The estimated lifetime risk of a woman being diagnosed with breast cancer in the United States of America is approximately 12%, with one in 38 dying from this disease. The earlier a woman is diagnosed with breast cancer and receives surgery, the better her chance of surviving over a long period of time. Breast diseases may occur with a spectrum of symptoms, from a symptomless breast lump to a lump with the symptoms of inflammation to a breast with a large or fungating mass. Risk factors for breast cancer are largely divided into modifiable and non-modifiable, with the single most significant being the presence of a relevant breast cancer gene. The interest in breast sarcoma has been piqued recently with the availability of a readily accessible blood test for Phyllodes tumor and recent findings of mutations in Phyllodes tumor. More commonly, patients present with benign breast diseases such as fibroadenomas, fibrocystic disease, and fibrocystic change, and require investigation with imaging studies. These patients require surgery to allay their fears or, in the rare instance, for histology.
Breast diseases may present either with symptoms or symptomless features, with or without risk of breast cancer. The modification of risk factors is necessary to avoid, delay, or improve outcomes of these diseases. It is essential that general practitioners and other non-breast-related healthcare professionals—looking after the newborn, children, and adults—identify individuals with a symptomatic or suspicious breast mass for malignancy and refer them to the well-established specialist breast unit. Likewise, clinicians should also refer all individuals with symptomless breast masses, together with women with bilateral breast pain or men with enlarged male breasts, to the breast specialists. Healthcare professionals involved in the management of breast diseases affect not only the outcomes of breast diseases but also the behavior and understanding of patients towards their treatments. The interest in this particular topic will provide a comprehensive picture of how breast disease specialist care is by far the most efficient way to treat breast diseases compared to all recent advancements in the treatment of breast diseases.
Common Types and Symptoms
Breast diseases are not uncommon in the Singapore population. The burden of breast diseases on the healthcare system in Singapore varies considerably, with breast cancer being the most common. It is also the leading cancer affecting women in Singapore. The proportion of young women with breast diseases requiring surgical intervention is also increasing. In particular, slowly growing tumors and non-cancerous cysts, as well as inflammatory breast skin conditions, are the most commonly reported. As most breast diseases occur at a time when women are usually at work and are in the midst of making families, there is a significant impact on the individual, family, and the community. Breast diseases generally range from benign conditions to breast cancer to inflammatory conditions.
Benign breast conditions may present as lumps over the breast or armpit, breast pain, mammary discharge, and breast lumps that are associated with signs of infection. Benign lumps may or may not be tender to touch. Breast cancer is the second most common cancer that affects women worldwide and the most frequently diagnosed cancer in women in developed countries. It is also one of the leading causes of cancer deaths in developed countries, including Singapore. Patients with breast cancer may commonly present as painless, hard, and irregular breast lumps that are stuck to the surrounding tissues. They may also notice redness or tethering of the skin over the lump, or a lump in the armpit area, breast pain, or redness. Dimpling of the skin or inverted nipple may also be a sign of advanced breast cancer. For common types of breast diseases, early diagnosis is important. Public awareness of these symptoms guides who should have a diagnostic test or treatment, when to do it, and makes it easier for healthcare practitioners to initiate appropriate therapy. Although watchful waiting is an option for some benign breast conditions, specialists should consider rapid and appropriate treatment. Regular breast health check-ups by the individual or healthcare professional can help detect breast disease in the early stage. The advice and information provided are essential for women in our community.
Diagnostic Techniques
Diagnosis is a critical part of the management of various breast conditions. It is perhaps the most important part of the jigsaw when it comes to breast cancer. The ideal situation is to diagnose the problem at its earliest, smallest form, or stage to ensure better chances of curing the disease. With the advancement of not only the diagnostic modalities and technologies, but also the understanding of breast conditions, better diagnostic techniques have definitely evolved over the years. Diagnosis generally involves taking a detailed history and performing a good clinical examination. Investigations to confirm or exclude the diagnosis or simply to investigate further the nature of the problem could involve any of the following: imaging, laboratory tests, or biopsy.
Clinical examination is important in the diagnosis of breast cancer. However, the diagnostic accuracy is not very good. Biopsies not only help in confirming the diagnosis, but are very important in guiding the treatment. The prognosis of breast cancer tends to be associated with the size of a palpable mass and the stage of the disease at diagnosis. A negative biopsy will reduce the anxiety of many patients as well as prevent unwarranted surgical interventions. Imaging plays a crucial role in aiding diagnosis. Imaging should be used to help clarify the nature of clinical and/or pathological abnormalities already detected. Breast imaging can also be utilized in generalized screening of high-risk populations, again to detect subtle lesions not presenting clinically. Advanced imaging technologies have been shown to improve diagnostic accuracy and specificity in the early detection of breast malignancy. Imaging, while having a relatively high false positive rate, can be used to detect non-palpable breast conditions. Magnetic resonance imaging has been used as a means to detect multifocal cancer in the contralateral breast in patients with a known diagnosis of breast cancer; however, the high false positive rate will depend on the experience of the radiologists involved. Overall, all the imaging techniques will give a higher rate of sensitivity than clinical examination. Depending on the experience of the individual centers, which is often multidisciplinary, this will usually result in a reduction of the need for a second look with the potential of reducing patient anxiety.
