Colorectal Cancer

Colorectal Cancer

What is Colorectal Cancer?

Colorectal Cancer (also known as bowel cancer and colon cancer) is cancer found in the colon or rectum (part of large intestines).

Image source: OncoLink

Most colon cancer start as a growth on the inner lining of the colon called polyps. Over time, these polyps can change into cancer.

Image source: National Cancer Institute

Factors which can increase chance of cancer include:

i) If polyp is larger then 1cm

ii) If more than 2 polyps are found

iii) If the cells in the polyp show pre-cancerous changes called dysplasia

How does the colon look like?

Image source: Mayo Clinic

The colon is around 5 feet long for undigested food to pass through before coming out as waste. The first section is called ascending colon, second section is the transverse colon and the third section is the descending colon. The last 2 sections are the sigmoid and rectum where the waste products sits and wait before being excreted. If you are constipated, the waste sits here longer.

How does Colon Cancer spread?

Over time a polyp can grow into the wall o the colon deeper into the layers of the wall and finally into blood vessels or lymph nodes. The final 4th stage is when the cancer has spread to other parts of the body. The chance of surviving the cancer gets LESS with each increasing stage.

Image source: My Support 360

What are the risk factors?

1) Age (most colon cancers start after 50 years old)

2) Diet

  • Long term consumption of read meat or processed meat
  • High temperature cooking such as barbecuing and pan-frying
  • Low fibre intake (constipation increases time toxins in contact with the colon)

 

3) Smoking

  • Smoking increases the risk of colon cancer and chance of dying from colon cancer

 

4) Family history

  • The increase in life time risk related to family history ranges from two to six fold
  • Risks are greatest in relatives of patients diagnosed young, tow or more affected relatives or relatives of patients with colon cancers

5) Obesity

  • Being overweight, having high fat diet and physical inactivity increases the risk of colon cancer

 

Why screen for colon cancer?

It is important to undergo screening for colon cancer because detecting colon cancer EARLY increases the chances of survival. Late stage cancers (such as stage 3 or 4) have worse prognosis. In fact at the polyp stage, the removal of polyp eliminates the chance of it progressing to later stage of cancer.

For those who have had polyps in the past should arrange for one or two yearly screening/surveillance. The screening of colon is by using a flexible endoscope called colonoscopy.

Screening is the testing of asymptomatic individuals to determine the risk of developing colon cancer and surveillance is the ongoing monitoring of individuals who have an increased risk for the development of the disease.

In conclusion, colon cancer is a major public health concern and is the 2nd most common cancer in Malaysia.

Cancer statistics in Malaysia:

 

Source: National Cancer Registry Report 2007-2011 (Oct 2016)

Screening lowers the incidence and mortality of colon cancer and colon cancer is preventable through removal of premalignant polyps and is curable if detected and treated early.

References: Johns LE et al. Am j Gastroenterol. 2001;96(10):2992, Morb mortal Rep 2011;60(26):884, Globocan 2012

Download Teleme’s mobile app and consult Dr Meheshinder, Colorectal Surgeon about Colorectal Cancer

 

 Dr. Meheshinder

Dr. Meheshinder

Colorectal Surgeon

 Dr. S. Mahendra Raj

Dr. S. Mahendra Raj

Gastroenterologist (gut physician)

Living with Diabetes and Lifestyle Changes

Living with Diabetes and Lifestyle Changes

It’s important to look after your own health and wellbeing, with support from those involved in your care in order to manage your diabetes condition.

image credit: Stock Unlimited

1. Connect with your healthcare professional closely

  • Regular (6-12 monthly) check on your eyes (consult an ophthalmologist).
  • Have your feet examined and fitted with appropriate shoes (consult a podiatrist).
  • Do regular blood tests (around 3 monthly) to monitor how well your diabetes is being controlled (consult a GP, physician or endocrinologist).
  • Self-Monitoring Blood Glucose must be performed if you are on insulin and recommended if you are on oral medication for self-empowerment.

