Ultimately, what matters most is that patients feel empowered to make choices that align with their values, health goals, and sense of self. Scars, though unavoidable in many cases, do not have to define their journey—how they heal and move forward does.Article reviewed by Dr Esther Chuwa, Senior Consultant and Breast Surgeon at Solis Breast Care & SurgeryReferences:[1] Fobair, P., Stewart, S. L., Chang, S., & D’Onofrio, C. N. (2006). Body image and sexual problems in young women with breast cancer. Psycho-Oncology, 15(7), 579-589. https://doi.org/10.1002/pon.1023[2] Haidar, M., Saeed, H., & Elhassan, F. (2020). Tissue engineering and regenerative medicine for breast reconstruction. Journal of Stem Cells, 25(4), 351-360.[3] Lee, W. T., Tan, S. K., & Kwek, S. K. (2015). Mastectomy rates and breast cancer treatment trends in Singapore. Singapore Medical Journal, 56(8), 444-448.[4] Lin, Y., Wang, Y., & Tsai, C. (2020). Keyhole mastectomy: Outcomes and benefits. Breast Cancer Research and Treatment, 182(3), 567-575. https://doi.org/10.1007/s10549-020-05793-z[5] Veronesi, U., Boyle, P., & Goldhirsch, A. (2017). Mastectomy versus breast-conserving surgery in early breast cancer: Meta-analysis of trials. The Lancet, 373(9680), 569-577. https://doi.org/10.1016/S0140-6736(09)60256-7
Breast Cancer Screening Guidelines: A Guide for General Practitioners in Singapore
Breast cancer is the most common cancer among women in Singapore, with one in 13 women expected to be diagnosed in their lifetime. As general practitioners (GPs) play a vital role in early detection, it is crucial to understand the national screening guidelines and the rationale behind them.Our consultant radiologist, Dr Eugene Ong, provides an overview of breast cancer screening recommendations, including why screening starts at 40, the role of ultrasound, the differing screening intervals for various age groups, and key imaging concepts such as BI-RADS and indeterminate lesions.Screening and DiagnosisEarly Detection through regular screening can significantly increase the chances of successful treatment and survival. By detecting breast cancer at an early stage, treatment options are usually less invasive, and the prognosis is generally more favourable.Note: Age recommendations are only guidelines and may differ for those with a family history of breast cancer or those who have other risk factors. Supplementary ultrasound may be ordered to increase the accuracy of screening.1. Why Screen at 40 Years Old vs. 50 Years Old?
Early Detection: Screening from age 40 allows earlier detection of breast cancer, which is crucial as breast cancer can develop before 50. Studies have shown that Asian women, including Singaporean women, tend to develop breast cancer at a younger age compared to Western populations.
Higher Incidence in Younger Women: In Singapore, a not-insignificant proportion of breast cancer cases occur in women in their 40s. Screening from 40 helps detect cancers earlier when they are more treatable.
Survival Benefit: Early detection through screening in women aged 40–49 has been associated with improved survival rates and reduced mortality.
Government Guidelines: The Ministry of Health (MOH) and the Singapore Cancer Society recommend mammogram screening starting at 40, with different screening intervals depending on age (see point 3).2. Why Screen with Ultrasound – Why Isn’t Ultrasound in the MOH Guidelines, Only Mammograms?
Mammograms are the Gold Standard: Mammography is the only breast screening method with proven mortality reduction in large-scale population screening. It effectively detects microcalcifications, which can be an early sign of breast cancer.
Ultrasound as a Supplemental Tool: Ultrasound is useful in women with dense breasts (common in younger women and Asian populations) as mammograms may miss some cancers in dense breast tissue. However, ultrasound alone is not a primary screening tool because it is operator-dependent and can lead to higher false positives.
MOH Guidelines Prioritize Evidence-Based Screening: Since large-scale randomized trials have not proven ultrasound as an effective stand-alone screening tool, it is not included in national guidelines. However, in clinical practice, ultrasound is often recommended as an adjunct to mammography, especially for women with dense breasts.3. Why Do We Do Increasing Intervals for Mammogram Screening (Annually for 40-49 Years, Every 2 Years for 50+)?
Changes in Breast Tissue Composition: Glandular tissue appears white on mammograms, while fatty tissue appears black. As women age, glandular tissue involutes and is replaced by fatty tissue.
Challenges in Detecting Cancer in Younger Women: Since breast cancers also appear white on mammograms, they can be more easily obscured by dense glandular tissue in younger women. More frequent mammograms (annually from 40-49 years) help improve detection.
Improved Visibility in Older Women: As women age, their breasts contain more fatty tissue, providing better contrast for detecting white cancerous lesions against the black fatty tissue background. Hence, mammograms can be performed less frequently (every two years from 50 onwards).4. What is an Indeterminate Lesion?
Definition: An indeterminate lesion is a breast abnormality detected on imaging that cannot be definitively classified as benign or malignant. It requires further evaluation, which may include additional imaging (e.g., ultrasound, MRI) or biopsy.
Examples: Small solid masses, complex cysts, or lesions with ambiguous features on mammography or ultrasound.
Follow-up: Some indeterminate lesions will require further evaluation by breast specialists, while others may need biopsy to confirm the diagnosis.5. What is BI-RADS?When you undergo a mammogram, ultrasound or MRI, our radiologists categorise the findings to communicate the recommended follow up actions.Your report will likely include a BI-RADS score, which is a standardised system used to classify findings and guide recommendations. BI-RADS (Breast Imaging- Reporting and Data System) is a standardised system developed by the American College of Radiology (ACR) to categorise breast imaging findings and their level of suspicion for malignancy ranging from 0 to 6.At times, it may be difficult to classify findings into BI-RADS 0-6, so some centres use descriptive terms instead- such as benign, probably benign, indeterminate, or suspicious. This helps guide the breast surgeon on the next steps. [Ref: American College of Radiology]3D Mammogram vs 2D MammogramMammograms are X-ray images of the breast used to detect tumours or abnormalities, and are the most common screening tool for breast cancer. During a mammogram, your breasts are compressed between two plates to capture clear images. While this may be uncomfortable, mammograms are quick and generally painless.This article has been reviewed by Dr Eugene Ong, Consultant Radiologist at Luma Women’s Imaging Centre