Breast Cancer

What is the breast cancer survival rate in Australia today?

With close to 20 years of breast surgery experience, Dr Cheung has personally treated thousands of breast cancer patients who have enjoyed long term survival.

Breast Cancer occurs in 1 in 8 Australian women before the age of 85 and is the most common cancer (after non-melanoma skin cancer).

Cancer Australia estimates that in 2019, there will be 19,535 new cases of breast cancer. 

Seventy percent of breast cancers occur in women aged 40 – 69 years with the average age at diagnosis, 61 years.

Today, with better screening and improved treatments, the number of deaths continues to decrease (from 17 per 100,000 in 1968 to 11 in 100,000 in 2014) while survival rates continue to increase.

In fact, the latest statistics shows the five-year relative survival rate across the board is now at 90.8% (Breast Cancer Network Australia) and as high as 99% for early stage breast cancer.

There are several risk factors for breast cancer including genetic predisposition; hormonal impacts including early or late menopause, use of HRT; having a high-risk breast condition such as Lobular Carcinoma in Situ and lifestyle factors such as obesity, low physical activity and excessive alcohol consumption.

According to Cancer Australia, one in four breast cancers are potentially preventable and cites, as an example, that one standard alcoholic drink a day can increase the risk by 7 percent.

Cancer Australia has launched the Breast Cancer Risk Factor website providing evidence-based information about 68 personal, family, genetic lifestyle and environmental risk factors that can increase or reduce the chance of developing breast cancer.

What are the symptoms of breast cancer?

Common symptoms include:

• Changes in the colour, texture, size and shape of a breast
• A lump, lumpiness or thickening of breast tissue and it can be a soft or hard mass, particularly in one breast only
• Changes to the breast skin such as redness or dimpling, like the skin of an orange
• Changes to the nipple such as becoming newly inverted; redness or discharge leaking from the nipple that is clear or bloody
• Peeling, crusting, scaling, or flaking of the skin of or around the nipple
• Swelling or pain under the armpit
• Persistent, unusual pain not related to your usual monthly menstrual cycle and occurring in one breast only

 Breast lumps may be due to breast cancer but in most cases are found to be cysts, fibroadenomas or other benign conditions.

However, any new or persistent symptoms should always be investigated by a doctor as soon as possible.

What are the treatments for breast cancer?

The most common types of breast cancer have a very good long-term prognosis, especially if detected early.

Breast cancer is a different experience for every person and while there are protocols there is no “one size fits all” and treatment is tailored to the individual.

There are several ways to treat breast cancer depending on the type of cancer, the stage and how far it has spread.

The most common treatments include surgery, chemotherapy, radiation therapy, chemotherapy, hormone therapy and targeted therapies.

Types of surgery for breast cancer:

 

Lumpectomy or wide local excision and is recommended in certain cases with early, small breast cancer.

Lumpectomy with intraoperative ultrasound – Dr Cheung has extensive experience in breast US and having this extra skill helps her in increasing precision of her excisions and minimises the need for hookwires for patients. This not only reduces pain, but enhances precision and reduces the chance of re-excision.

Oncoplastic – which integrates the latest in cosmetic surgery techniques into the breast cancer surgery. Knowing the techniques of oncoplastic surgery is a game changer for patients who have tumours in unfriendly places in the breast (eg near the nipple, or in the lower part of the breast) where most breast surgeons will say a mastectomy is their preferred operation.

For many patients, breast conservation not only gives superior results on breast cancer survival, it also provides better psychological and functional outcomes  over a mastectomy.

Hence, oncoplastic breast surgery is a crucial option in the field of breast surgery.

Mastectomy is the surgical removal of the whole breast affected by cancer. There are three types of mastectomy surgeries– simple (removal of skin, nipple and breast tissue); skin sparing (nipple and areola are removed but skin envelope is retained for reconstruction) and nipple sparing (the breast tissue is removed, leaving behind the skin envelop and nipple with areola). Any type of mastectomy can be associated with breast reconstruction either using an implant or patient’s own tissue.

Types of surgery for breast cancer:

 

Radiation

Thisherapy uses X-rays to destroy any cancer cells possibly left in the breast and is usually administered after surgery over a 3- 6 week period. It is not usually recommended after a mastectomy. It can also be used to shrink tumours.

Chemotherapy

Chemotherapy is used to reduce the risk of cancer recurrence and uses drugs (tablets or intravenous) to help destroy any cancer cells that may have remained after surgery. It is also used to reduce the risk of cancer recurrence. It may be used in addition to radiation therapy.

Neoadjuvant Chemotherapy

This is one of the latest advances in the management of breast cancer. Although still only conservatively adopted by surgeons in Australia (12%) compared with the UK and US (30%), there is increasing evidence of the benefits of giving neoadjuvant or preoperative chemotherapy to shrink a tumour before surgery. This approach increases the option of having breast-conserving surgery (lumpectomy) instead of mastectomy and gives patients the option of immediate breast reconstruction and nipple-sparing mastectomy.
Given the option, an overwhelming majority of patients (84%) choose immediate breast reconstruction.
After neoadjuvant chemotherapy, the need for post-mastectomy radiotherapy is reduced thereby improving the overall cosmetic outcome of immediate breast reconstruction.

