What is Preventive Mastectomy and Who Should Consider It?

Does a family history of breast cancer put you at a higher risk of getting the disease?We speak with Dr Tan Yah Yuen, Senior Consultant and Breast Surgeon about preventive mastectomy for individuals with elevated risk of breast cancer.What is preventive mastectomy and can I remove a single breast?Preventive mastectomy (or risk-reducing mastectomy) is surgery that is done to remove one or both breasts to reduce the risk of developing breast cancer. All of the breast tissue is removed, maintaining the skin overlying the breast, and may include maintaining the nipple and areola. This is followed by an immediate breast reconstruction.By definition, a mastectomy means the removal of the entire breast. A partial removal of the breast will not be suitable if the aim is to reduce the long-term risk of cancer, which can occur in any part of the breast.For risk-reducing mastectomy, the nipple and original skin of the breast can be conserved, together with immediate reconstruction. This will restore the appearance of the breasts to as near normal as possible.Who should consider risk-reducing mastectomy?Women who are at significantly elevated risk of breast cancer may consider preventive or risk-reducing mastectomy.These include:Women with BRCA 1 or 2 genetic mutations where the life time risk of breast cancer can be as high as 70- 85%. Women with biopsy-proven breast abnormalities that place them at a significantly higher life time risk of breast cancer e.g. lobular carcinoma in situ, atypical ductal hyperplasia, atypical lobular hyperplasia etc. The risk of breast cancer in this group varies from 20-50%, generally not as high as BRCA gene mutations. For women with a strong family history of breast cancer but without BRCA gene mutations, it is debatable whether they should consider risk-reducing mastectomy. It is best for these women to have a discussion with their breast specialist about their individual risk and circumstances.Are there many women who consider risk-reducing mastectomy? How old are they?A majority of the patients who consider risk-reducing mastectomy are fairly young, with ages ranging from mid 30s-50s.Is risk-reducing mastectomy considered a last-resort measure?Rather than a looking at risk reducing mastectomy as a last resort, risk-reducing mastectomy should be seen as a pro-active, self-empowered decision on the woman’s part to reduce her life time risk of breast cancer.  This frees her from the constant psychological burden of elevated breast cancer risk, and the desire to be in control of their own fate outweighs their fear or anxiety of the surgery.How does risk-reducing mastectomy help women with elevated risks of breast cancer?A risk-reducing mastectomy will reduce a woman’s risk of breast cancer by at least 90%.  Hence, if a woman with a BRCA1 gene mutation who has a 70% lifetime risk of breast cancer undergoes bilateral risk-reducing mastectomy, her risk of breast cancer will be reduced to 7%.  This is a very significant reduction.The reduction in risk cannot be 100% because there is usually a very small amount of residual breast tissue in the nipple, under the skin or peripheral chest wall that cannot be completely removed. Hence the term “risk-reducing” is preferred over “preventive”.It is important to note that for women who choose double mastectomy when a breast cancer has already been diagnosed, the surgery does not eliminate or reduce the risk of distant organ relapse of the original breast cancer.Aside from risk-reducing mastectomy, what other options are there for women with high-risk factors/family history?A non-surgical option to reduce one’s risk is chemoprevention, which is the use of oral medication to prevent cancer. The risk of breast cancer is estimated to be halved with chemoprevention.  However, the medication is associated with side effects and as such, is not a popular option among women.A woman may also opt for high-risk surveillance. This allows for early detection but technically does not reduce one’s risk.  High-risk surveillance includes a yearly MRI of the breasts, in addition to mammogram and ultrasound.Leading a healthy lifestyle may modify one’s risk – this includes a healthy diet comprising plenty of fresh fruits and vegetables, reducing consumption of processed and red meats and reducing alcohol intake. Regular exercise and avoiding weight gain can also modify a woman’s risk of breast cancer.When can reconstructive surgery take place? Can it be done during the mastectomy itself? Are there different types of reconstruction surgeries available? Reconstruction of the breasts is preferably done at the same time as the mastectomy. This will achieve the most favourable aesthetic outcome.Reconstruction for double mastectomy is ideally performed with silicone implants, which will result in a symmetrical appearance of the reconstructed breasts.Alternatively, women may opt for reconstruction using their own body tissue (autologous) such as tummy fat, or back muscle.  