Breast cancer is the most common cancer in Malaysia. According to the Global Cancer Observatory 2020, published in March 2021, it comprised 17.3 per cent of all cancers in males and females, and 32.9 per cent of all cancers in females.
There were 8.418 new cases and 3,503 deaths reported in 2020, with a five-year prevalence of 29,453.
According to the Malaysian National Cancer Registry report for 2012-2016, published in 2019, there were 21,634 cases reported in 2012-2016 compared to 18,206 cases from 2007 to 2011.
The overall cumulative risk increased to 3.7 in 2012-2016 from 3.4 in 2007-2011. The risk for 2012-2016 was highest among Chinese (4.5) and lowest among Malays (3.4). The overall lifetime risk was one in 27 compared to 1 in 30 in 2007-2011.
Among the Chinese, it was one in 22, among Indians one in 23, and among Malays one in 30. The incidence increased after the age of 25 years with a peak at 60-64 years, and then reduced above 65 years.
Staging was reported in 13,485 cases (62.3 per cent). Of these, 47.9 per cent were detected at late stage (III & IV) which was higher than in 2007-2011 (43.2 per cent).
About half of breast cancer sufferers have no identifiable risk apart from female gender and age. The risk factors in breast cancer are non-modifiable and modifiable.
The non-modifiable risks are female gender is the most significant risk factor with only about 0.5 to 1 per cent of breast cancers occurring in men; increasing age, particularly more than 50 years; and family history of inherited “high penetrance” mutations increases the risk markedly, the most dominant being BRCA1, BRCA2, and PALB2 gene mutations.
These mutations occur in a limited number of women and when it does, there is also an increased risk of ovarian cancer. Lack of a family history does not mean that there is a reduced risk.
Other risk factors include family history of breast cancer especially at a young age, early menarche, late menopause, and previous breast cancer.
The modifiable risks include nulliparity, breastfeeding, obesity, physical inactivity, tobacco smoke exposure, alcohol abuse, prolonged hormone therapy, and excessive radiation exposure.
Behavioural choices and interventions that reduce the risk of breast cancer include prolonged breastfeeding, regular physical activity, weight control, and avoidance of exposure to tobacco, harmful use of alcohol, prolonged hormone therapy, and excessive radiation exposure. If all the potential modifiable risk factors are controlled, this would regrettably reduce the risk of breast cancer by at most 30%.
Women who have BRCA1, BRCA2, and PALB2 genes could contemplate risk reduction like surgical removal of both breasts. The consideration of such a highly invasive procedure affects a very limited number of women, have to be evaluated carefully and should not be rushed.
Breast cancer can cause bodily changes. As every individual’s body is different, it is important to know what is normal for one’s body. This includes the look and feel of the breasts.
Breast cancer can cause changes in the breasts, nipples, armpits and the skin in these areas. The symptoms include a breast lump or thickening, alteration in the size, shape, or appearance of a breast, dimpling, redness, pitting, or other alteration in the skin, change in nipple appearance or alteration in the skin surrounding the nipple (areola), and/or abnormal nipple discharge.
Breast cancer most commonly presents as a painless lump or thickening in the breast. There are many reasons for the development of breast lumps.
In fact, about 90 per cent of breast lumps are not cancerous and include conditions like cysts, fibroadenomas, and infections. It is vital for anyone with a breast lump to consult a doctor without delay even if there is no associated pain.
The early seeking of medical attention at the first sign of a potential symptom permits more successful treatment.
Every woman should be familiar with their breasts, particularly older women, as the risk of breast cancer increases with age. This can be done by using a mirror to know the usual look and shape of the breasts, becoming familiar with how the breasts feel at different times of the month (this can be done in the shower, lying in bed, or getting dressed), feeling from the collarbone to under the breasts and armpit, and feeling near the surface and deeper in the breasts.
The things to look for include lump(s) in the breasts or armpits, changes in the skin of the breasts, i.e. dimple, puckering, or redness; nipple changes, i.e. pointing in when it used to point out or unusual discharge, an area that feels different from the rest of the breast, and unusual pain.
A consultation with the doctor is advisable as soon as possible if any changes are noticed, or if there are any worries. Many of the changes are not due to breast cancer but it is best to consult the doctor about what is happening.
Breast screening can detect cancers that are too small to see or feel. This helps in early detection and better treatment results if there is breast cancer.
There are clinical practice guidelines for screening mammography in Malaysian women:
- It may be performed biennially in women aged 50 to 74 years in the general population, i.e. no personal or family history of breast cancer.
- In women at high risk of breast cancer, where no genetic variant has been identified, i.e. first-degree relative of gene carriers who have not been tested, personal or family history of breast cancer, screening mammography may be considered between 30 and 39 years of age, performed annually from 40 to 59 years, and biennially from 60 years onwards.
- In carriers of BRCA1, BRCA2, and PALB2 genes, annual magnetic resonance imaging (MRI) should be offered from 30 to 49 years of age, annual mammography from 40 to 69 years, and biennial mammography from 70 years onwards.
- Referrals should be made to a surgical or breast clinic early (within two weeks) for further evaluation if there are signs and symptoms in women aged more than 35 years or in high-risk women, and if there are signs of cancer.
Where there are no mammography facilities, breast ultrasound can be used for screening, as it has a reported diagnostic sensitivity of about 89 per cent and specificity of about 99 per cent.
The WHO Global Breast Cancer Initiative (GBCI)’s objective is to reduce global breast cancer mortality by 2.5 per cent per year, thereby averting 2.5 million breast cancer deaths globally between 2020 and 2040.
This mortality reduction would avert 25 per cent of breast cancer deaths by 2030 and 40% by 2040 among women under 70 years of age.
The GBCI’s pillars toward achieving these objectives are health promotion for early detection, timely diagnosis, and comprehensive breast cancer management.
As just under 50 per cent of all breast cancers are diagnosed late in Malaysia, efforts must be stepped up for early detection and diagnosis.
Dr Milton Lum is a Past President of the Federation of Private Medical Associations, Malaysia and the Malaysian Medical Association. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.
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