Hormone therapy

This is given as an oral medication to treat hormone receptor positive breast cancer.
It works by reducing the amount of oestrogen in the body by slowing down or blocking the growth of oestrogen receptors on cancer cells.
It can be used following surgery, radiation therapy and chemotherapy and has been proven effective in reducing the risk of recurrence.

Targeted therapy is the use of drugs to stop the growth of certain types of cancer cells and is only suitable for some women. They can be used in conjunction with other breast cancer treatments.
You may have heard this word in recent times – immunotherapy is a new form of cancer therapy that boosts the body’s immune system to help it fight cancer.
Dr Cheung works with a team of cancer specialists who will direct you to the most appropriate treatment for your cancer type.

Breast Pain

What is breast pain?

Also known as “mastalgia”, breast pain is very common, affecting 7 out of 10 women at some stage of life. While it may cause anxiety along with varying degrees of discomfort, it is not typically a sign of breast cancer.

What are the symptoms for breast pain?

There are two main types of mastalgia – cyclical and non-cyclical.

Cyclical breast pain is linked to the monthly menstrual cycle and fluctuating oestrogen and progesterone levels, causing breasts to become tender or painful just before a period.

Non-cyclical pain, accounting for around one third of breast pain, is not related to the menstrual cycle and can be caused by infection or non-cancerous breast lumps.

In some instances, women can have referred breast pain caused by illness such as shingles or pneumonia or it may be brought on by muscles strain or strenuous physical activity.

Non-cyclical breast pain symptoms:

• Burning, aching or sore breasts
• More common in women in their 40s or older
• Pain can come and go
• Tends to be localised to one side of one breast

Cyclical breast pain symptoms:

• Heavy, full and aching breasts
• Commonly begins in the second half of the cycle, peaking in the 3-7 days leading up to a period and settling when the period begins
• Commonly affects women in their 20-30s
• Usually involves the upper outer breast area into the underarm
• Can worsen in perimenopause and into menopause

What are the treatments for breast pain?

If the breast pain is mild or disappears once a period starts treatment may be unnecessary. Some simple and effective measures offering relief include:

• Wearing a well-fitting supportive bra (sports bra)
• Wearing a soft support bra to bed
• Taking painkillers such as paracetamol or ibuprofen
• Low dose oral contraceptive pill can improve cyclical breast pain but for some women it can make it worse
• There is no evidence for making dietary changes or taking vitamins
• Evening primrose oil has been reported to help some women
• Excessive caffeine consumption has also been linked to breast pain and reducing intake can help.

Breast Lumps

What are breast lumps?

A breast lump is a growth of tissue or a localised swelling that feels different to the surrounding breast tissue.

Finding a lump in your breast can instantly induce panic and anxiety and while some breast lumps may be cancer, the majority are not.

Reassuringly, it is estimated more than 90% of lumps found in young women (aged in their 20-50s) are benign or non-cancerous.

It is normal for breast tissue to change throughout the menstrual cycle with most women experiencing tenderness and lumpiness at regular intervals.

Being familiar with the changes in how your breast tissue feels at different stages throughout your cycle, and regular checking, is important to help identify new lumps should they occur.

What are the symptoms for breast lumps?

• A defined lump with definite borders
• A thickened area that feels different to the surrounding breast tissue
• A firm hard mass within the breast
• A visible difference in breast sizes
• Breast pain or tenderness

What are the treatments for breast lumps?

Most lumps are not cancerous and do not pose a risk, but all lumps should be examined by a doctor.

Lumps may be caused by a cancer but are commonly found to be normal lumpiness caused by menstrual cycle changes, cysts, fibroadenomas or other benign conditions.

Breast Cysts

What are breast cysts?

Breast cysts are fluid filled sacs inside the breast, usually round or oval shaped and feel a little like a grape but can sometimes feel firm.  Occasionally, they can cause pain an discomfort.

Importantly, they are usually not cancerous (benign) and are not indicative of an increased risk of developing breast cancer.

They are most common in women aged between 35 and 50 years but can present in women of any age.

It is not known what causes breast cysts, but they may develop as a result of hormonal changes in the menstrual cycle.

Some evidence suggests excess estrogen can stimulate breast tissue causing cysts to form.

What are the symptoms for breast cysts?

• Smooth, round or oval lump with distinct edges that can be easily moved around
• Tenderness or pain near or around the breast lumps

What are the symptoms for breast cysts?

• Smooth, round or oval lump with distinct edges that can be easily moved around
• Tenderness or pain near or around the breast lump

What are the treatments for breast cysts?

Cysts do not need treatment unless they are large and painful or cause discomfort in which case aspiration with a needle to drain the fluid can relieve symptoms.