For women with small-volume breasts, sometimes fat transfer using liposuction alone may even be sufficient for reconstruction.How has reconstructive surgery helped your patients in their daily lives? Reconstruction is definitely very helpful for women to move on after a single or double mastectomy.  It restores her body image and allows her to dress and carry out her daily activities including sports without worrying about appearance.Because of improved reconstruction techniques in recent years, this has made risk-reducing mastectomy more acceptable.Do you have any advice to give to women who are scared or too busy to take charge of their breast health? Women should not be scared to, or say they are too busy to take charge of their breast health.  After all, health is most important thing in our lives.Breast cancer is a very curable disease and the key is early detection and treatment. Hence, breast cancer screening is very important and I advise women to be pro-active in taking charge of their breast health. Screening will really make all the difference.Article contributed and reviewed by Dr Tan Yah Yuen, Senior Consultant and Breast Surgeon at Solis Breast Care & Surgery 
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4 Things You Need to Know About Oncoplastic Breast Surgery

Cancer in Singapore has been on the rise, with breast cancer being the most common cancer among women here. It accounted for 29.7% of total female cancer cases from 2016-2020, according to the Singapore Cancer Registry Annual Report 2020. Most patients with breast cancer will require surgery to remove the cancer cells. The good news is that mastectomy is not the only surgical option.Breast-conserving surgery such as oncoplastic breast surgery[1] enables patients to preserve their breasts, maintaining their quality of life, with proper removal of the cancer tissue for treatment. Oncoplastic breast surgery is also increasingly being used for large tumours[2]. Many clinical studies have shown that the overall and disease-free survival rates of oncoplastic breast surgery are equivalent to those of mastectomy[3].How does oncoplastic surgery achieve the above goals? The first step is the removal of the breast cancer from the breast. Following this plastic surgery techniques are performed to either reshape the remaining breast tissue into a smaller but normal breast, or tissue from areas around the breast (below the breast or from the side of the breast) is used to fill the space created by the cancer removal. A trained oncoplastic breast surgeon can do all of that. Occasionally, for more complex cases, a plastic surgeon may be part of the surgical team.Oncoplastic surgery with radiation equals mastectomy survival ratesAccording to a Swedish study of 48,986 Swedish women diagnosed with early-stage breast cancer and who had breast cancer surgery from 2008 to 2017, the five-year breast cancer-specific survival rates by surgery group were 98.2% for those who had a lumpectomy with radiation. The research was published online on May 2021 by the journal JAMA Surgery[4].Improves patients’ quality of life and pleasureOncoplastic surgery, also offers several positives when compared to a mastectomy. As the surgical procedure combines cancer resection with plastic surgery techniques to reshape the breast for a final aesthetic outcome, it allows the woman to retain her breast. The retained breast can fit into the patient’s bra, enabling her to move and feel the reconstructed breast as part of her body.Oncoplastic surgery, used to address both medical and aesthetic concerns has also been shown to significantly improve the long-term wellbeing of women. As it is a less radical form of surgery, surgical trauma and morbidity to breast cancer patients are minimised.The results of a survey research published in the International Open Access Journal of the American Society of Plastic Surgeons[5] revealed that 89% of participants rated oncoplastic surgery as better than mastectomy. At the same time, the research also reported high outcome scores for breast appearance, physical and emotional wellbeing even after the procedure had been done for 15 years.Oncoplastic surgery preserves the breast by correcting the lumpectomy defectIn oncoplastic surgery, the oncoplastic breast surgeon pays attention to the shape and appearance of the breast. Patients’ breasts will usually retain sensation as most of their natural breast tissue is preserved after the surgery.As the breast specialist can also remove more tissue in oncoplastic surgery than with lumpectomy alone, this is more likely to result in cleaner margins[6]. In addition, for larger-breasted women who undergo a breast reduction as part of oncoplastic surgery, having less breast tissue may lower the risk of cancer recurrence and make future breast screenings easier[7].Similar to a regular lumpectomy, the breast specialist performing oncoplastic surgery will send the removed tumour for pathology testing. The pathologist will make sure that the breast specialist achieves clean margins. Having a clean margins test[8] means that no cancer is present at the edges of the rim of healthy tissue, which was removed along with the tumour, by the surgeon.Single surgery, single recovery periodWith oncoplastic surgery, everything can be done in a single operation/procedure. This includes the removal of the breast cancer, with immediate partial reconstruction using the patient’s remaining breast tissue, or neighbouring tissue. Patients generally take about four to six weeks to recover and strenuous activities should be avoided during this period.Are you interested to learn more about oncoplastic breast surgery? Our breast specialists at Solis Breast Care and Surgery Centre will guide you every step of the way. Schedule an appointment with us right away by clicking here.