When Ms Kathy Chioh found out she had breast cancer around the age of 40, she had no doubt she would want her breast reconstructed after the tumour was removed.
After discussing it with her breast surgeon and plastic surgeon, she decided to have a fairly new procedure, which used fat from her thigh to partially reconstruct her breast, as even breast conserving surgery would leave a deformity.
The procedure usually takes fat from only one thigh as it would yield enough to reconstruct a breast.
Her plastic surgeon, Dr Evan Woo, who runs the Evan Woo Plastic Surgery Clinic at Mount Elizabeth Novena Medical Centre, said that the resulting asymmetry between the thighs would not be that perceptible when she is wearing clothes.
If there is asymmetry that patients are not happy with, touch-ups could be done during the nipple reconstruction stage a few months later.
One of the considerations for the slim and petite 42-year-old housewife was to preserve her tummy tissue in the unfortunate event that cancer strikes again in either of her breasts, even if her risk of recurrence was not high.
Another patient, Ms Juliana Lok, 40, was diagnosed with breast cancer when she was 38. At that point, she had been trying for a baby for a few years and had adopted a baby girl.
She chose to have breast reconstruction immediately after her mastectomy, which is the surgical removal of one or both breasts.
As she was still hoping to have a child after her cancer treatment, her surgeon avoided using her tummy tissue to rebuild her breast, as this would weaken her abdominal wall muscles. Tissue from her thigh was used instead.
But Ms Chioh and Ms Lok are among the minority here. Despite an increasing array of surgical methods in breast reconstruction for women in many different circumstances, few actually choose it.
There are some 1,400 new cases of breast cancer a year in Singapore, yet doctors say fewer than three in 10 women choose to rebuild their breasts.
A 10-year review at Singapore General Hospital (SGH) found that only 448 patients had breast reconstruction after cancer between January 2001 and December 2010, out of about 7,000 cases of breast cancer over the period.
Over at KK Women's and Children's Hospital (KKH), about a quarter of patients who had their breasts removed due to cancer opted for reconstruction in the last five years (2009 to 2013).
KKH performs about 250 operations a year for breast cancer, said Dr Lim Swee Ho, the acting head and consultant at the hospital's breast department.
At National University Hospital, doctors estimate that about 35 per cent of the 400 women who undergo breast cancer surgery each year choose to have breast reconstruction, said Dr Chan Ching Wan, a senior consultant at the division of general surgery (breast surgery).
Overall, studies have found that, for a variety of reasons, Asians tend to be less likely to undergo breast reconstruction than Caucasians, said Dr Christopher Chui, an associate consultant at the department of plastic, reconstruction and aesthetic surgery at SGH.
INCREASING PATIENT AWARENESS
Here, doctors are trying to increase patients' awareness of their options through a fairly new group called Breast Reconstruction Awareness Singapore, said Dr Chui.
The society, launched in October, aims to provide women with relevant information so they can make an informed decision.
Studies done in the United States, Britain and Australia show that women choose not to have breast reconstruction due to reasons such as advanced age at the time of the mastectomy, concerns about complications from further surgery and uncertainty about the outcome, said Dr Chui.
Some have mistaken fears that the reconstruction can cause the cancer to return or mask a recurrence.
And there are others who believe the procedure is not essential for one's physical or emotional well-being, or they do not want anything unnatural in the body.
Here, doctors say many women are understandably more concerned about the prognosis of their cancer than the physical changes that would arise from surgery, and prefer treatment that would be the simplest and most straightforward, said Dr Benita Tan, a senior consultant in the department of general surgery at SGH.
Many were not keen on breast reconstruction surgery as this may involve taking tissue from other parts of the body, she said.
It would mean more surgery, as well as longer hospital stays and post-operative recovery, she added.
Another reason is that Singapore still has a fair number of women who discover their breast cancer at a later stage, said Dr Tan.
Data from the National Disease Registry Office (NDRO) shows that only about 40 per cent of breast cancer cases are in the very early stages - stage 0 and stage 1 - compared with higher numbers in the US, Britain and some Asian countries such as South Korea.
This results in a shift in the priorities of both patients and doctors caring for patients with advanced disease, with reconstruction taking a back seat while they hasten chemotherapy and other treatments such as radiotherapy.
Women with non-invasive and early stage tumours get to the stage of considering reconstructive surgery more quickly, as they may not need chemotherapy or radiotherapy after the mastectomy.
"If we are able to diagnose the cancer earlier, more women may be receptive to breast reconstruction and benefit from it," said Dr Tan.
This would be possible only if there is a better awareness of breast cancer, treatment options and prognosis, as well as increased participation in breast cancer screening, she added.
AGE MATTERS
Age is another factor for the low rates of reconstruction here, as women who get breast cancer here are older.