Imaging Technologies
Imaging technologies are crucial for diagnosing breast diseases. Early detection of abnormalities has a profound impact on the patient’s prognosis. The optimal modality employed depends on the clinical query or symptoms associated with the breast, the patient’s history, and the skills and expertise of the radiologist involved. Mammography is a modality that is traditionally performed to detect abnormalities of the breast at an early stage. It is also used as a screening tool in patients who are asymptomatic. Although mammography can provide high sensitivity and specificity, it depends largely on the breast density of the patient.
Breast ultrasound, on the other hand, is a supplemental tool that provides further information on the lesions observed on mammography. Three-dimensional automated breast ultrasound has revolutionized how we interpret the breast, yet breast ultrasonography is highly operator-dependent. Similarly, the performance of breast magnetic resonance imaging (MRI) is highly operator-dependent due to the ability to obtain proper images of adequate resolution. The sensitivity of MRI seems to be the highest when the percentage of breast density is relatively lower. Despite sensitivity and specificity in non-dense breasts, lowering the specificity does lead to more false positives and higher biopsy rates. However, with improved technologies, the use of abbreviated protocols has proven to be sensitive to malignancies with good scan time, enabling interpretation and diagnosis. This shows the rapid advancement in technologies to visualize breast tissue and the spectrum of new conditions, some of which necessitate or merit specialist attention.
Treatment Modalities
Breast diseases can be treated with a variety of therapeutic options. While conservative observation would suffice for most patients with benign breast conditions, the range of treatments for malignant breast diseases is much wider. Some cancers are so indolent that they might never become symptomatic within the remaining life span of an affected woman and may be conservatively managed. Conversely, an increasing number of new therapeutic agents have been discovered to specifically target the cancer cells in a bid to render women completely cancer-free and, if possible, avoid surgical intervention altogether. The list of malignant breast diseases with an expanding incidence among younger women also includes pregnancy-associated breast cancer and other rarer histological and molecular types of breast cancer. Although there are many modalities to treat breast cancer, it is important to remind ourselves that the most basic and time-tested treatment option remains surgical intervention, albeit this may or may not be augmented by other medical modalities and/or radiation treatment. A combination of these therapeutic strategies can be further used as either primary treatment or adjuvant therapy to surgery to prevent the spread and metastasis of the cancer cells. Current guidelines recommend that proposed breast disease management and treatments should be supported by evidence-based medicine and personalized based on the patient’s co-morbidities and personal preferences. It is important for an individual to identify and understand its effects and side effects before deciding on the treatment options available. Cancer treatment may include surgery, radiotherapy, systemic treatment such as chemotherapy, hormonal therapy, or targeted therapy. Every patient with a diagnosis of cancer should be discussed by a multidisciplinary team. It has been shown that patients whose cases are reviewed by an MDT have better outcomes. In addition, there have been recent advances in the treatment of breast cancer with new immunotherapy agents becoming available as well as other agents coming onto the market from clinical trials. As such, eligible participants can also be enrolled in clinical trials as part of their cancer treatment.
Surgical Interventions
As part of the treatment of breast diseases, surgical intervention is often deemed necessary. Innately, surgical intervention is essential in a complete and efficient treatment of any malignancy. Depending on the disease stage and type, these surgical interventions can vary greatly in terms of invasiveness, recovery, and even potential risks and benefits, and are often discussed in the course of active management and surgical decision-making. A comprehensive breast cancer care plan would ideally consist of effective cancer therapy delivery in a timely and potentially quality-of-life preserving manner while preserving the cosmetic result.
The lumpectomy as a means of early breast disease therapy has advanced in delivering better and superior cosmetic results than the conventional mastectomy in breast conservation, while sometimes improving prognosis. Techniques such as sentinel lymph node biopsy have reduced the risk of sequelae from the more radical axillary dissection when identifying nodal spread of disease. Knowledge of the benefits and risks of the surgical options is necessary for the patient to make informed decisions based on the respective stage, biology, and systemic therapy options for each case. A relatively recent and evolving innovation in the surgical repertoire is the advancement of complementary oncoplastic surgical techniques, applied to skin-sparing mastectomies in breast reconstruction and the therapeutic excision of large proportion malignancies in hopes of delivering a cosmetically acceptable result that is safer.
When discussing the role of surgery in the treatment of breast disease, an important consideration to weigh in decision-making is the improvement of life and quality of life. Thus, in the occurrence of benign breast changes, mammoplasty always aims to remove the bulk of glandular tissue, potentially reducing the chance of future malignancy and also serving as a continued management modality for fibrocystic change. The variety of surgical techniques also offers the need for oncoplastic surgery, a marriage of plastic surgery and therapeutic breast surgery, offering high-risk patients a therapeutic mastectomy, combined with bilateral immediate breast reconstruction if desired. A critical component of this discussion when developing a surgical care plan is typically when to perform the operation as well as what its results, limitations, and potential complications are, and in what sequence the needed surgeries should be performed. Other factors are also important to consider: shorter operative time compared with traditional techniques, quicker recovery, shorter hospital duration, less need for combined general and regional anesthesia, and possibly less risk.
