Breast Service

All cancers begin as a mutation at the cellular level. Breast cancers start from abnormal changes that result in a single cancerous cell, which divides and replicates into an evolving and enlarging cluster, until it gains enough mass to finally reveal itself as a cancerous tumour. The speed of development from normal breast to cancer cell and then to mass can vary. Breast cancer is often diagnosed when the patient feels a palpable lump, which is often painless. However, look out for more subtle signs, such as skin and nipple areolar changes, nipple discharge, and in the best-case scenario, screening allows detection when we are completely asymptomatic, when changes are visible only on imaging modalities. All breast lumps (painless or otherwise), breast textural changes, breast skin changes, nipple-areolar changes, and nipple discharge etc. should be evaluated by a healthcare provider experienced in breast evaluation or a breast specialist. In the event of any uncertainty, the SKH Breast Centre is happy to eluate your concerns for either peace of mind, or for early treatment.

The most common presentation of breast cancer is a painless breast lump. While breast cancer tends to occur in older women, and rarely some men, the disease can strike young women as well. All breast changes should be evaluated by a healthcare provider experienced in breast evaluation or a breast specialist because early detection can positively change the trajectory of treatment and survival.

• Breast calcifications can appear on a mammogram white speck. Breast microcalcifications are fine white specks, termed "micro" as they are small and less than 0.5mm in size. In general, calcifications are usually benign and non-cancerous, but certain patterns can be an early sign of pre-cancerous lesions or early cancer, particularly if the calcifications are 1. microcalcifications, 2. heterogenous (vary in size and shape), and 3. clustered in one area of the breast. 
• Your breast surgeon and breast radiologist will carefully interpret these findings. If the breast calcifications appear indeterminate or suspicious on your initial mammogram, you may be re-called or required to proceed with additional magnification views to get a closer look. Ultimately, we may recommend a breast biopsy to confirm the true nature of these lesions. When appropriate, stereotactic (mammographic) vacuum assisted biopsy (VAB) can be offered for both diagnostic and therapeutic purposes – to clarify the nature of the microcalcifications and remove them entirely as treatment. If these results return as benign (non-cancerous) you would have been adequately assessed and completely treated. If these results lead to a diagnosis of high-risk lesions or early breast cancer, you will be further advised.

• A breast cyst is a fluid-filled sac within the breast. A simple cyst is benign, and its size is related to the amount of fluid entrapped within. In the absence of suspicious features and/or solid components on complete clinical and radiological evaluation, a simple breast cyst has negligible risk of malignancy. This means you will likely be advised to leave the cyst alone as simple breast cysts are generally not dangerous. Treatment is necessary only when you have specific symptoms of concern, for example pain from cyst wall distension, infection, or if they are very large and unsightly. For these cases, we can perform "needle aspiration" to extract the cyst contents, usually under image guidance, for comfort or resolution. You should not require any further surveillance in straightforward cases.
• We don’t conclusively know what causes some women to develop breast cysts, but we do know that there is a degree of hormonal influence, as cysts can change in size and texture with a women’s monthly hormonal fluctuations that take place as part of menstrual cycles. Therefore, breast cysts tend to occur in ladies of childbearing age and occur rarely post-menopause.
• Monitoring may be required in complex cysts for a limited time period of 1 to 2 years. Further evaluation may be required in unusual situations whereby the cysts are associated with solid and suspicious components and a biopsy may instead be proposed. Your breast specialist would be able to advise accordingly.

• Mastitis is the inflammation of breast tissue that can sometimes be associated with infection. Mastitis is most prevalent among breastfeeding women resulting in lactational mastitis. Superimposed infection can be caused by skin organisms. Any mastitis with superimposed infection may require antibiotic therapy.
• A breast abscess can develop when one accumulates an infective collection of pus. This may require antibiotics in combination with needle or surgical drainage. When the overlying skin is otherwise healthy, our preference is usually image-guided needle aspiration of pus. One, or several attempts may be required in order to resolve the condition without surgical intervention in order to preserve the integrity of your skin and breast tissue. When abscesses are large, multiloculated, or when the overlying skin is damaged, surgical management may be the preferred option instead.
• Less commonly, some occurrences of mastitis are related to an episodic or progressive inflammatory chronic condition known as “granulomatous mastitis”. This condition is a benign autoimmune process, but can be locally aggressive, distressing, and challenging to control. Diagnosis frequently involves teasing out if there are aggravating factors that may be infectious, related to diabetes, sarcoidosis, α1-antitrypsin deficiency, smoking, or others. In the event that no provoking cause is found (idiopathic granulomatous mastitis), therapy may include corticosteroids or methotrexate. 
• Mastitis or breast abscesses that are not adequately treated can lead to a series of breast deforming complications, so it’s important to seek timely treatment from your breast specialist.

