Women in Singapore are getting breast cancer at a younger age but it’s only diagnosed when it’s more advanced

These days, it is not unusual for specialist breast cancer surgeon Dr Anthony Tang to see breast cancer patients in their thirties, or even in their twenties, with sizeable lumps.
Very recently, he treated a woman in her thirties with a 5cm lump which she had left unchecked for around two years. By the time she consulted him, the cancer had progressed to Stage 2, approaching Stage 3, he told CNA Women.
Early onset breast cancer – breast cancer occurring in women under the age of 45 – is on the rise, said Dr Tang, medical director of The Breast Clinic.
“But because of the perception that it is near impossible for young people to get breast cancer, very often, young women who feel a small lump in the breast may dismiss it,” Dr Tang noted.
This is why, in his practice, Dr Tang noted that early onset breast cancer is often detected at a slightly later stage – often in Stage 2 or 3.
A specialist breast cancer surgeon for over 20 years, Dr Tang said that in the past, most of his patients were post-menopausal, in their late fifties or sixties.
Today, one in six women who gets breast cancer is under the age of 45. The youngest patient Dr Tang has treated was only 22 years old.
Early onset breast cancer is often more aggressive, commonly presenting as triple-negative breast cancer or HER2-positive breast cancer, Dr Tang noted.
Cultural changes contribute to these numbers, he said.
“Having children before the age of 35, breastfeeding, and having more children can lower the risk of breast cancer,” he explained. However, more Singapore women are having fewer children, giving birth at a later age, and opting not to breastfeed.
Genetic predisposition and getting periods at a younger age also increases the risk of breast cancer.
“Unfortunately, a lot of these factors are in many ways out of our control,” said Dr Tang. 
However, two risk factors known to increase risk of breast cancer – a sedentary lifestyle and being overweight – can be addressed.
Having an active lifestyle and a good diet doesn’t just reduce breast cancer risk, it also reduces the risk of other cancers and illnesses, such as diabetes and high blood pressure, he said.
In his practice, Dr Tang has seen many young women ignore breast lumps too long before seeing a doctor.
“The thing about breast cancer is that the most obvious sign is the lump, but besides having the lump, there’s almost nothing else. There’s no pain or discomfort,” he said.
“People always think that cancer and things that are dangerous should have a warning sign – they should be painful. Unfortunately, breast cancer is painless. It doesn’t disrupt their life. So they don’t think it’s dangerous.
“It just slowly grows bigger. And with time, the likelihood that it can spread to other parts of the body increases,” Dr Tang added.
Since it is not common for young women to breast cancer, some general practitioners may dismiss lumps as benign as well, Dr Tang said.
It is true that breast lumps are common and often benign. So there is no need to panic if you notice one. However, since a new lump is the most common sign of breast cancer, it is important to get it checked by a specialist to rule out malignancy.
Sometimes, women delay getting a lump checked out of fear, Dr Tang said. “Being brave and seeing your doctor whenever you notice something new is the biggest take-home message that I can give to all young women out there.
“If you pick [cancer] up very early, the treatment is much simpler. You may not need so many different types of [treatment] modalities such as chemotherapy. You can almost certainly save the breast. And if you treat cancer at early stages, it will definitely save lives,” he said. 
In Singapore, women between the ages of 40 and 49 are recommended to have yearly mammograms.
“Whether you feel any pain, whether you feel a lump or not, it doesn’t matter. Please go for your mammograms once a year. Because these mammograms will pick up early changes, which we see more often nowadays, that could be signs of very early breast cancer,” advised Dr Tang.
Mammograms are not recommended for women below 40 because young women have higher breast density that makes mammograms less effective in detecting cancer. 
Instead, from the age of 20, women should start doing monthly breast self-examination. You can watch a how-to video on the Singapore Cancer Society website or on the Breast Cancer Foundation website.
