What are the key factors that contribute to breast cancer risk, and how can individuals reduce their risk through lifestyle choices?
Several risk factors have been established to increase one's risk of developing breast cancer, and these can be divided into modifiable and non-modifiable factors:
a. Non-modifiable risk factors include increasing age, female gender, personal or family history of breast cancer, early menarche, late menopause, having dense breasts, and people with a previous history of neoplastic disease of the breast, i.e., previous history of carcinoma in situ or atypical hyperplasia of the breast. Other factors, such as exposure to therapeutic radiation to the chest at an early age, usually for the treatment of Hodgkin's lymphoma, can also increase the risk of developing breast cancer.
b. On the other hand, modifiable risk factors are those that can be altered through lifestyle changes. Among the modifiable risk factors are nulliparity, lack of breastfeeding, older age at first childbirth (35 years and above), use of oral contraceptive pills, combined hormone replacement therapy in postmenopausal women, obesity, sedentary lifestyle, smoking, and alcohol consumption. By being aware of the modifiable risk factors, women can make conscious decisions and alter their lifestyles to avoid these risk factors.
What are the recommended guidelines for breast cancer screenings, and how effective are they in detecting the disease at early stages?
Screening is done on people without any symptoms. The age to start screening depends on the risk of developing breast cancer, and this can be categorised into average risk, moderate risk, and high risk, where the lifetime risks of developing breast cancer are 12.4%, 15-20%, and more than 20%, respectively.
Major risk factors that are used to determine a woman's risk category include a personal or family history of breast, ovarian, or peritoneal cancer, associated BRCA1/BRCA2 mutations, a known carrier of a mutated gene for hereditary breast or ovarian cancer syndrome in self or relative; previous breast biopsy showing a high-risk lesion e.g., atypical hyperplasia, reproductive factors; and radiation therapy to the chest. In the absence of any of these factors, a woman falls under the average risk category, and screening mammography is recommended for women aged 50-74 years, performed every 2 years.
For women with moderate risk (those with a family history of breast cancer in a first-degree relative but do not have a genetic syndrome), screening mammography should be performed annually from age 40-49 years and annually or biennially from age 50-59 and every 3 years from 60 onwards.
As for women of high risk (those with a known personal or family history of BRCA gene mutation or inherited cancer syndromes, strong family history of breast or ovarian cancer, and a history of chest radiation at a young age), annual MRI breast is recommended at the age of 30-49 years, annual mammography from age 40-69, and a mammogram every 3 years from age 70 onwards.
Screening not only plays a major role in detecting cancer in the early stage even before a person develops any symptoms but also detects a pre-invasive lesion where cancer has not yet developed. At the early and pre-invasive stages, a cure is definite as it is easier to treat.
Are there any new technologies or techniques in breast cancer detection that show promise in improving early diagnosis?
Mammography is the best-studied and the only imaging modality that has been shown to reduce breast cancer mortality. Mammography is available as screen-film mammography, digital mammography, and digital breast tomosynthesis (also known as 3D mammography).
Digital breast tomosynthesis (DBT) is a new screening and diagnostic breast imaging tool to improve the early detection of breast cancer. Several meta-analyses have shown that DBT plus full-field digital mammography (FFDM) yielded higher detection rates for breast cancer in asymptomatic women compared to FFDM alone.
Therefore, digital breast tomosynthesis is recommended in the screening and diagnosis of breast cancer, but its usage is limited by its availability.
What are the challenges or barriers that prevent certain communities from accessing breast cancer screenings and healthcare resources, and how can these be addressed?
A study conducted on Malaysian women revealed that 7 out of 10 women believe breast cancer screening should only be pursued when they experience symptoms. This lack of awareness regarding screening guidelines and the true purpose of screening represents a significant barrier that hinders women from getting screened.
Beliefs about health and illness can profoundly impact health behaviours. A person's beliefs and cognition play a crucial role in determining how they respond to health recommendations, either positively or negatively. Positive beliefs about the benefits of early cancer detection increase the likelihood of healthcare-seeking behaviours, such as regular screening. Conversely, negative beliefs associated with breast cancer can lead to delayed presentation, even when a person experiences symptoms. Some women also experience anxiety about the screening procedure, which may lead them to avoid it altogether. The word "cancer" itself often evokes feelings of fear and thoughts of mortality, discouraging many women from addressing the issue.
Further, lower attendance in screening mammograms is observed among individuals with lower education and socioeconomic status. Emotional and financial barriers, such as the fear of diagnosis and losing a breast, as well as concerns about the associated costs, are commonly reported obstacles to screening.
To improve screening behaviour and promote early detection, it is essential to identify and address negative beliefs, raise awareness, and provide knowledge about breast cancer through effective public health strategies. By doing so, we can enhance screening rates, ultimately leading to earlier detection, improved treatment outcomes, and increased survival rates for breast cancer patients.
Can you provide examples of successful community programmes or initiatives that have effectively promoted breast health education and early detection?
The Breast Cancer Welfare Association (BCWA) of Malaysia is an NGO dedicated to providing breast health education and breast cancer screening services to women in the community. Their Breast Health Awareness Programme aims to raise awareness about breast cancer and encourages women to conduct breast self-examinations (BSE). It also advocates for clinical breast examinations (CBE) for women above 40 and mammograms for women above 50.
