OCTOBER 2017

If your breast cancer is of the hormone- receptor-positive, HER2-negative variety, and your risk of recurrence is low, you might be eligible for the Oncotype DX test, which analyses 21 genes to establish whether endocrine therapy might be the right choice for you. Endocrine therapy includes: aromatase inhibitors (like Kathy’s anastrozole, mentioned earlier), which suppress oestrogen production; the “anti- oestrogen” Tamoxifen; and ovarian suppression through drugs such as goserelin and leuprolide. All medications of course have their side-effects, some of which can be dangerous; whether they’re suitable for you will depend on all sorts of factors, including whether or not you’re menopausal. Your oncologist should be best placed to advise you on these. Surgery Singaporean Theresa Tan (50 this year) echoes Kathy’s advice to go for screening; she also recommends getting a second opinion. One day in June 2010, after she woke up with “a weird pain”, the first doctor who looked at her mammogram diagnosed Stage 3 cancer. Another doctor, an ultrasound and a biopsy later, she was diagnosed with ductal carcinoma-in-situ (DCIS), a Stage 0 cancer. Despite the cancer being in such an early stage, her surgeon suggested a full mastectomy of the right breast, and that was because such a large area was affected – 3cm by 4cm. Theresa opted for immediate reconstructive surgery in the form of a TRAM flap, a plastic surgery procedure where fat is taken from the belly to form a new breast. “I got a tummy tuck at the same time,” says Theresa, “and a new bellybutton.” At 11 hours, not only was the surgery long, she adds, but it hurt terribly during the recovery period. She has scoliosis, and the tummy tuck affected her back severely: “I walked around hunched over for five months, until physiotherapy and exercise literally straightened me out.”

It took her a while to get over not having both nipples, she says. Seven years later, and cancer-free, she is now “very happy” with the outcome. “My aesthetic surgeon did a beautiful job – my reconstructed breast is the same size as my natural left breast now. And I’m actually fitter than I’ve ever been, because I started working out after the surgery.” I wonder: How usual is it for someone with Stage 0 breast cancer to have a full mastectomy? Dr Chan explains that the DCIS type of breast cancers can sometimes be more extensive, creeping along the breast ducts towards the nipple. “So, even though these patients will not need chemotherapy, they would still require surgery to remove the tumour. If the disease is extensive, a mastectomy with immediate breast reconstruction will give the best oncologic and cosmetic outcome.” Choices – can one just say no? Though we can’t choose our genes (not yet, anyway!), we can and do make nutritional and other lifestyle choices that can affect whether and how our genes are expressed. As women, we’re also in the driving seat when it comes to screening for breast cancer, frommonthly self-examination to scheduling regular

mammograms. And a diagnosis of breast cancer does not diminish your autonomy: from the treatment options your doctors may present you with, you alone have the right to decide the path you wish to follow. So, when it comes to the conventional trio of surgery, radiation and chemotherapy – can you just say no? The answer is a qualified “yes” – as long as you are of sound mind. And though declining all or any particular medically recommended treatment is not the norm, it does happen. Studies have reported that less than one percent of patients refuse all conventional treatment, and three to 19 percent refused chemo either partially or completely. In Dr Georgette Chan’s experience, too, only a very small proportion of patients refuse to undergo surgery – but it does happen. Sometimes it’s for religious reasons, or because they’re in denial, unable to accept the diagnosis. She continues to monitor such patients closely, she says, because “when they see their tumour getting bigger, they tend to come to their senses”. The earlier breast cancer is detected, she emphasises, and the sooner you begin the appropriate treatment, the better the outcome is likely to be. Aside from religious convictions – a belief that prayer will do the trick, for

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