In-house breast imaging unit at KK Breast Centre. Busting the Fear for Breast Cancer by Yah Yuen Tan Consultant Surgeon, KK Breast Centre KK Women s and Children s Hospital, Singapore Sze Yiun Teo Consultant Radiologist, Diagnostic Imaging KK Women s and Children s Hospital, Singapore www.asiabiotech.com Volume 12 > Number 7 > 2008 49
At KK Women s and Children s Hospital, the KK Breast Centre is the world s first to provide FDA-approved digital mammography services that leverages on the synergy of computer radiography and computer-aided detection. This synergy of technologies enables the radiologist to manipulate the mammogram images in real-time, be it zooming in or magnifying the image. It can also highlight breast abnormalities to the radiologist for further interpretation. Digital mammography has been proven superior to film mammography for women with dense breasts, pre and peri-menopausal women and women younger than 50 years old. Radiologist helping patient to position the breast in preparation for digital mammography. One in 17 women above the age of 40 will be diagnosed with breast cancer. Breast cancer is the number one cancer affecting Singapore women. Because of this, KK Women s and Children s hospital has a specialized team of doctors, nurses and paramedical staff dedicated to the early detection and treatment of breast cancers all of whom are housed within the KK Breast Centre. The KK Breast Centre is a onestop centre fully dedicated to looking after breast Health. The centre uses state-of-the-art breast imaging to provide digital mammography, breast ultrasonography, surgical consultation, minimally invasive biopsies and procedures all under one roof, with quick turnaround time. We take a look at two key cutting-edge technologies available at the centre. Digital Mammography Many women are not aware that regular screening for breast cancer allows the cancer to be detected early; and early detection and treatment increases the likelihood of a cure. Having a mammogram which essentially is an X-ray of the breasts done on an outpatient basis is key in picking early stage abnormalities in the breast. With the help of a radiographer (the healthcare professional performing the mammogram test), the patient positions her breast for a gentle compression from the mammogram equipment. This compression is necessary to examine maximum breast tissue. Having a mammogram done on a one- to two-yearly basis is important when a woman is more than 40 years old. Sentinel Lymph Node Biopsy When breast cancer cells move or metastasize to other parts of the body, the first lymph node that they will travel to is the sentinel lymph node one of the many lymph nodes located in the armpit. Typically, when a patient is diagnosed with breast cancer, they must undergo axillary lymph node dissection (removal of all armpit nodes) to check for the spread of cancer. This process helps to stage the cancer to check for how advanced the cancer cells have grown. Removal of armpit nodes, however, would sometimes lead to chronic swelling of the arm. To prevent unnecessary removal of armpit nodes and hence needless chronic swelling of the arm, sentinel lymph node biopsy is performed. Two medicines are first injected into the breast to track the drainage of fluid from the breasts into the armpit. These include a medicine with a very 50 Volume 12 > Number 7 > 2008 www.asiabiotech.com
The radiologist uses computer aided detection to help magnify or zoom into the mammogram images. tiny amount of radioactivity (only one-sixth of which is used in a normal bone scan) and a blue dye. At the time of operation only the sentinel nodes are retrieved with the help of those two medicines and will then be examined immediately. If these nodes are free of cancer, no further nodes are removed from the armpit. Conversely, if the sentinel nodes are not affected, the surgeon then continues to do a complete removal of underarm nodes. Because of the benefits for the patient, the sentinel lymph node biopsy is becoming the standard of care in the management of early breast cancer. Having performed more than 200 sentinel lymph node biopsies, breast surgeons at the KK Women s and Children s Hospital have also helped to train other doctors in this aspect. With the advent of modern medical science, screening methods are now less invasive and more accurate, translating into obvious benefits for patients. The high incidence rate of breast cancer should not cause panic amongst women, but should serve as a reminder for women to start regular breast screening at an appropriate age; because early detection of breast cancer is highly treatable with good clinical outcomes. Breast Cancer Facts: The Basics Causes Breast cancer, like cancer originating in other parts of the body, can occur because the cells in the tissue have undergone an irreversible change. This change has given the cells the ability to continue growing and multiplying in an uncontrolled manner. It is not clear how this change has come about. One theory is that it is the accumulative effect of an unhealthy diet and lifestyle over a long period of time. This may explain why the number of women diagnosed with breast cancer is higher in Western developed countries and modern societies, compared to the less developed and rural regions. There is no evidence that antiperspirants, underwire bras, previous injury or yearly mammograms cause breast cancer. In 5% to 10% of women, breast cancer occurs because of a genetic abnormality. This abnormality may occur spontaneously in the woman, or it may have been inherited from her ancestors. If it is an inherited genetic abnormality, there often will be other members of her extended family who may have breast cancer, ovarian cancer or other types of cancer. However, more than 80% of newly diagnosed women do not www.asiabiotech.com Volume 12 > Number 7 > 2008 51