Specialist Care in Singapore
This comprehensive healthcare network includes a tiered medical structure ranging from primary care clinics, hospital-based specialists in general surgery and gynecology, to general and subspecialist outpatient clinics in the public hospitals. There is ready access to radiological, oncological, genetic, and reconstructive specialists. Additionally, all public hospitals run dedicated breast diagnostic and mammographic clinics with a full range of facilities for both investigations of symptoms and screening mammography. Treatment decisions are facilitated through multidisciplinary team meetings and a variety of support services provided to breast cancer patients through dedicated nurse coordinators and cancer societies. The availability of cutting-edge research institutions helps ensure that breast cancer prevention, diagnosis, and treatment methods are at the cutting edge. At all levels, the Specialist Reasons for Refusal Guidelines are used for decision-making. Overall, Singapore’s healthcare system is designed to be as comprehensive and accessible as possible. While many international patients use Singapore’s specialist care services, in order for a patient to be seen as an overseas referral, there has to be an official referral from a local consultant specialist. Currently, we see referrals managed by regional hospitals in the neighboring countries. Hereunder, we profile the way specialist breast care is accessible to our local population. Throughout, the treatment of breast disease is possible when there is an established network of care relationships between primary care physicians and hospital-based nurse counselors. Good referral communication and clinical nurse coordinators. A good collaboration: 1. Helps ensure increased diagnostic accuracy through feedback and further consultation. 2. Expedites access to specialist care when needed. 3. Enhances quality of patient care.
In Singapore, specialist care in relation to breast disease involves the general surgical, plastic and reconstructive surgical, gynecological, hematological, radiation, medical, endocrine, and oncological disciplines. These specialists work in dedicated breast oncology units conceptually as a team and are familiar with treating breast diseases. In the majority of cases, specialist care providers do group practices, work over several hospital locations, or are contracted to hospital networks. Conversely, medical oncologists may prefer to stay within hospital systems and do not always do outpatient care. All clinical breast disease activity is provided at specific hospital locations, collectively known as the Breast Centres. Of note, most breast surgeons routinely undertake both general surgery procedures as well as breast surgery procedures at their hospitals, and further improvement of the referral pathways between family physicians and the developed network of metropolitan breast clinics or further infusion of cash into the established tertiary hospital developed collaborative care system would potentially require breaks in the current care group relationships. Although administrative, the network provides continuity of care and is a non-financial deterrent to see all the information for difficult cancer cases may be obtained from a single care group system. All women have to be referred by family physicians, other specialists, or obstetricians and gynecologists to see a breast disease specialist. All overseas patients requesting treatment in Singapore must be referred by an overseas doctor. The provision of other services can be made available for screening and surveillance purposes, such as genetic risk assessment, breast cancer menopause support services, psycho-oncology care and support, and family genetic counseling. In this setting, women may see a nurse counselor for risk assessment and are advised regarding further treatment pathways. Following workup, women are referred to a cancer physician or melanoma surgical oncology units and not directly to surgeons or therapists.
There is active and ongoing research in Asia and various parts of the world to translate biological understanding into more effective prognostication and treatment for patients with breast disease. The shape and feel of research and practice are evolving in the direction of moving away from one-size-fits-all treatment modalities to a more nuanced approach utilizing personalized biologic determinants of treatment in determining local and system control. One area of significant development is in the integration of technology for diagnostics and treatment. Secondly, there is a growing focus on patient-reported outcomes and perspectives, ensuring a more patient-centric approach to management. These trends will continue into the future, and substantive development is expected as a result. Currently, predictive markers, patient experience, influence and behavior, the interplay of surgery and reconstruction with treatment, integrative supportive care, and technological developments in surgery and treatment will all continue to develop further, with interest likely to grow.
Uniquely, these developments have been influenced by cross-disciplinary engagement between researchers, clinicians, and patients. The future is bright. We believe a more biologically focused approach to managing a patient and the disease will allow future developments to be made in real-world practice. In the context of our local socio-demographic circumstances, it is likely that there will be an increasing need for patient-doctor collaboration. There is, however, still a need to be aware of potential barriers to healthcare delivery, such as cost and infrastructure. In implementing new promising technologies, these barriers ought to be explored and potential solutions formulated. At the community level, education will also be important. Both in the training of new doctors and the empowerment of the public to take charge of their health, education is a key component of future disease management as we expect it to be. Nursing research is equally important in ensuring that the best supportive care and rehabilitation therapy are made available. Taking all steps into consideration, it is likely that further efforts will be made in the field of breast diseases to champion the cause of specialized care.