Breast Rash

Breast rashes effect most women in their lifetime. Here’s to tell the difference between something harmless, and something more worrying:

Intertrigo – is caused by a combination of moisture, heat, lack of air circulation and friction between skin folds, and often accompanied by a fungal or bacterial infection.

Common symptoms include a reddish-brown rash, raw, itchy or oozing skin and unpleasant odour.

To prevent Intertrigo wash under your breasts morning and night with a gentle soap

Wear a well-fitting supportive bra, and if you gain weight tight bras may rub on skin, irritating further.

Mastitis

• Mastitis is inflammation of the breast that occurs most often in breastfeeding mums, but can also occur in older women.
• Untreated mastitis can result in a breast abscess, which is a walled-off area of pus and bacteria in the breast.
• Common symptoms include pain, swelling, redness, warmth and fevers.

Washing powder allergy

• Breast skin is prone to allergic reactions from washing powder as well as other allergies, along with eczema, dermatitis or psoriasis.

Shingles

• Shingles generally appears as a band of blisters on one side of the body, sometimes near the breast area.

Inflammatory Breast Cancer (IBC)

• Inflammatory Breast Cancer is a rare and aggressive form of breast cancer more common in younger women.
• Unlike other breast cancers that form a lump, IBC spreads along and blocks the lymphatic vessels in the skin of the breast causing the breast to become red, swollen and tender (similar to an infection). The breast skin can also look dimpled.
• Any persistent breast rash, even without a lump should be investigated.

Paget’s Disease

• Paget’s disease of the nipple is a rare form of breast cancer that affects the nipple-areolar complex. Most people with Paget’s disease also have a breast cancer somewhere else in the same breast, either an invasive cancer or preinvasive cancer known as ductal carcinoma in situ (DCIS). The main sign of Paget’s disease is a change in the nipple and/or areola
• It can occur in men as well as women.

Nipple Discharge 

Nipple discharge can occur spontaneously, or when the nipple is squeezed.

It can be one sided, or both sided, blood stained, clear, green, milky or yellow.

Nipple discharge is normal with breast pumping and requires no treatment.

In this case, it is important to stop expressing or squeezing the nipple and breast, as this causes more fluid to be made.

The discharge will usually stop when you stop expressing.

However, nipple discharge is considered abnormal if it occurs unrelated to pregnancy or breastfeeding.

There are many causes of abnormal nipple discharge including:

• Duct ectasia: a benign condition in which there is enlargement & inflammation of the milk ducts under the nipple
• Duct papilloma: a growth within the milk duct near the nipple
• Nipple eczema: dermatitis affecting the skin of the nipple
• Paget’s disease of the nipple: a type of breast cancer involving the nipple
• Breast cancer nipple discharge that is spontaneous, blood-stained, persistent and unrelated to pregnancy or breastfeeding requires clinical assessment by your doctor and imaging of the breasts with ultrasound and mammogram (and sometimes MRI).
• Nipple discharge associated with other symptoms such as a lump or skin changes always requires investigation.

Breast Ptosis

What is breast ptosis?

Breasts can develop ptosis, or start to sag over time.

As skin ages, breasts lose tone and some elasticity causing them to lose their natural shape and firmness.

Collagen and elastin are the major structural proteins and are in a constant battle with time and the environment.

How these proteins age depends on genetics, but smoking can accelerate the process.

What are the symptoms for ptosis or sagging breasts?

• Ptosis can be congenital with some girls developing breasts that sag and have downward pointing nipples.
• During pregnancy breasts become engorged, which stretches the ligaments, then post-pregnancy they lose that volume and droop
• After weight loss, sagging can happen if the breast tissue does not have enough elasticity to regain shape

What are the treatments for ptosis or sagging breasts?

A breast lift (mastopexy) can be performed with breast enlargement surgery (augmentation) if there is insufficient tissue or fat to obtain the desired curvature.

The operation is highly individualized. Dr Cheung will be able to advise you of the safest and most long lasting techniques.

Patients find this operation very desirable as it offers patients an instant lift.

The surgery to fix breast ptosis is done as day surgery.

Most patients can return to normal activity in about 1-2 weeks. There are no special dressings to do after the surgery and all the sutures are dissolvable. Dr Cheung will advise you of the type of supportive bras to wear and for how long.

Nipple inversion

Many patients have nipple inversion. This is often benign and not necessarily due to cancer.

The operation to correct nipple inversion is done as day surgery and is under a short general anaesthetic.

Breast Assymetry

Most women have some degree of breast asymmetry however the degree of asymmetry differs a lot.

Some breast asymmetry is congenital (born with it), and some asymmetry is due to previous trauma or breast surgery or treatments.

Some patients are born with tuberous breast deformity or a lack of development of one breast and the associated chest wall muscle (Poland’s syndrome).

Breast cancer surgery from many years ago and radiotherapy cause the treated breast to shrink over time and this may cause imbalance and severe asymmetry over time.

Many patients who had their treatments performed over 10 years ago are seeking to restore their balance.

Breast asymmetry can be improved by making the larger breast smaller or increasing the size of the smaller breast.