We have preserved rapid access clinic appointment slots for such situations. Patients can be referred by a doctor, or you may schedule an appointment via the HealthBuddy app, SKH main line at 6930 6000 or email us at appointments@skh.com.sg.

As an integrated breast unit, our patients can expect a 1-Stop BrEAST service – One Stop Breast Evaluation, Accelerated Screening and Treatment. This means early access for clinical evaluation by a breast specialist, direct-to-imaging (including mammography, breast ultrasound, and breast MRI when required), and direct-to-biopsy when lesions are suspicious or indeterminate. Your breast specialist will see you again at the follow-up appointment to convey the results of your evaluation. Video- or Telephone- Consultation may be offered when appropriate.

I was recommended a breast biopsy. Why was this so and what can I expect? A breast biopsy may be recommended for lesions which are indeterminate, suspicious, or have the appearance of a cancer. Considerations also include the individual patient’s background risk of breast cancer. At SKH, we perform image guided breast biopsies via modalities like ultrasonography, mammography, and MRI. For suitable lesions, image guided vacuum assisted biopsy (VAB) is a good minimally invasive approach for patients to receive sampling and completion lesion extraction at the same time. 

• At the SKH Breast Centre, we offer video or telephone consultations for eligible patients:
  • Follow-up review for normal or non-critical findings.
  • Surveillance of ‘probably benign’ breast diseases.
  • Patients who are overseas (on request).
• You will be offered the option of telemedicine whenever appropriate, or you may request for the service through your breast health provider. SKH utilizes Zoom Cloud Meetings, a secure online video conferencing platform approved by the Ministry of Health for video conference consultation.  Link: https://www.skh.com.sg/patient-services/skh-telemedicine.

Oncoplastic breast surgery (oBCS) is a “tumour-specific, partial and immediate breast reconstruction method that applies aesthetically derived volume-displacement, volume-replacement, or volume-reduction techniques to the field of breast cancer surgery, to allow for higher volume excision with minimal aesthetic compromise”. This means cancer resection alongside deliberate remodelling of breast tissue to restore one’s form and appearance. Oncoplastic breast surgery was revolutionary in our efforts towards increasing the chance of breast conservation for our cancer patients. Before the evolution of oBCS, it was believed that the upper limit of reasonable resection was a mere 10% before a cosmetic deformity would result. That made for a very low threshold that pushed a good proportion of patients away from a simple breast conserving surgery (BCS) towards mastectomy. The emotional impact of losing a breast can be overwhelming. It induces trauma, disrupts sense-of-self and sexual functioning. oBCS increases the proportion of patients eligible for BCS, and considers cosmetic outcomes individualised to patient-tumour morphology, cancer biology, and patient choice.

Minimally invasive breast surgery (MIBS) involves the use of endoscopic-laparoscopic instruments or robotic surgical platforms to perform a subcutaneous mastectomy (whole breast resection) or breast conserving surgery (BCS, partial breast resection). For the surgeon, the use of a camera and endo-robotic instruments allows for improved visualisation, agility, and precision in dissection and haemostasis. The most obvious advantage of the minimally invasive endoscopic or robotic technique is that the surgeon is empowered to make smaller inconspicuous incisions that can even be sited off the main mound of the breast. This means there is no incision on the substance of the breast itself. The planning of the small, off-the-breast scar is not just purely aesthetic. Smaller inconspicuous incisions cause minimal scarring, less postoperative pain, greater patient satisfaction, and wound complications are said to be rare events. The breast skin and nipple-areolar complex remains surgically unaltered, and a scar is potentially not found on the breast itself in a direct face-on manner. The goal of scar minimization is to encourage a resultant natural effect. This has even allowed some patients to forget breast surgery, or even breast cancer, was once a part of their lives.