“From their twenties, all women should start trying to know their bodies better. You should know what your breast usually feels like. Take that as the baseline. If they feel something new, especially if there is a hard lump, get it checked,” said Dr Tang.
Although a lump is the most common sign of breast cancer in young women, other symptoms include bloody discharge from the nipple, and dimpling or retraction of the breasts or nipple, said Dr Tang.
Other rare signs of cancer include a persistent rash around the nipple and areola that doesn’t go away despite topical treatments from a GP, or a red patch on the skin over the breast that doesn’t go away despite antibiotics from the GP, he added.
Women with a family history of breast cancer need to be more proactive in screening. The general guideline is to start breast cancer screening 10 years younger than the age of the youngest member of the family who had breast cancer, recommended Dr Tang.
Say you have three aunts and one cousin with breast cancer. If your cousin got breast cancer at the age of 39, you should start doing scans when you’re 29.
Doctors may also recommend more frequent screenings for high-risk patients.
A mammogram is the most common screening test for breast cancer. However, they are not as effective for women under 40 with denser breasts. For young women not in the high-risk group who would like to go for a screening, Dr Tang recommends doing an ultrasound.
“I would strongly encourage all women to get medical insurance coverage before they go for any scans,” he said.
“It is very common and normal for scans to pick up small benign cysts or nodules, which the vast majority of women have. However, if any lesion is seen on scans, insurance companies would often exclude all breast diseases from the coverage, even though these lesions are normal, completely not dangerous and can be left alone,” he explained.
For young women in the high-risk group, Dr Tang recommends undergoing magnetic resonance imaging (MRI), which is costlier but more accurate. If cost is a concern, patients can alternate between a mammogram and ultrasound for one year, and MRI the next, he added.
You might recall the news of Angelina Jolie doing bilateral mastectomies and breast reconstruction after genetic testing showed that she carried a genetic mutation that significantly increased her risk of developing breast cancer.
Gene testing is available at breast cancer clinics and hospitals in Singapore, and done via a blood test. Those who test positive – or are gene positive – for BRCA1 and BRCA2 gene mutations have up to 85 per cent chance of getting breast cancer. They also have up to 58 per cent chance of developing ovarian cancer.
Dr Tang suggested that patients in their late twenties with a strong family history of breast cancer consider gene testing. This includes having multiple family members with breast cancer, especially if they are younger, a male family member with breast cancer, or a female family member with breast cancer on both breasts.
In Singapore, patients are required to speak with a genetic counsellor prior to gene testing so that they understand the pros and cons of doing it.
They should be aware of how gene testing will affect their and their relatives’ eligibility to buy insurance, as well as their insurance premiums, said Dr Tang.
Should patients test gene positive, this will also affect their children, who have a higher risk of inheriting the gene, and who may feel the need to do gene testing as well, he added.
If tested gene positive for breast cancer, women may opt for a double prophylactic mastectomy, like Jolie, which involves removing all breast tissue and retaining the original skin and nipple for breast reconstruction “so that the risk of breast cancer drops from 85 per cent to around 2 per cent”, said Dr Tang.
Women also have the option of removing their ovaries after they are done with family planning to reduce the risk of ovarian cancer.
Alternatively, instead of such preventative surgeries, gene positive patients may choose to go for more frequent screening.
The surgeon added that though breast cancer rates have increased among younger women, there have been significant advances not just in screening, but also in cancer care. This includes advancements in surgery, chemotherapy, targeted therapy (which uses drugs to attack specific proteins in the tumour), radiotherapy, fertility preservation and breast reconstruction.   
“Everyone used to think that cancer is a death sentence… But it’s not the case anymore. Today, it is curable – and even more curable with better outcomes when it is detected early,” said Dr Tang.
CNA Women is a section on CNA Lifestyle that seeks to inform, empower and inspire the modern woman. If you have women-related news, issues and ideas to share with us, email CNAWomen [at] mediacorp.com.sg.