Colposcopy - What is it?

When your cervical screening test has shown evidence of abnormal cells, you will be referred to a Gynae for a colposcopy examination. An abnormal result usually means that small changes have been found in the cells on the cervix (the neck of the womb). These changes act as early warning signals that cervical cancer might develop in the future. However, it is important to remember that it is very rare indeed for these abnormalities to be cancer.

Colposcopy is a screening and simple examination that allows the Gynae to see the type and site of the abnormality on your cervix.

During the examination, you will be asked to undress from waist downwards (though a full skirt need not be removed). A nurse will hep you to position yourself on a special type of couch. The couch has padded supports on  which you rest your legs.

When you are lying comfortably, the Gynae will gently insert a speculum into your vagina, just as when you had your cervical screening test. The Gynae will look at your cervix using a colposcope. The colposcope is specially adapted type of microscope. It is just a large magnifying glass with light source attached. It looks like a large pair of binoculars on a stand. It does not touch you or go inside you.

The Gynae will then dab different liquids onto your cervix to help identify and highlight any areas of abnormal cells. The abnormal areas will appear white. If any abnormal area is identified, a small sample of tissue (a biopsy) will be taken from the surface of the cervix. A biopsy is about the size of a pinhead. You may feel slight stinging but it should not be painful. The procedure will take about 15 minutes.

It will take about a few days before you get the results of the biopsy. The Gynae then will tell you what is wrong and what treatment, if any, is needed.

This article was contributed to Tab A Doctor by,
By Assunta Hospital, Malaysia

Breast Cancer Stages, Associated Risks and Treatment Options

Stage 0 breast cancer usually refers to a condition known as ductal carcinoma-in-situ (DCIS). This is a precancerous condition. Given time, this condition if untreated may progress to form a frankly cancerous tumour which is described as invasive breast cancer. With the further passage of time, it will progress from a small cancer (stage 1) to a larger cancer with spread to the surrounding lymph nodes (stage 2 and 3) and eventually spread to other organs such as the lungs, liver, bones and brain through the blood stream (stage 4).


All stages of invasive breast cancer, from stage 1 to 4, has the ability to travel to other parts of the body outside the confines of the breast, take root and lie dormant, eventually to reactivate and grow in those areas causing a relapse. That is why in most cases of breast cancer relapse, the disease does not recur in the breast but in other organs. In such situations, the cancer is considered advanced and incurable.

 

Fortunately, in the pre-cancerous stage of DCIS (as is the case under consideration), the tumour cells have yet to acquire the ability to travel and spread through the blood stream. Thus, there is no possibility of the disease relapsing in other organs in future causing death. In other words, the long term survival form DCIS (stage 0 breast cancer) is practically 100%. The long term outlook of your relative is therefore very optimistic.


While the risk of the disease spreading and causing a relapse in other organs is absent, there is still a significant risk of a new breast cancer developing in the opposite breast. A new breast cancer, if it does form, may either be of the same stage 0 or it could develop as a higher stage cancer. This is particularly true of your relative who has both a personal as well as a family history of breast cancer.


Women are at much higher risk of developing breast cancer compared with men because the female hormones in women has a stimulatory effect on the transformation of normal breast cells into breast cancer cells. This may potentially be the underlying cause of breast cancer development in your relative. A laboratory test may be performed on the breast cancer tissue that was removed 3 years ago to see if the cancer cells respond to the stimulation of female hormones. This test may still be performed even though the surgery was performed 3 years ago as local hospitals have a practice of preserving and storing all tumour tissue removed during surgery for 5 or more years.


If the test shows that the cancer cells are responsive to female hormones, you relative may consider taking an anti-hormonal treatment to reduce the stimulatory effect of the body's female hormone on the opposite breast thereby reducing the risk of a new cancer forming in that breast. Studies have shown that such a proactive treatment may reduce the risk of a future breast cancer by 50-70%.


If your relative has any female siblings, they are at high risk of developing breast cancer as they now have 2 first degree relatives (mother and sister) with breast cancer. They should consider consulting an oncologist to discuss preventive treatment as I have described.


