Precise breast cancer surgery now available here

Precise breast cancer surgery now available here

SINGAPORE - Breast surgery to remove a cancerous lump entirely while saving as much of the breast as possible can now be made more precise with the use of ultrasound scanning during surgery.

It helps surgeons see, locate and remove the cancer cells more accurately.

At least four hospitals are now using this technology as a guide during breast conserving cancer surgery.

A study by one of them, Changi General Hospital (CGH), found it cut down on the need for patients to come back for a second operation by four times.

The retrospective study of 86 CGH patients operated on between December 2004 and last March found that only 9 per cent of patients who had ultrasound scanning during surgery had to come back a second time to have more cancerous tissue removed.

This is a great improvement compared with data prior to 2004, which found that 38 per cent of patients had to have a second operation. This was before ultrasound scanning was used during surgery. CGH data from microscopic examinations of the excised breast tissue after the surgery showed these women still had remnant cancer cells.

The number of people affected by breast cancer is on the rise, with about 1,700 women diagnosed here last year. An average of 1,624 women found they had breast cancer each year between 2007 and 2011. It is the most common cancer among women, accounting for 30 per cent of new cancer cases diagnosed.

An average of 381 women died of the cancer each year during the same period.

When the tumour is large but has not spread beyond the breast, the entire affected breast will have to be removed in an operation called mastectomy.

Breast conserving surgery is offered to those who have early-stage cancer and small tumours - which affects between one in three and one in four women here.

This means about 400 to 500 women every year can have surgery which conserves their affected breasts. With such surgery, however, there is a risk that women may need a second operation if the cancer is not wholly excised from the breast.

At the same time, surgeons do not want to remove more tissue than necessary to prevent greater disfigurement.

Some hospitals now use ultrasound scanning technology to guide the surgeon in this respect.

Associate Professor Tan Su-Ming, chief of surgery and director of the Breast Centre at CGH, said: "Before using ultrasound during surgery, we relied on feeling around the cancerous lump to remove it."

How the scanning works

Using intra-operative ultrasound scanning, surgeons can accurately locate the cancerous lump and be more precise in removing the affected area of breast tissue.

A rim of breast tissue around the cancerous lump is also removed at the same time to ensure that all cancer cells are excised. This is called the margin and it should be clear of cancer cells.

After the tissue is surgically removed, it is scanned again using ultrasound.

Additional breast tissue would be removed if the cancer-free margin is found to be less than 15mm in width.

This technique has been used on 113 breast cancer patients at CGH.

It is not the only hospital using scans routinely during breast conserving surgery now. Surgeons at KK Women's and Children's Hospital have used the technique since 2005, said Dr Hong Ga Sze, head and senior consultant at the KK Breast Department.

To attain an even higher level of accuracy, surgeons, guided by ultrasound, may also mark the outline of the area to be removed with multiple wires during surgery.

An accurate removal of cancerous tissue is essential for both better medical and cosmetic outcomes, said Dr Hong.

Ultrasound scanning during breast conservation surgery is offered by some surgeons at Mount Elizabeth Hospital and the National Cancer Centre Singapore (NCCS).

The use of ultrasound scanning during breast conserving surgery at NCCS depends on the surgeon.

For the last 1 1/2 years, Dr Ong Kong Wee, senior consultant at the department of surgical oncology at NCCS, has used it for all his patients during breast conserving surgery. "It gives me another gauge, other than touch, and helps me to remove the cancer with more accuracy at little or no expense to the patient," he said.

At NCCS, between 15 and 20 per cent of women will need a second operation after breast conserving surgery.

At some centres, the use of ultrasound during breast conserving surgery will add a few hundred dollars to the fees for the operation. The average bill size for lumpectomy in hospitals here ranges between $1,500 and $6,500, based on figures from the Ministry of Health's website.

Some not convinced

But though at least four hospitals feel that ultrasound guidance contributes to a clean excision of tumours, not everyone believes the evidence shows it makes a difference.

For instance, ultrasound scanning is not used at the National University Hospital (NUH) in breast conserving surgery.

Dr Chan Ching Wan, a consultant at the division of general surgery (breast surgery), said breast conserving surgery at NUH is done in two ways.

If the cancer is large enough to be felt, the operation is performed by touch. Dr Chan uses her fingers to gauge the periphery of the tumour and cuts around it, leaving a rim of breast tissue around it.

If the cancer is too small to be felt, then she inserts a narrow wire before the operation (either using ultrasound or mammogram guidance before the operation) into the tumour. The tumour is removed using the wire as a guide. The tissue is then checked, using ultrasound scans or X-rays, to see if the margins are clear of cancer.

