Health & Fitness

Tuesday October 20, 2009

Fighting The Disease

By Punitha Yogaratnam

One of the most commonest cancer afflicting Malaysian women is breast cancer. According to the Malaysian Oncological Society, one in 19 women in this country is at risk of this disease. Despite that, most women are not taking the necessary precautions to detect breast cancer.

The Breast Cancer Welfare Association says early detection is the key to fighting breast cancer. And one of the ways a woman can do this is to perform a monthly breast self examination.

However, Professor Dr. Yip Cheng Har from the Department of Surgery, University Malaya Medical Centre, Kuala Lumpur says that most women do not practice BSE monthly or they do it wrongly. "There are many pamphlets (on the subject) available over the Internet. However a lot of women are still doing it wrongly. They find lumps which are not lumps, or they do not find lumps when there is a lump," she says.

In an interview, Prof Yip, who started the breast clinic in UMMC in 1993, says that a woman should begin practicing BSE at the age of 20 and that a woman at the age of 40 and above should have a mammogram once in two years.

What are the various techniques available in Malaysia to detect breast cancer?

Prof Yip: There are three methods of early detection – breast self examination, clinical breast examination and screening mammography which is only done at the age of 40 and above. Screening ultrasound is not recommended because there are many false positives – ultrasound shows a lot of abnormalities which are harmless and this could worry the woman unnecessarily.

What is breast cancer?

Breast cancer is a malignant tumor that arises from the cells of the breast. A malignant tumor (or cancer) occurs when normal cells become abnormal and start dividing without any control, and when it grows it may invade into the surrounding tissue and into the blood and lymphatic vessels and hence spread to the lymph nodes under the armpit and also to other organs in the body such as the lungs, liver and bones.

Do you see a rise in breast cancer patients today compared to two or three years ago?

I do in UMMC, but this does not mean there is an actual rise in numbers. It just could mean that more people are hearing of our breast unit and we are getting more patients. According to the National Cancer Registry from 2002-2005, there is no increase for those years. Unfortunately there is no data after 2005.

Why is it there is no data after 2005?

The National Cancer Registry was stopped and the cancer registration is now regional instead of national so each state has its own cancer registry. So far we have not had any reports yet. This is under the Ministry of Health. It is not mandatory to report cancers so reporting is done voluntarily and it can be a problem getting data. However, we estimate there are around 4,000 new cases per year.

What are the various types of treatments available to Malaysian women with these disease?

We have all the treatments available here – surgery, chemotherapy, radiotherapy, hormone therapy and targeted therapy such as herceptin. The Health Technology Unit in the Ministry of Health is currently updating the clinical practice guidelines for the management of breast cancer. These are evidence based guidelines and it provides guidance on the best method of treating the disease.

What is the best method to diagnose the disease?

Screening mammogram may detect the cancer early before a lump is felt and hence prognosis for the woman will be excellent.

Do you think the average Malaysian woman has enough information on breast cancer?

The average Malaysian woman can read about the disease everywhere – newspapers, in magazines, hear it on the radio and see it on TV. There are also a number of celebrities with breast cancer, so information is not lacking.

Is there a concern than that more Malaysian women are not performing breast self examinations?

Since the Shanghai BSE study in 2002, where it was reported that breast self examination was not shown to reduce the mortality rate from breast cancer, most Western countries have removed BSE from their guidelines on early detection. However in Malaysia, where women do not see a doctor to examine their breast (clinical breast examination) and there is no mammogram screening, we still encourage women to examine their breast. But most women do not practice BSE monthly.

Is early detection for the disease lacking in this country? Do you think enough is being done to educate young women about breast cancer and its effect?

Early detection is certainly lacking, and education is required. There are a lot of educational activities going on, but we really need to study the barriers to early detection – why women can have a lump for months before gathering up the courage to see a doctor, and why women prefer to seek alternative therapy before conventional medicine.

What do you think the outlook is for Malaysian women and this disease?

The prognosis for women is excellent when they are diagnosed with Stage 1 breast cancer. Over 90 percent will have a five-year survival rate. Unfortunately, most women are diagnosed when they are in Stage 2 (in UMMC) and in some parts of the country 50 percent are only diagnosed when they are in Stage 3 and Stage 4.

In a newspaper article earlier this year you said that the challenge in Malaysia is to have comprehensive services on the diagnosis and treatment of breast cancer. Can you elaborate and what kind of services were you referring to?

Breast cancer is multidisciplinary – the surgeon alone cannot do everything – you need the radiologist and the pathologist together with the surgeon to make the diagnosis, and after that you need the oncologist for chemotherapy / radiotherapy.

Along the way, we need the breast care nurse, counselor, plastic surgeon, psycho-oncologist, physiotherapy, rehabilitation specialist – all to offer a "package" for the woman with breast cancer. The ideal situation would be to have a breast clinic, where a woman who has a breast symptom can walk in, see the surgeon, have a mammogram or ultrasound done depending on the age, biopsy if there is a lump – all to be done in the same clinic visit, and in some countries overseas, the result is available the same day.

I attended a meeting in Korea, where an American nurse gave a lecture on quality issues in breast cancer care, and she maintains that NO woman should have no more than ONE sleepless night waiting for a biopsy result. In the private sector, perhaps we can achieve this, but certainly not in a busy government clinic.

Are there any drugs or clinical trials available in Malaysia for those diagnosed with breast cancer?

All drugs for routine treatment of breast cancer is available, but the newer ones may be too expensive for the average woman to afford. We do conduct a lot of clinical trials on breast cancer – these trials are usually international and multicentric. This means it is carried out in hundreds of centres to recruit enough patients to be able to analyse whether a new treatment is more effective than the standard treatment. The current trial for early breast cancer we are doing is the Beatrice trial where a new drug called Avastin is given for a year to women with early breast cancer which are triple negative (that is the estrogen and progesterone receptors are negative, and HER2 is negative).

This is randomized to either Avastin or no Avastin and these women are followed up to see which group does better. Over 3,000 women have been recruited world wide and recruitment have been stopped. The results will be ready in five years' time.