By Dr. Donald Greig
21 October 2023
October is just not a month to consider breast imaging and clinical examination, it raises awareness of the importance to look after your body as certain conditions and diseases become more prevalent as you age. In this commentary, we would like to focus on breast cancer in support of October's Breast Cancer Awareness month.
Breast Cancer in Hong Kong
Breast cancer is the most common cancer among females in Hong Kong. It accounted for 28.4% of all new cancers in females diagnosed in Hong Kong in 2020. It rarely occurs in males. with 32 new cases of breast cancer in males in 2020.
In 2020, 4956 new cases of female breast cancer were diagnosed and the crude incidence rate was 121.9 per 100 000 female population. As the graph shows, its incidence has risen almost linearly over the past decade.
The median age of breast cancer patients was 58 in Hong Kong, compared with the age of 62 in the United States, 60 in Australia. In Hong Kong, the lifetime breast cancer risk for women is about 6.8%, meaning that roughly 1 in every 14 women will be diagnosed with invasive breast cancer. However, this figure does not mean that your personal risk is 6.8%. In 2020, 49% of the women diagnosed with breast cancer were aged 40-59. The older the age, the greater the risk.
This is a global trend. Incidence rates are rising in South America, Africa, and Asia where rates were historically low. Worldwide, an estimated 2,964,197 new female breast cancer cases are projected to occur in 2040, a 31% increase from the corresponding 2,260,127 cases in 2020.
What should I do for my annual assessment and at what age should I consider having my first breast imaging?
This is in part dictated by your risk profile, especially if you have a family history of breast cancer, how proactive you are about your own health and access to breast healthcare and specialists.
At HKSS, we recommend that annual breast screening starts at age 40 years and should continue annually thereafter. There is no arbitrary upper age limit to stop screening as breast cancer incidence increases with advancing age (see later graph). If you have a family history of breast cancer in a first degree relative: mother, sister, or daughter, then we may advise screening from the age of 35 years or earlier if there is an indication to do so.
Breast Cancer Screening has 4 components:
Clinical history and examination
Risk assessment taking into account lifestyle, measurable parameters, and the Gail Risk Assessment Tool which can potentially identify high risk individuals (5-year and life-time risk) based on 6 factors who may benefit from taking a five-year course of anti-oestrogen medication to reduce the risk of breast cancer by 50% if a woman is in the high 5-year high risk group
Low dose Mammograms which have proven value in detecting early breast cancer and reducing mortality associated with breast cancer
Breast ultrasound is an adjuvant investigation which adds to the information obtained through mammography but should NOT in itself be used as a sole imaging investigation for screening for breast cancer
In younger, at-risk patients, consideration using MRI (without radiation exposure) may be used for screening.
Who is at risk for breast cancer?
The female gender is the strongest breast cancer risk factor. Approximately 0.5–1% of breast cancers occur in men. The treatment of breast cancer in men follows the same principles of management as for women.
Certain factors that increase the risk of breast cancer including increasing age, obesity, harmful use of alcohol, family history of breast cancer, history of radiation exposure, reproductive history (such as age that menstrual periods began and age at first pregnancy), tobacco use and postmenopausal hormone therapy.
Approximately half of breast cancers develop in women who have no identifiable breast cancer risk factor other than gender (female) and age (over 40 years).
Family history of breast cancer does increase the risk of breast cancer, but most women diagnosed with breast cancer do not have a known family history of the disease. Lack of a known family history does not necessarily mean that a woman is at reduced risk.
Certain inherited high penetrance gene mutations greatly increase breast cancer risk, the most dominant being mutations in the genes BRCA1, BRCA2 and PALB-2. Women found to have mutations in these major genes may consider risk reduction strategies such as more stringent screening protocols, more regular clinical examinations and surgical removal of both breasts.
Which factors can reduce the risk of breast cancer?
There is strong evidence that the following DECREASE the risk of premenopausal breast cancer:
vigorous physical activity
greater body fatness
There is strong evidence that the following DECREASE the risk of postmenopausal breast cancer:
physical activity (including vigorous physical activity)
greater body fatness in young adulthood
Lastly, there is strong evidence that lactation (breastfeeding) DECREASES the risk of breast cancer (unspecified menopausal status).
Signs and Symptoms of Breast Cancer
Breast cancer can have combinations of symptoms, especially when it is more advanced. Most people will not experience any symptoms when the cancer is still early.
Symptoms of breast cancer can include:
a breast lump or thickening, often without pain
change in size, shape or appearance of the breast
dimpling, redness, pitting or other changes in the skin
change in nipple appearance or the skin surrounding the nipple (areola)
abnormal or bloody fluid from the nipple.
People with an abnormal breast lump should seek medical care, even if the lump does not hurt.
Most breast lumps are not cancer. Breast lumps that are cancerous are more likely to be successfully treated when they are small and have not spread to nearby lymph nodes.
The purpose of annual breast screening is to detect early non symptomatic breast cancers so that early intervention can provide a much better prognosis BEFORE symptoms or signs appear.
The age specific incidence of breast cancer:
A commitment to breast cancer screening should be viewed as a life time mission statement.
If you or anyone you know would like a comprehensive breast cancer assessment, please make an appointment with Dr. Greig at Hong Kong Surgical Specialists.
Tel: +852 2715 4577
References / Statistical and Information sources:
Global Cancer Observatory
National Institute of Health
The Breast Cancer Registry Hong Kong
World Health Organization