An active lifestyle with regular exercise and a healthy diet may reduce the risk of future breast cancer relapse. The probable explanation is that such a lifestyle is associated with a lower rate of obesity. As the fat tissue in a woman's body is capable of converting substances in the blood into female hormones, this may lead to a greater stimulatory effect on the transformation of normal breast tissue into breast cancer. Avoiding obesity, in this case, is therefore particularly important.


Surgical removal of a cancerous breast lump while conserving the breast is usually the preferred treatment if such a surgery can be performed with a reasonable cosmetic outcome. Such a breast conserving surgery is usually followed by radiotherapy to the affected breast. The long term survival from breast cancer in such an approach is similar to total removal of the breast (mastectomy) and is better for the patient's self-image and psychological health.

This article was contributed to Tab A Doctor by,

By Dr Wong Seng Weng, Medical Director, The Cancer Centre, a subsidiary of the Singapore Medical Group

Parents warned against giving paracetamol and ibuprofen for mild fever

Parents should not give children with a mild fever regular spoonfuls of paracetamol and ibuprofen, doctors advise today, as they warn that doing so could extend their illness or put their health at risk.

A misplaced “fever phobia” in society means parents too frequently use both medicines to bring down even slight temperatures, say a group of American paediatricians, who warn that children can receive accidental overdoses as a result.

As many as half of parents are giving their children the wrong dosage, according to a study carried out by the doctors.

In new guidance, the American Academy of Pediatrics advises that a high temperature is often the body’s way of fighting an infection, and warns parents that to bring it down with drugs could actually lengthen a child’s illness.

Family doctors too readily advise parents to use the medicines, known collectively as “antipyretics”, according to the authors of the guidance.

GPs also often tell parents to give their children alternate doses of paracetamol and ibuprofen – known as combination therapy – believing the risk of side effects to be minimal.

In its official guidance, the National Institute for Health and Clinical Excellence (Nice) says the use of the drugs “should be considered in children with fever who appear distressed or unwell”.

Although Nice says that both drugs should not “routinely” be given to children with a fever, it states that this approach “may be considered” if the child does not respond to being given just one of them.

Children’s paracetamol solutions such as Calpol and ibuprofen solutions such as Nurofen for Children are sold over the counter in chemists. Recommended dosage quantities vary by age.

There is a range of solutions for different age groups, meaning it is possible for parents with children of different ages to mix up which they are giving.

According to the British National Formulary, which GPs consult when prescribing or advising on medication, children should receive no more than four doses of the right amount of paracetamol in a 24-hour period, and no more than four doses of ibuprofen a day.

In its guidance today, however, theAmerican Academy of Pediatrics notes that both medications have potential side effects and says the risks should be taken seriously.

Doctors, the authors write, should begin “by helping parents understand that fever, in and of itself, is not known to endanger a generally healthy child”. “It should be emphasised that fever is not an illness but is, in fact, a physiological mechanism that has beneficial effects in fighting infection.”

Despite this, the academy says, many parents administer paracetamol or ibuprofen even though there is only a minimal fever, or none at all.

“Unfortunately, as many as half of all parents administer incorrect doses,” the authors say. A frequent error is giving children adult-sized doses, while children who are small for their age can also receive doses that are too high even if their parents follow the instructions correctly.

Paracetamol has been linked to asthma, while there have been reports of ibuprofen causing stomach ulcers and bleeding, and leading to kidney problems.

“Questions remain regarding the safety” of combination therapy, say the authors, led by Dr Janice Sullivan, of the University of Louisville Pediatric Pharmacology Research Unit, and Dr Henry Farrar, of the University of Arkansas.

Dr Clare Gerada, the chairman of the Royal College of GPs, said: “In my experience of 20 years as a GP, parents are usually pretty careful.

“I think the most important thing to be worried about is keeping medicines out of the reach of children, because some taste quite nice.”

