Breast cancer is the most common cancer in Malaysia.
According to the Global Cancer Observatory 2020, published in March 2021, it comprised 17.3% of all cancers in males and females, and 32.9% 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 in 2007-2011.
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 one in 30 in 2007-2011.
In Chinese, it was one in 22, Indians one in 23 and Malays one in 30.
The incidence increased after the age of 25 years with a peak at 60-64 years, and then reduced for those aged above 65 years.
Staging was reported in 13,485 cases (62.3%). Of these, 47.9% were detected at the advanced stages of III and IV, which was higher than in 2007-2011 (43.2%).
Risk factors
About half of breast cancer sufferers have no identifiable risk apart from female gender and age.
The risk factors in breast cancer can be divided into those that are non-modifiable and modifiable.
The non-modifiable risks are:
- Female gender – this is the most significant risk factor, with only about 0.5-1% of breast cancers occurring in men.
- Increasing age – particularly after the age of 50.
- Family history of inherited “high penetrance” mutations – these increase the risk markedly, with the most dominant being the 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 though.
- Family history of breast cancer – especially if it occurred at a young age.
- Early menarche
- Late menopause, and
- Previous breast cancer.
The modifiable risks include:
- Nulliparity (never having been pregnant before)
- 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.
However, even if all the potential modifiable risk factors are controlled, this would reduce the risk of breast cancer by 30% at most.
Women who have the BRCA1, BRCA2 and PALB2 gene mutations may contemplate risk reduction strategies like pre-emptive surgical removal of both breasts.
The consideration of such a highly-invasive procedure for something that affects a very limited number of women, has to be evaluated carefully and should not be rushed.
Breast awareness
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, as well as the skin in these areas.
The symptoms can include:
- A breast lump or thickening of the tissue
- Alterations in size, shape or appearance of a breast
- Dimpling, redness, pitting or other alterations in the skin on or around the breasts
- Change in nipple appearance or alteration in the skin surrounding the nipple (i.e. the 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% of breast lumps are not cancerous, and include conditions like cysts, fibroadenomas and infections.
However, 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 while 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. dimples, puckering or redness
- Changes in the nipple, 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
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.
They are:
- It may be performed once every two years in women aged 50-74 years in the general population, i.e. those with no personal or family history of breast cancer.
- In women with high risk of breast cancer where no genetic mutation has been identified – i.e. a first degree relative of gene carriers who has not yet been tested and/or has personal or family history of breast cancer – a screening mammogram may be considered at 30-39 years of age, an annual mammogram when 40-59 years of age, and a biennial mammogram from 60 years of age onwards.
- In carriers of the BRCA1, BRCA2 and/or PALB2 gene mutations, annual magnetic resonance imaging (MRI) should be offered when they are 30-49 years of age, an annual mammogram when 50-69 years of age, and a biennial mammogram from 70 years of age onwards.
Referrals should be made to a surgical or breast clinic early (within two weeks) for further evaluation if there are signs and symptoms of breast cancer in women aged more than 35 years or in high-risk women, and if there are signs of cancer at any age.
Where there are no mammography facilities, breast ultrasound can be used for screening as it has a reported diagnostic sensitivity of about 89% and specificity of about 99%.
Global goals
The World Health Organization (WHO) Global Breast Cancer Initiative’s (GBCI) objective is to reduce global breast cancer death by 2.5% per year.
This would avert 2.5 million breast cancer deaths globally between 2020 and 2040.
This death reduction would prevent a quarter 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 half of all breast cancers are diagnosed late in Malaysia, efforts have to stepped up for early detection and diagnosis.
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email starhealth@thestar.com.my. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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