The need for a second operation for patients undergoing breast conserving surgery at NUH ranges between 15 and 20 per cent.

"This rate is on the better side of standard. Worldwide literature puts re-operation rates at between 25 and 50 per cent," said Dr Chan.

When asked if the results of CGH's study would have an impact on her decision to use ultrasound during surgery, she replied that she not yet seen the data for the numbers that CGH quoted. She added that while there have been studies on ultrasound scanning that show an improvement in re-operation rates, there are also studies which show no or little improvement.

"But, it is definitely an additional tool that can be used to improve patient care," she said.

Another issue with breast conserving surgery is that women may not choose to go for it anyway, she added.

Radiation therapy is a necessity after breast conserving surgery to lower the risk of cancer occurring again in the same breast. Rather than having to undergo radiation therapy and taking that risk, some women may opt to have the whole breast removed instead.

Also, by the time the lump is big enough to be felt, mastectomy with breast reconstruction may be the recommended option, Dr Chan said.

Tan Tock Seng Hospital and Raffles Hospital also do not offer the use of ultrasound during breast cancer surgery.

While this method is still being debated as a viable option, surgeons all agree on one thing - women should have regular screening to detect breast cancer early. Early detection would increase the number of options for treatment.

Mrs Jean Ang, a housewife, had the decision for breast conserving surgery made for her by her husband, in consultation with her sister and doctor. Mr Ang thought removing her entire breast when the cancer was only about 1cm and had not spread to the lymph nodes was too drastic.

CGH's Prof Tan offered Mrs Ang the option of breast conserving surgery, which the couple and Mrs Ang's sister decided would be the best option.

The 59-year-old mother of two said she was in too much shock to make the decision herself.

However, she is glad she chose to have breast conserving surgery in September 2011 at CGH, followed by six weeks of radiation therapy. She had not wanted to lose her breast.

The side effects of radiation therapy were redness in the breast and a slight hardening of the tissue.

"Now my left breast is slightly smaller than my right, but the shape is still there," said Mrs Ang. "I do not need to buy any new bras or shirts."

Radiotherapy on the operating table

At the National Cancer Centre Singapore (NCCS), some women with early-stage breast cancer can have breast conserving surgery and radiotherapy in the same operation.

Radiation therapy is required after breast conserving surgery to lower the risk of cancer occurring again in the same breast. But it is usually administered after the operation, over four to six weeks.

Dr Ong Kong Wee, senior consultant at the department of surgical oncology at NCCS, said radiotherapy given during surgery, or intra-operative radiotherapy (IORT), is a new type of treatment.

He, together with consultant radiation oncologist Wong Fuh Yong, carried out the first IORT procedure in June last year at the centre.

The radiotherapy is delivered to the tumour bed for 30 to 50 minutes immediately after the tumour is removed.

Studies have shown that this single session of radiotherapy offers the same survival outcome and fewer side effects as conventional radiotherapy of four to six weeks.

For stage 1 breast cancer, the five-year survival rate is about 90 per cent. For stage 2 breast cancer, it is about 80 per cent.

But, as Dr Ong points out, there is no question that survival rate would be the same. The worry is whether the recurrence rate would increase.

Results from the latest trial, still ongoing and headed by University College London in Britain, show that there is no difference in the recurrence rate, which is about 1.5 to 2 per cent within the first five years.

IORT costs about $7,000 to $8,000 compared with $5,000 to $6,000 for conventional radiotherapy. It is currently not subsidised.

Dr Ong said the IORT option could convince more women not to choose mastectomy, which some do now because they do not want to deal with weeks of radiation treatment.

About 10 to 15 per cent of all cases of breast cancer, particularly those at an early stage, are suitable for IORT, he said.

The size of the tumour must be smaller than 3cm in diameter, and the cancer must not have spread to the lymph nodes. Patients must also be more than 50 years old. Other factors include how aggressive the tumour is and the patient's responsiveness to hormone treatment.

Of the 15 cases of breast conserving surgery with IORT done so far at the NCCS, only one case required mastectomy to remove the whole breast subsequently.

At least half of the operations were also done using intra-operative ultrasound scanning.

Dr Ho Gay Hui, senior consultant at the department of surgical oncology at NCCS, said the partial radiation delivered by IORT spares a patient's normal tissue.

This tissue may include the skin of the breast, the remaining breast tissue, underlying ribs, the lung and the heart.

The NCCS will be conducting clinical trials in future to see if the use of IORT can be extended to a larger group of breast cancer patients.


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