This article was originally published on telegraph.co.uk

Your Guide To Assisted Conception

Sometimes nature needs a helping hand. Your doctor would be able to recommend the most suitable method of assisted conception after running some tests. The approach recommended is dependent on several factors, namely the age of the female partner, the duration and cause of infertility and the preference of the couple. The following is an overview of the current treatment available for treating infertility. 

Ovulation Induction
This is the most basic of all infertility treatment. For women who do not ovulate regularly, fertility tablets (sometimes injections) are given to stimulate the ovaries to produce eggs. The doctor then scans the ovaries to try to pinpoint the best time for intercourse. Alternatively, the woman may wish to time the intercourse by performing self-urine LH test.
 
Laparoscopic Keyhole Surgery
This is a surgery where tiny “keyhole” cuts are made on the tummy and special laparoscopic instruments are inserted. The aim of the surgery is to diagnose the cause of infertility (diagnostic laparoscopy) as well as to treat infertility (therapeutic laparoscopy). Surgery may be advised if you have blockage or adhesions of the Fallopian tubes, endometriosis, ovarian cysts and certain uterine fibroids. In general, the chance of falling pregnant is doubled after this surgery. 

Intrauterine insemination (IUI)
IUI is often used when the woman is not ovulating regularly and has at least one open Fallopian tube or the husband has sperms that have low quality. This treatment is also useful for couples who cannot have intercourse adequately due to erectile dysfunction or vagisnismus (painful intercourse). The semen is washed and treated. A small plastic tube is inserted into the woman’s womb and the processed semen is inseminated close to the eggs, at the time she is most fertile. This usually takes place in conjunction with stimulation of the ovaries with medications. 

In-vitro fertilization (IVF)
IVF is usually considered if the woman has damaged Fallopian tubes which are not amenable to surgical correction, or the husband has borderline low sperm count or quality, or when there are antibodies in the sperm. IVF is also sometimes considered if the couple has unexplained infertility. The woman undergoes a series of injections to stimulate the ovaries and when the eggs are matured they are collected. This is done using ultrasound and a fine hollow needle. Once the woman is sedated, a small probe is placed into the vagina to guide the needle to the ovaries, and the eggs are sucked up. The eggs are then mixed with the sperms in a flat, glass petri dish and kept in culture in the incubator for at least two days. The fertilized eggs (embryos) are then transferred back into the womb using a fine plastic tube. 

Intracytoplasmic Sperm Injection (ICSI)
ICSI is used if the male partner has extremely low sperm count or quality. It is also useful for couples who have had IVF cycles where very little or no fertilization occurred. Eggs are collected as for IVF. Mature eggs are chosen and each one is held on a tiny pipette while a single sperm is injected directly into the centre of the egg using microinjection equipment. Fertilization occurs in about 70% of the time and the fertilized eggs are subsequently transferred back into the womb. 

In-vitro Maturation (IVM)
In-vitro maturation (IVM) involves retrieving immature eggs from an unstimulated or partly stimulated ovary, and maturing these eggs in the incubator. Subsequently, these matured eggs are fertilized using ICSI. This is an attractive alternative to conventional IVF as it minimizes the discomfort and risks of ovarian stimulation as well as there is a significant reduction in costs. IVM is particularly useful in women who have polycystic ovaries, as the risk of Ovarian Hyper-stimulation Syndrome (OHSS) is high. 

Preimplantation Genetic Diagnosis (PGD)
Following IVF, one or two cells are removed from a fertilized egg (embryo) using very specialized techniques. These cells are then tested for specific genetic disorders such as thalassemia and/or the correct numbers of chromosomes to exclude conditions such as Down Syndrome. Only healthy embryos are then transferred back into the womb. Despite earlier reports, PGD has not been shown to improve pregnancy rates. 

Laser Assisted Hatching (LAH)
For a pregnancy to result from IVF or ICSI, the embryo must successfully implant into the uterus following the embryo transfer. Using a precision laser, an opening is made in the zona pellucida (the shell surrounding the fertilized egg) to weaken the wall of the embryo. The opening made by laser hatching helps the embryo hatch from zona pellucida and implant correctly. This procedure is recommended for women undergoing Frozen Embryo Replacement (FET) and women with recurrent IVF failure. 

