At-a-Glance

One of the deepest impressions I had as a young medical student was meeting a patient in the ward, with a locally advanced breast cancer. The lady had found a lump some years ago, but was too scared to see a doctor, and delayed for years before stepping forth. By then, it was growing out of the chest, with bleeding, foul-smelling discharge. I remember feeling very sad, and was in disbelief: how can such a thing happen in Singapore? Healthcare is so easily available, any GP or polyclinic can help her, why did she not tell anyone?

That’s why over the years, even after training as a specialist, my main target is to reach out to this 10% of women, who are so fearful and in denial, that they choose never to see a doctor.

Breast cancer is so treatable in the early stages- stage 0, stage 1—by delaying seeking help, the fate that women are most scared of (chemotherapy, dying) will actually happen. While if you do regular yearly screening, we can prevent such an outcome!

All women from age 18 should start doing monthly breast self-check – if you find something new- see any doctor.

The doctor should verify if the condition is normal or not, and advise for additional scans if needed. Sometimes patients are referred to a breast surgeon to discuss biopsy, or to advise on the possible conditions and discuss if the patient needs more imaging, or surgery.

Nowadays, many patients are actually quite aware and come by to speak to a breast specialist just to understand more. Risk assessment, types of screening. It’s a good thing, because early detection saves lives.

Just because you see a surgeon doesn’t mean that you need surgery. It’s just because our training path is under “General Surgery”, by MOH protocols, so our professional title is “FRCS, General Surgeon”.

Different doctors run their practice differently. I personally always treat the person as a whole, do a detail history taking, physical examination, and tie in with the scans to have a diagnosis first. Sometimes we need a biopsy to verify what the condition is. Then, depending on the actual diagnosis (cancer, fibroadenoma, cyst, abscess, inflammation etc)- different treatments are needed. Some conditions can just wait and see, some need antibiotics, some need anti-inflammation medications, and some need surgery. I hope this helps you to understand what a specialist review entails.

Patients have the right to choose. Patients should understand what is going on with their bodies, and hear out the different options. I give you an extreme example, I have patients who have been diagnosed wit cancer, and refuse treatment. It is their right- then my job is to educate them on the outcome—if the cancer is left alone, what will happen in the coming months to years.

To me, that is the real patient autonomy.

Success story: 32 year-old with stage 4 cancer- breast spread to bone and liver, went for chemo, managed to shrink all the cancer. Came back to me for surgery, and currently 3 years cancer free. This is one of the best outcomes we can have, when the patient is brave and follows our medical advice, follow protocol, and get a good outcome.

Challenging cases: A patient with a small stage 1 cancer- opted for minor surgery, just removing the lump. But then refuses all other treatment—even though I have advised that cancer treatment needs radiation, systemic treatments. The risk for recurrence is high. It is something that worries me, because instead of suppressing the cancer completely, we only did partial treatment. It is not enough. But, doctor cannot force patients- it is their body, it is their right.

Some women thought that as they get older, cancer risk is less or they will not get cancer. This is wrong. Cancer risk increases with age, for almost all cancer types. Therefore, the importance of maintaining regular yearly health screening cannot be understated.

• I never rush patients, they can take 15min- up to 1.5H to talk and discuss.
• I try to use the language most familiar with the patient; or use a translator.
• I write down options, in the form of a flowchart- and this is given back to them.
• I use educational slides, and google images to show them what I mean.
• I use educational techniques, and ask the patient to tell me back, what they understand so far.

As for all work, we should enjoy our work so that it doesn’t feel stressful. Being a breast specialist means me a lot of joy and meaning as I help patients with their various concerns. But sometimes, I also can feel burnt out, when some people don’t follow advice, or there’s some mistrust. I have been a doctor for 20+years, I have learnt to never take it personally

I’m looking forward to the development and validation of the breast cancer vaccine!

Three simple take home messages:

1. Do monthly breast self-exam
2. See a doctor once a year for a professional check
3. Start annual mammogram screening at 40 onwards!