 

image credit: Stock Unlimited

2. Change Your Lifestyle

  • Healthy eating by reducing the amount of fat, salt and sugar and increase the amount of fibre (20-30 g/day) in your diet. A balanced diet should consist of 45–60% energy from carbohydrate, 15–20% energy from protein and 25–35% energy from fats. Limit consumption of sugar sweetened beverages to less than 2 servings per day or <10% of daily calorie intake. Switch diet from high to lower glycemic index (GI) foods or consult a nutritionist.
  • Regular exercise can help lower your blood glucose level. However, before starting on a new activity, do talk to your healthcare professional first because your insulin treatment or medication may need to be adjusted. You may consult a fitness trainer to arrange an exercise program for you.
  • Quit smoking as it increases your risk of developing a cardiovascular disease such as heart attack or stroke.
  • Limit alcohol intake to the recommended daily amounts and never drink alcohol on an empty stomach.
  • Look after your feet by wearing appropriate and well-fitting shoes. Avoid walking barefoot as this increases the risk of injury.

 

image credit: Stock Unlimited

2. Pregnancy

If you have diabetes and plan to have a baby, do talk to your healthcare professionals to ensure your blood glucose level is well controlled before and during pregnancy. Diabetic control can be challenging during pregnancy.

Sources: National Institute of Diabetes and Digestive and Kidney Diseases, NHS Choices, Diabetes Australia

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Type 2 Diabetes Treatment and Medication

Type 2 Diabetes Treatment and Medication

Treatment

Currently there is no known cure but the disease can be controlled to enable the individual to have a better quality of life. The main aim of management is directed at reducing complications and prevent premature death by keeping consistently good diabetic control.

 

All patients with diabetes should undergo lifestyle modification, which consists of dietary therapy and increased physical activity.  Unfortunately, more than 80% of patients still find difficulty keeping good control.

 

The need for oral medications or insulin therapy depends on the symptomatology, state of glucose control and the presence of any complications.

 

Target control for Type 2 Diabetes

Glucose control Fasting 4.4 – 7.0
  After meals 4.4 – 8.5
  HbA1c ≤6.5%
 
Lipids control Triglycerides ≤1.7
  HDL cholesterol >1 (males)

 

 

 

>1.2 (females)

  LDL cholesterol ≤2.6
 
Blood pressure control ≤135/75
Exercise 30 minutes / day
Body weight (if overweight) Aim to lose 5-10% over 6 months

 

image credit: Pixabay

Choice of medication

If changing your lifestyle (such as diet, exercise or weight loss) has not improved your condition, your doctor may need to start you on medication.  Oral Anti-Diabetic medication can be used as monotherapy or in combination with other OAD(s) and/or injectable agents such as insulin or GLP-1 receptor agonists.

 

1. Biguanides (Metformin)

Metformin lowers blood glucose especially fasting blood glucose by decreasing hepatic glucose production. It reduces HbA1c by about 1.5%. Most common adverse effects are nausea, anorexia and diarrhoea and can be minimised if it is taken together with/or after meal or taking the extended release (SR or XR) formulation.

Drug Formulation Brand
Metformin 500 mg Glucophage Diabetmin
Metformin SR 850 mg Diabetmin Retard
Metformin XR 500 mg / 750 mg/ 1g Glucophage XR

 

2. Sulphonylureas

Sulphonylureas reduce plasma glucose by increasing insulin secretion. It reduces HbA1c by about 0.4-1.6%. It should be taken 30 minutes before meals.  The major adverse effect is hypoglycaemia (this risk is higher in renal impairment, liver cirrhosis and the elderly) and weight gain.  Be careful of drug interaction with NSAIDs, anti-thyroid medication and anticoagulants.