Sperm or Egg Banking
For certain individuals, there is a need to preserve their sperm or eggs for use at a later stage. This may include men or women who may need to undergo surgery to remove their reproductive organs due to a cancerous condition, or undergo chemotherapy which may render them sterile. It is now possible to freeze adequate amounts of sperms and eggs in cryobank for future use. There are also women who want to freeze their eggs before they reach the end of their reproductive life as they have not found the right life partners yet.

This article was contributed to Tab A Doctor by,
Dr Wong Pak Seng, Obstetrics and Gynaecologist, Sunway Medical Centre

Breast Cancer – What are the choices?

Introduction 

Breast cancer is the most common cancer among women in Singapore. Worldwide, it is also the most common cancer among women. Breast cancer cases have increased because of the aging population (chances of getting breast cancer increases with age) and more women are now aware and are going for regular breast checks.

Risk factors 

The risk factors for breast cancer are:
• Women over the age of 40 years (but can occur at any age)
• Personal history of breast cancer in the same breast or contralateral breast
• Family history of breast, ovarian, uterine cancer or colon cancer
• Genetic predisposition (defects in BRCA 1 or BRCA 2 genes)
• Radiation exposure (treatment) to the chest during childhood or adolescence or young women
• Early onset of menses(before age 12) or late menopause(after age 55)

Fig. 1

• Use of combined hormone replacement therapy
• Use of birth control pills
• Never had children or had children after age of 30
• Excessive alcohol intake

• Obesity

Signs and symptoms (Fig.1 and 2)

The signs and symptoms of breast cancer are:
• Persistent lump in the breast or axilla
• Change in breast skin colour or appearance such as redness, puckering or dimpling

Fig. 2

• Change in breast size or shape

• Discharge from the nipple especially if it is bloody

• Change in the nipple or areola, such as scaling, persistent rash, or nipple retraction

Diagnosis and Staging Tests

Tests used to diagnose and monitor patients with breast cancer may include:

• Breast ultrasound to show whether the lump is solid or fluid-filled. (Fig.3) 

Fig. 3

• Mammography to screen for breast cancer or help identify the breast lump (Fig. 4 and 5) 

Fig. 4

Fig. 5

• Breast MRI to help better identify the breast lump or evaluate an abnormal change on a mammogram

• Breast biopsy, using methods such as needle aspiration, ultrasound-guided, stereotactic, or open (Fig.6)

• CT(computed tomography) scan to check if the cancer has spread

• PET(positron emission tomography) scan to check if the cancer has spread 

Fig. 6

Staging

Stage 0 (Ductal / Lobular carcinoma in situ or DCIS / LCIS ) (5 year survival 95%)

The cancer cells are found in the milk ducts or lobules of the breast. The cancer cells have not spread out of the milk ducts or lobules of the breast. 

Stage I (5 year survival 90%)

The breast tumour is less than 20mm in size. No spread to lymph nodes

Stage II (5 year survival 75%)

There is breast tumour 20mm in size or smaller and breast cancer cells are found in 1 to 3 axillary lymph nodes or,

There is breast tumour more than 20mm in size without any breast cancer cells in the lymph nodes.

Stage III (5 year survival 55%)

There is breast tumour of any size with breast cancer cells in 4 or more axillary lymph nodes or lymph nodes near the breastbone; or

The breast tumour is more than 50mm in size with breast cancer cells in 1 to 3 axillary lymph nodes or lymph nodes near the breastbone.

Stage IV (5 year survival 15%)

The breast cancer cells have spread to other organs of the body like lungs, bone, liver and brain.

Treatment 

Treatment for breast cancer includes surgery, chemotherapy,  radiotherapy and hormone therapy.