To make mammograms more accessible, the Ministry of Women, Family, and Community Development offers an RM50 subsidy for eligible women.
Additionally, the National Cancer Society Malaysia conducts a Free Community Outreach Programme that provides free screening to underprivileged communities, further supporting early detection efforts.
Furthermore, the Mammogram Subsidy Programme, initiated by the Government, promotes early detection of breast cancer by offering women the opportunity to have mammograms at registered private mammogram centres associated with Lembaga Penduduk Dan Pembangunan Keluarga Negara (LPPKN).
How can individuals become more proactive in monitoring their breast health and performing self-examinations? What are the key signs and symptoms to watch out for?
It is crucial for women to maintain vigilance regarding their overall breast health and to be self-aware, promptly noticing any abnormalities in their breasts and performing regular breast self-examinations. If any abnormality is detected, seeking immediate medical attention is essential.
Women should be particularly concerned about signs and symptoms such as a lump in the breast or axilla, which may be painful or painless, changes in the breast skin like redness, dimpling, or thickening, alterations in the nipple, such as a retracted nipple or nipple discharge, and changes in the shape of the breast. Being vigilant and proactive in recognising these changes can lead to early detection and timely medical intervention, potentially improving outcomes in breast health.
Are there any specific lifestyle changes or habits that have been shown to reduce the risk of breast cancer? How can these be incorporated into everyday life?
Lifestyle changes have proven to be effective in reducing the risk of breast cancer in women at risk and those who have been diagnosed, to prevent recurrence. Recent reports indicate that successful lifestyle modifications can potentially prevent 25-30% of breast cancer cases.
These lifestyle changes encompass various aspects, including dietary adjustments, smoking cessation, abstaining from alcohol consumption, maintaining a healthy weight, and adopting an active lifestyle that involves regular physical exercise.
Regular exercise, in particular, plays a crucial role in lowering breast cancer risk by influencing hormones such as oestrogen, insulin, and insulin-like growth factor 1 (IGF-1), which can have a positive impact on other risk factors like obesity and insulin resistance. By incorporating these lifestyle adjustments, women can take proactive steps to safeguard their breast health and overall well-being.
What role does genetic testing play in assessing breast cancer risk, and how can individuals make informed decisions about genetic testing?
Genetic testing aims to identify cancer predisposition genes. Individuals with pathogenic/likely pathogenic variants in BRCA1 and BRCA2 face an increased risk of breast, ovarian, and other related cancers. In cases where the BRCA gene is mutated, the lifetime risk of developing breast cancer is 45-85%, and for ovarian cancer, it is 10-45%.
Women with a strong family history of breast and/or ovarian cancer, who are concerned about hereditary breast cancer, have the option to undergo genetic testing. The presence of any one of the following criteria is used to identify at-risk individuals for genetic testing: ovarian cancer, breast cancer diagnosed at age ≤ 45 years, 2 family members with breast cancer both diagnosed at age ≤60 years, triple-negative breast cancer diagnosed at age ≤60, male breast cancer, and being diagnosed with breast cancer plus a parent, sibling, or child. The risk of being a carrier increases with the number of affected family members, the closeness of the relative, and the age at which the relative is diagnosed.
Individuals meeting any of the mentioned criteria for one or more hereditary cancer syndromes should consider having genetic testing along with pre-test counselling. Post-test counselling is essential for individuals detected to have pathogenic/likely pathogenic BRCA1 and BRCA2 genes, which includes screening, risk-reducing surgeries, and chemoprevention. By being aware of their cancer risks, women can make informed decisions regarding risk-reducing surgeries and address the psychosocial effects that accompany them.
Are there any disparities in breast cancer survival rates based on socioeconomic factors or access to healthcare? How can these disparities be addressed to ensure equal outcomes for all?
Regrettably, there exists a significant disparity in breast cancer survival rates among patients from different socioeconomic groups. Data compiled by Cancer Research Malaysia (CRM) reveals that high-income breast cancer patients in Malaysia have a survival rate of over 90%, whereas low-income patients have a survival rate of 65%. In general, low-income patients are nearly twice as likely to succumb to breast cancer each year, primarily due to delayed diagnosis and limited access to treatment.
Various factors have been identified as contributing to better survival rates in the high-income group. These include greater breast cancer awareness, higher attendance for screening leading to early detection, access to private healthcare and targeted therapies, and higher compliance with prescribed treatment.
Conversely, the low-income group is found to lack awareness, with less than 10% attending the screening, resulting in late-stage disease presentation. Additionally, they tend to seek second opinions from alternative/traditional medication and have limited or no access to targeted therapies. Some women may initially seek healthcare from primary care doctors, highlighting the importance of enhancing the skills of primary care doctors to promptly refer women with suspected breast cancer, thereby increasing early detection rates.
Finally, improving public healthcare funding to extend the availability of targeted therapy for low-income patients in need will significantly enhance breast cancer outcomes in this group.
For more information on Sri Kota Specialist Medical Centre (SKSMC) and the treatment options available, kindly visit: https://www.srikotamedical.com/
Dr. Ina Shaliny
Consultant Clinical Oncologist