[1] PubMed.gov, Oncoplastic breast surgery: comprehensive review[2] PubMed.gov, Oncological advantages of oncoplastic breast-conserving surgery in treatment of early breast cancer[3] National Library of Medicine, Recurrence and survival after standard versus oncoplastic breast-conserving surgery for breast cancer[4]Breast Cancer.org, Lumpectomy Plus Radiation Offers Better Survival Rates Than Mastectomy for Early-Stage Breast Cancer[5] National Library of Medicine, Patient-Reported Outcomes Are Better after Oncoplastic Breast Conservation than after Mastectomy and Autologous Reconstruction[6] Breast Cancer.org, Reconstruction After Lumpectomy[7] Breast Cancer.org, Reconstruction After Lumpectomy[8] Breast Cancer.org, Reconstruction After LumpectomyOther References:1)    SingHealth Duke-NUS Breast Centre, SingHealth, Oncoplastic breast surgery2)    PubMed.gov, Oncoplastic breast surgery: comprehensive review
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Detecting Breast Lumps Earlier with 3D Scans

Breast scans in 3D – New technology offers more accurate detection of breast cancerMammograms help women detect breast cancer early, often when a tumour is too tiny to feel. In Singapore, most standard mammograms are in 2D, where two X-ray pictures are taken of each breast from two different angles.Now, new technology offers a three-dimensional view of each breast, allowing doctors to pinpoint problems more accurately.3D mammography is an advanced form of breast screening where x-rays along a continuous arc are captured and reconstructed by computer into digital images. It is similar to CT scans in which a series of thin photographic ‘slices’ are assembled together to create a 3D reconstruction of the breast.This new technology is expected to help in the earlier detection of breast tumours that may not be clear on conventional mammograms. This is because 3D imaging provides clearer slices abnormalities at different depths within the breast tissue which appear as overlapping structures on 2D imaging.“Breasts are made up of milk ducts, glands and supportive breast tissue as well as fatty tissue. Dense breasts consist of more glandular tissue than fatty tissue,” explained Consultant Radiologist Dr Eugene Ong, Director of Luma Women’s Imaging Centre, “Dense tissue and tumours both appear white on a traditional mammogram. Tumours may be camouflaged when projected over the white background of overlapping glandular tissue and may not be detected on 2D imaging as a result. 3D mammography allows doctors to see through the dense areas. Many scientific papers show definite benefit in breast cancer detection over standard 2D mammograms.” - Dr Eugene OngThe screening process is also different. During a 2D mammogram, a technician will compress each breast between two transparent plates to spread out the breast tissue and make it as uniform as possible. Many women find the breast compression uncomfortable and even painful.In a 3D screening, less pressure is needed. Patients who have experienced 2D mammography in the past now report less discomfort during 3D imaging. An imaging arm moves in an arc over the breast, continuously taking many x-rays from different angles.Risks from the procedure are minimal. All mammograms emit radiation but the doses are very low and well within safety guidelines. Some of the newer 3D machines even use less radiation than the older 2D machines.With breast cancer accounting for almost 30% of all female cancers in Singapore, the Health Promotion Board recommends that women over the age of 40 should schedule annual mammograms after consulting a doctor on the benefits and limitations of mammogram at this age. Women above 50 years old should have a mammogram once every two years. It is advisable for women with a family history of ovarian and breast cancer to consult a doctor to discuss their risk factors and earlier screening if required. Early detection and treatment of breast cancer provide better outcomes for beating the disease.Other than going for breast imaging as part of a breast cancer screening program, new ways of screening for breast cancer are being developed. With the advancement of science, breast cancer can now be identified through a blood test, MastoCheck. It is a test that identifies specific proteins that indicate the probability of early breast cancer in the body. MastoCheck coupled with breast imaging increases the sensitivity and accuracy of early breast cancer detection.Article contributed and reviewed by Solis Breast Care and Surgery Centre and Luma Women’s Imaging Centre.
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