Ultrasound of breasts is sometimes done so that the doctor can accurately locate the abnormality. have a family history of breast or other cancers. but as the cancer grows, the following symptoms may appear: a persistent lump or thickening in the breast or armpit area, changes in the color or skin of the breast, areola or nipple (example dimpling or puckering), nipple retraction or changes, or blood or discharge from the nipple. Clinical Outcomes of KK Women s and Children s Hospital for Breast Cancer The average five-year survival rates of each of these stages are as follows: Stage Clinical Outcome 0 99% I 96% II 85% III 54% IV 20% children s hospital in Asia to have received accreditation from the Joint Commission International. In 2007, more than 35,000 international patients came to seek medical treatment at KK Women s and Children s Hospital. International patients come for any of the 45 subspecialties the hospital provides for both women and children, and need not worry about logistical arrangements. The International Medical Services Department at the hospital provides assistance such as suitable doctor referral, medical appointments, medical evacuation, travel arrangements, transport and accommodation and language translators. n Risk Factors There is a higher risk of getting breast cancer if one is: above 40 years old and female, have a close relative like mother, sister or grandmother who has breast cancer, have taken hormone replacement therapy for more than five years after menopause, or have previously had certain types of abnormal breast biopsy. Breast cancer can, however, affect anyone at anytime, with or without the risk factors. It is therefore important to perform monthly breast self-examination, yearly mammogram and clinical breast examination by a medical professional. Signs and Symptoms There is usually no pain or symptom when breast cancer is its early stages, However, it is important to note that these numbers are averaged figures. Each patient is unique with multiple factors contributing to her final survival. With rapid improvements in breast cancer treatments, it is expected that these figures are improving even as you read this. These figures further emphasize that detection of breast cancer at an early stage offers the best chance of cure and survival. International Patients at KK Women s and Children s Hospital KK Women s and Children s Hospital is the only teaching hospital for pediatrics in Singapore. Focusing on subspecialty care for only women and children makes it possible for the hospital to constantly achieve excellent clinical outcomes. The hospital is also the only women s and Contact Details: KK Women s and Children s Hospital Address: 100 Bukit Timah Road Singapore 229899. Appointments for international patients, please contact us at: Tel: +65 6394 8888 (24-hour hotline) Fax: +65 6292 5145 Email: international@kkh.com.sg URL: www.kkh.com.sg 52 Volume 12 > Number 7 > 2008 www.asiabiotech.com
Picture courtesy of A.D.A.M Medical Illustration. Location of sentinel lymph node. KK breast surgeon, Dr Yah Yuen Tan, consulting a patient. About the Authors Dr Yah Yuen Tan (MBBS, FRCS (Edin), FRCS (Glasg), FRCSEd (Gen Surg), FAMS) developed a keen interest in breast diseases and cancer very early on during her training years at the Singapore General Hospital and the Tan Tock Seng Hospital. This interest has grown over the years and today she passionately believes that the standard of care for breast cancer patients in Singapore can be equivalent to that of international renowned cancer centers around the world, after spending training stints in both the US and Japan. Dr Tan is also a Fellow of the Royal College of Surgeons (Edinburgh and Glasgow). Dr Tan s sub-specialty interests include minimally invasive breast biopsy methods, sentinel lymph node biopsy for breast cancer and mammary ductoscopy. Dr Sze Yiun Teo (MBBS, FRCR (UK)) is a consultant radiologist from the Department of Diagnostic Imaging, KK Women s and Children s Hospital. She specializes in breast imaging, image-guided breast biopsy and women s imaging. She is actively involved in patient care and clinical research in these areas. In addition to her role as Fellow of the Royal College of Radiology (UK), Dr Teo is also a member of the Singapore Radiological Society as well as the American Roentgen Ray Society. www.asiabiotech.com Volume 12 > Number 7 > 2008 53