• Breast reconstruction can be intended for the whole breast following a mastectomy, or partial breast following a substantial partial removal from a breast conserving surgery (see oncoplastic breast surgery). Reconstruction can be immediate or delayed, based on the patient’s cancer or social needs. Immediate reconstruction is favoured and most patients are suitable for this, unless there are specific contraindications unique to the individual. 
• There are numerous long-term studies demonstrating positive psychosocial benefits of restoring the physical form of the breast. While the priority remains cancer care, patients who have breast restoration are better able to achieve an innately natural and symmetrical appearance, tend to be physically more confident, weight-balanced on both sides, and they will not be dependent on an external bra prothesis that corrects only the external appearance. Benefits extend to social confidence and positive sexual functioning. The regained breast shape may even allow patients to forget breast surgery, or even breast cancer, was once a part of their lives.
• For any patient facing a mastectomy, the SKH Breast Centre believes that skin and nipple-areolar complex (NAC) preservation and consideration of breast reconstruction are requisite therapeutic components. The NAC represents a geometric and aesthetic focal point of the breast, and the breast itself retains significant psycho-emotional importance to most women. The nipple-sparing mastectomy (NSM) can be performed for any tumour of any size that does not involve the skin or NAC directly. Clinical signs of nipple and/or areola involvement and a positive retroareolar margin (on sampling and microscopic frozen section examination during the surgery) are the main contraindications to nipple and/or areolar preservation. 
• We offer the full spectrum of breast reconstruction including prosthetic (implant-based) methods and autologous (tissue from one’s own body). Prosthetics (breast implants) and adjunctive procedures are often preferred by women who wish to avoid prolonged and extensive operations involving a second body site. Others prefer autologous reconstruction, which utilises deep skin, subcutaneous fat, and/or muscle from an alternative body part in order to reconstruct the breast. Autologous reconstruction requires a second site of surgery but establishes enduring natural aesthetics and tactile results. The most commonly utilised option for autologous reconstruction is abdominal based, using flaps such as the free abdominal perforator flap and the transverse rectus abdominis myocutaneous (TRAM) flap. For suitable patients, the free deep inferior epigastric perforator (DIEP) flap, has edged itself as the preferred reconstruction method that allows close to ideal breast defect restoration, while minimizing damage to the muscle strength of the abdomen, since the ‘free’ DIEP flap utilises skin and subcutaneous tissue and spares the underlying rectus abdominis muscle, as compared to the TRAM flap. Superficial inferior epigastric artery, profunda artery perforator, latissimus dorsi (back), gluteal artery (buttock), upper gracilis (thigh), PAP flap (upper inner thigh), omental (intraabdominal adipose) flap, and others, continue to provide the suitable individual niche benefits. The transfer of new vascularized tissue to the breast wound bed tends to make the texture of the new breast closer to natural body tissue and can be shaped better for a symmetrical appearance, even after radiotherapy.
• Breast reconstruction is a safe procedure and there is a suitable type of reconstruction method that will best suit each patient’s personal situation. Our breast and plastic and reconstructive microsurgeons work alongside our patients to select the best approach for mastectomy, and the best site of tissue reconstruction for their patient unique condition, breast size and shape, body contour, physical requirements, and lifestyle.

• Any breast cancer patient who undergoes a complete axillary lymph node dissection (ALND) has a 15 to 20% risk of developing lymphedema, i.e. chronic upper limb swelling due to fluid retention in the tissues. When a patient requires an ALND for cancer spread to the axillary lymph nodes, this surgery is an important step towards cancer eradication, however there will be inherent compromise to the lymphatic system when all the lymph nodes in the axilla are removed en-bloc. In the affected group of patients, excess fluid and proteins accumulate in the tissue of the arm, resulting in swelling.
• Should this occur, there are specialized treatment options including manual lymphatic drainage (MDL), compression bandaging or garments, and a lymphovenular bypass / anastomosis surgery or lymph node transfer. In conjunction with the SKH Lymphedema Service, there are weekly multidisciplinary clinics that aim to review and treat lymphedema in a holistic manner.
• As prevention is better than cure, the SKH Breast Centre also offers prophylactic lymphovenular bypass surgery for all patients with planned axillary lymph node dissection (ALND), to decrease the risk of developing lymphoedema post-cancer surgery. This aims to lower the risk of developing lymphedema at the time of ALND itself. Consult your treating surgeon for suitability and more details.

There is no evidence to say that one must deliberately restrict any part of their diet after their biopsy or surgery. We do advice avoidance of particular medications and herbs prior to and around any invasive procedure, as some have known or unexpected blood thinning effects that may increase risk of bleeding or affect your ability to recover. The most important consideration here is a healthy balanced diet that keeps you strong and positive during this period of recovery. Consider an increased proportion of healthy foods such as brown rice, wholemeal bread, fruits, vegetables, fish, lean chicken, tofu, dairy, and water during any period of surgical recovery. You should try and remain physically active (within reason) as long as your surgeon hasn’t highlighted any concerns pertaining to recovery.