If a woman is over 50 by the time she is diagnosed, it is less likely that she would want breast reconstruction, said Dr Chui.
Major reasons given for not having reconstruction include fear of complications and perceiving themselves as being too old for the procedure, he added.
Data from the NDRO shows that only 20 per cent of the women here with breast cancer are under 40 years old.
It is known that younger patients may be more concerned with their appearance after surgery, body image and sexuality. Therefore, they are more likely to want breast reconstruction, said Dr Tan.
They may generally be in better health as well, making them more likely candidates to be considered for reconstructive surgery.
In the 10-year review of women treated at SGH, those who opted for breast reconstruction were on average 46 years old, although the median (most common) age range of the entire group was 50 to 59 years, said Dr Tan.
"Our older patients tend to cite that they are already old and there is no function or need for the breast and do not want to consider breast reconstruction," she said, adding that there is an ongoing study to analyse this issue.
The truth is, age is no barrier for breast reconstruction. The oldest patient to do so at SGH was 70 years old.
"She did very well and benefited from the surgery. It is also important to note that women are living longer and the peak age group for breast cancer is now 60 to 69 years (based on data from 2008 to 2012) and we could expect more older women to opt for breast reconstruction in the future," said Dr Tan.
Still, however slowly, awareness has grown over the years.
The proportion of patients undergoing reconstruction increased from 5.9 per cent in 2001 to 15.7 per cent in 2010 at SGH, said Dr Tan.
It is the same at NUH, now that patients are more informed and doctors have a better understanding of tumour biology and use safer modern techniques, procedures and anaesthesia, said Dr Jane Lim, a senior consultant at the NUH Aesthetic Plastic Surgery Centre.
As a result, women are coming to accept breast reconstruction after a mastectomy.
It is a trend that surgeons, such as Dr Woo, hope will continue.
"An often overlooked aspect of treating breast cancer is the psychosocial aspect of the disease process and its treatment," said Dr Woo, who is also a consultant in the department of plastic reconstructive and aesthetic surgery at KKH.
Losing one or both breasts not only leaves a patient with physical scars but also has a significant psychological impact, said Dr Woo.
The loss can be traumatic and have a negative impact on a woman's body image and sexuality.
RECONSTRUCTION BENEFITS
Immediate breast reconstruction can restore a woman's body image and is psychologically beneficial.
Studies have reported improved overall satisfaction, body image, self-esteem, feelings of attractiveness, and decreased anxiety and depression in patients who have immediate reconstruction compared with patients who delay it, said Dr Chui.
The benefits outweigh any problems and few patients express any regret at having undergone breast reconstruction.
Studies have also shown that those who have had their breasts reconstructed have a quality of life as well as social and sexual relationships that are not significantly different than those of healthy women, he said.
Furthermore, restoring breast symmetry is not just for aesthetics alone.
It gives the woman the ability, comfort and convenience of wearing clothes normally, without a need to put on a prosthesis and to have body balance in back care, especially for women who have larger breasts, said Dr Tan.
It is also important for women to recognise that breast cancer does not mean having to lose the breast, she added.
Treatment could be a combination of surgery, chemotherapy, radiotherapy, hormonal therapy and targeted therapy (molecular drugs) that is individually tailored to the patient's condition.
Women with small, single tumours could be suitable for breast conservation surgery, depending on the nature of the disease.
With good techniques, this would result in only slight changes to the breast, allowing women to keep their breasts without significant deformity, said Dr Tan.
These days, even women with slightly larger tumours may still be able to save their breasts using newer techniques, said Dr Tan.
Reconstructive surgery is particularly valuable among Asian women, who tend to have smaller breasts. There is almost certainly a deformity if no corrective surgery is done even after a lumpectomy (breast lump removal), said Dr Woo.
All patients should be offered the option of breast reconstruction, said Dr Graeme Perks, president of the British Association of Plastic Surgeons who was in Singapore last week for the Royal Australasian College of Surgeons meeting.
In Britain, there are guidelines to recommend reconstruction to all patients undergoing a mastectomy, he said.
"I think we should have similar guidelines here and this needs collaboration between the breast and plastic surgeons," said Dr Woo.
Both Ms Chioh and Ms Lok have no regrets about choosing reconstruction.
"I thought I would have a hole in my breast after surgery to remove the cancer. But my breast looks normal and the scars are minimal," said Ms Chioh, a housewife with a 21-year-old daughter.
Meanwhile, Ms Lok has decided to stop trying for a baby. Her adopted baby girl is now 18 months old. The former air stewardess said she would not have done anything differently.
She said: "I was very happy when the surgeon offered me the option of having a reconstructed breast using my own tissue. I did not like the idea of a breast implant.
"Now, I feel normal again."
This article was published on May 15 in Mind Your Body, The Straits Times.
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