In breast cancer surgery, there is breast-conserving surgery (BCS) and there is mastectomy.(fig.7)

Fig. 7

Breast-conserving surgery (BCS) involves only the removal of the tumour or lump including the surrounding normal tissue (called lumpectomy) or a segment of the breast (segmental mastectomy). In BCS, if the margins of the tissues removed is found to have cancer cells a wider excision should be done to make sure that the margins are clear of cancer cells.

Mastectomy involves removal of the whole breast. In simple mastectomy, the entire breast is removed including the nipple. In skin-sparing mastectomy, the entire breast tissue is removed sparing the skin over it as breast reconstruction can be done. This procedure cannot be done if the breast tumour is too large or the skin of the breast is affected by cancer. In nipple-sparing mastectomy, the entire breast tissue is removed excluding the nipple and skin of the breast. This procedure cannot be done if the nipple or the skin near the nipple is affected by cancer. In modified radical mastectomy, the entire breast is removed including the nipple and the axillary lymph nodes. 

Choosing between Breast Conservation Surgery and Mastectomy (Table 1)

When choosing between BCS and mastectomy, the patient and the doctor should consider 

• the size and number of tumours, 

• location of the tumour in the breast,

• if the cancer cells have spread to surrounding areas, 

• the size of the breast, 

• family history

• patient’s wish

Table 1

Factors to consider	Breast Conservation suitable	Mastectomy advised
Size of cancer	Small	Large esp >5cm
Number of cancers	Only one	Multiple
Location of cancer	Away from nipple	Near the nipple
Involvement of skin or muscles	None	Skin or deep muscles involved
Size of breast	Good size	Small breasts
Family history	Low risk	Strong family history
Pros and Cons	After Breast Conservation Surgery	After Mastectomy
Need for adjuvant radiotherapy	Required treatment to the remaining breast tissue	May not need if margins are clear and muscles not involved
Need for chemotherapy	Depends on stage	Depends on stage
Need for hormone therapy	Depends on hormone receptor status of the cancer	Depends on hormone receptor status of the cancer
Follow up	Close follow up on remaining breast tissue and contralateral breast	Focus mainly on contralateral breast
Survival rate	Same in early stages (together with radiotherapy) as mastectomy

In radiotherapy, x-rays are used to kill the cancer cells before or after surgery. Possible side effects of radiotherapy are diarrhoea, bleeding and fatigue.

In chemotherapy, a drug is used to kill the cancer cells before or after surgery. Possible side effects of chemotherapy are nausea and vomiting, loss of appetite, fatigue, hair loss and diarrhoea. 

In hormone therapy, anti-estrogen or aromatase inhibitors are used to stop the action of estrogen or stop the production of estrogen as breast cancer cells require estrogen to grow and multiply.

Risk reduction

Breast cancer prevention lowers the chance of one person getting breast cancer but it does not guarantee that you will not get breast cancer. 

You can reduce risk by:

• avoiding use of combined hormone replacement therapy

• avoiding use of birth control pills 

• avoiding excessive alcohol intake

• maintaining normal body weight

• having children before age 30

• breastfeeding your children

• knowing your family history and seeking advice if there is a strong family history of cancer

• going for breast screening

Women at high risk of breast cancer may also undergo preventive mastectomy or prophylactic mastectomy. These women are those with personal history of breast cancer, strong family history of breast cancer, women who are genetically predispose to develop breast cancer (women who have defects in their BRCA 1 or BRCA 2 genes like Ms Angelina Jolie) or young women who had radiation exposure (treatment) to the chest.

Screening recommendations

The recommended screening for breast cancer are:

 

• breast self-exam once a month. If you detect or notice any breast lump, please consult your doctor.

• clinical breast exam by a doctor once every year from 40 years and above

• mammogram once a year from 40 to 49 years and every 2 years from 50 years onwards. 

• we also recommend breast ultrasound together with the mammogram to improve detection rate. 

• if mammogram and breast ultrasound results are not clear, CT scan or MRI of the breasts can also be performed.

This article was contributed to Tab A Doctor by,

By Dr Kum Cheng Kiong, Senior Consultant Surgeon, Center of Screening and Surgery