• Depending on the nature of surgery, you may have been discharged with the following dressings and wound care advice:
• Translucent topical ‘skin’ adhesive dressing (such as Dermabond or Preneo etc.): 
  • Your surgeon has applied a waterproof skin dressing or glue after wound closure. In addition to suture closure, the ‘glue’ acts as an additional adhesive that holds the wound edges together and provides a waterproof environment that lasts approximately 5 to 14 days, for your convenience. 
  • You may wash the surrounding area gently with soap and water, and pat dry.
  • Do not swim or soak in chlorinated water. Do not apply anything to the site, including creams, lotions, solutions, topical medications, and makeup.
  • If the ‘glue’ appears to peel off, do not rub it off or pick at it prematurely. Instead, allow it to fall off naturally. Any remaining adhesive can be safely removed 14 days after your operation.
• Simple wound dressing as a top layer, and "steristrips" as an internal layer:
  • Your surgeon has applied 'steristrip' dressings after wound closure. These are thin adhesive strips that holds the wound edges together. On top of steristrips, a ‘simple dressing’ is applied, and this should last 2 to 3 days from the day of your operation. 
  • You may shower over the top-most dressing gently with water and pat dry if the top-most dressing is water-resistant, otherwise do not shower over the dressing to keep it dry. Do not peel, rub off the dressing, or soak the entire wound in water. You may replace this with a similar dressing if it becomes very stained or soaked. This top-most ‘simple dressing’ can be removed 2 days after your operation. 
  • After the top dressing is removed, you may shower over the steristrips gently with water and pat dry. Do use soap directly, do not peel, rub off the dressing, or soak the wound in water. The' steristrips' may be removed in 14 days, if it has not otherwise come off by itself.
• Water-resistant foam dressing (such as Mepilex border):
  • Your surgeon has applied a water-resistant foam dressing after wound closure. A foam dressing has an absorbent pad and provides a waterproof environment that lasts approximately 7 days, for your convenience.
  •  You may wash over the dressing gently with water then pat dry. Do not peel, rub off the dressing, or soak the wound in water.
  • This foam dressing should be removed 7 days after your operation. 
• When and how to seek further treatment: For any additional concerns, contact our Breast Care Team between 8.30am to 5pm (Monday to Friday) at the phone number provided on discharge, or see a doctor if unwell during weekends or after office hours.

• Screening Mammograms Save Lives
  • For the asymptomatic (well) patient with an average risk of developing breast cancer, breast self-examination and regular mammography is the best and most cost-effective breast cancer screening approach available to date. Regular breast mammograms have been proven to save lives. It can detect the presence of cancerous lesions even before a lump is formed, or small lumps even before they can be felt.
  • In employing low-dose breast x-ray images to spot unusual changes, abnormalities, or tumours in breast tissue before you can even see or feel it, mammograms can screen for and detect high risk lesions, pre-invasive carcinoma or early-stage non-palpable cancers that allow us to execute preventative measures, or early and often more simplified treatment options. Screening mammograms play a central role in early detection and have been demonstrated to lower breast cancer mortality. 
  • For women with dense breasts, ultrasound is sometimes used as an adjunct screening method to complement your mammogram, although best evidence indicates an increased rate of detection for incidental benign lesions. Breast magnetic resonance imaging (MRI) is offered in patients with a high risk of breast cancer, or patient-unique situations. The utility of an adjunct screening ultrasound or MRI should be carefully discussed with your breast specialist. When suspicious lesions are detected, breast biopsies or intervention are sometimes required for complete diagnosis and/or treatment.  
  • For the symptomatic patient (with a specific concern or complaint), “screening” is not appropriate. Consult a breast specialist directly. Combination breast imaging is more frequently utilized for diagnostic purposes. This may include mammography, breast ultrasonography, and breast magnetic resonance imaging when required. 
• Recommendations for Breast Self-Examination and Screening Mammography
  • For women of average risk for breast cancer, it is recommended that one commences mammogram screening from the age of 40. In Singapore, we recommend screening mammography annually from the age of 40 years old, and every 2 years above the age of 50. Breast tissues in younger and/or premenopausal women are denser and more challenging to interpret. Hence, it is recommended for women aged 40-49 years old to go for mammogram screenings at a higher frequency. 
  • For young ladies who have been established to be of high risk for breast cancer, or any individual who has been diagnosed with a high-risk genetic mutation, consult your breast specialist for an ideal screening regime, which may include the addition of breast magnetic resonance imaging (MRI).
• Screening Mammograms are subsidized under HPB’s Screen for Life Program
• The SKH Breast Centre supports Health Promotion Board’s (HPB) Screen for Life (SFL) programme.
• Criteria for eligibility includes:
  • Singapore citizen or permanent resident.
  • 40 years old and above.
  • Asymptomatic, i.e., no breast symptoms like lumps or bloodstained nipple discharge
  • Has not gone for a screening mammogram in the last 24 months.
  • Has not been breastfeeding for the past six months
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  • Although regular screening mammograms remain important for early detection of asymptomatic cancers, breast cancers may still develop in between the intervals of planned screening X-rays. This is why we also emphasize the importance of regular monthly breast self-examination as a crucial part of breast awareness so that any ‘surprise lumps’ that manifest in between can be detected as early as possible.