Drug Formulation Brand
Glibencamide 5 mg Daonil
Gliclazide 80 mg Diamicron Glmicron Glyade
Gliclazide MR 60 mg Diamicron MR
Glipizide 5 mg Minodiab

 

3. Meglitinides

Meglitinides also increase insulin secretion but bind to a different site within the SU receptor.  It can reduce HbA1c by 1-1.2%.  It should be taken 10 minutes before meals and is associated with less risk of weight gain compared to sulphonylureas and hypoglycaemia may be less frequent.

Drug Formulation Brand
Repaglinide 0.5 mg / 1 mg / 2 mg Prandin

 

4. Alpha-Glucosidase Inhibitors (Acarbose)

Acarbose reduces the rate of absorption of polysaccharides in the small intestine by inhibiting glucosidase enzymes and should be taken with meals. It lowers postprandial glucose without causing hypoglycaemia but is less effective in lowering glycaemia than metformin or SU, reducing HbA1c by 0.5–0.8%. The side effects are bloating, abdominal discomfort, diarrhoea and flatulence.

Drug Formulation Brand
Acarbose 50 mg / 100 mg Precose Glucobay

 

 5. Thiazolidinediones (TZDs)

Thiazolidinediones are peroxisome proliferator-activated receptor-gamma (PPAR-) agonists and act by increasing insulin sensitivity in muscle, adipose tissue and liver.

It can reduce HbA1c by 0.5–1.4% but improvement in glycaemic control may only be seen after six weeks with maximum effect at six months.

Side effects include weight gain (due to redistribution of body fat), fluid retention, heart failure, macular oedema and osteoporosis. They are contraindicated in patients with heart or liver failure.

Drug Formulation Brand
Rosiglitazone 4 mg / 8 mg Avandia
Plogitazone 15 mg / 30 mg Actos

 

6. Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

It lowers A1c by 0.5–0.8% and does not cause weight gain with minimal risk of hypoglycaemia.

Drug Formulation Brand
Sitagliptin 25 mg / 50 mg /100 mg Januvia
Vilagliptin 50 mg Galvus
Saxagliptin 2.5 mg / 5 mg Onglyza
Linagliptin 5 mg Tradjenta
Alogliptin 6.25mg /12.5mg /25mg Nesina

 

7. Sodium-glucose Cotransporter 2 (SGLT2) Inhibitors

This class of drugs selectively inhibits SGLT2, a transporter in the proximal tubule, thus reducing glucose reabsorption leading to an increase in urinary glucose excretion. It reduces HbA1c by 0.2% to 0.8%. It is accompanied by weight loss (2.5 to 3.0 kg) and modest blood pressure reduction together with lower risk of hypoglycaemia.  Side effects include significant increase of genitalia and urinary tract infection. It is not recommended in patients with kidney problems.

Drug Formulation Brand
Dapagliflozin 5 mg / 10 mg Forxiga
Canagliflozin 100 mg / 300 mg Invokana
Empagliflozin 10 mg / 25 mg Jardiance

 

image credit: Getty Images

8. Insulin Injections

Insulin may be required when good glucose control cannot be achieved despite optimal OAD treatment. Sometimes, insulin may be required for short term use during pregnancy, acute illness or undergoing surgery.  The ideal insulin regimen should mimic the physiological insulin response to meals and endogenous hepatic glucose production. The choice of insulin regimen is individualised by your doctor, based on your glycaemic profile, dietary pattern and lifestyle.

It is vital to perform Self-Monitoring Blood Glucose while on insulin especially when travelling on holiday because meal times may be different from your usual routine.    You can purchase one online if need be.

 

image credit: Pixabay

Complications

Untreated diabetes can cause serious health problems in the long term such as:

  • heart disease and stroke
  • peripheral neuropathy
  • diabetic retinopathy
  • kidney disease
  • foot numbness or ulcers
  • sexual dysfunction
  • miscarriage

Sources:
1) https://www.niddk.nih.gov
2) MOH Clinical Practice Guidelines on Management of Type 2 Diabetes 2015

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Consult a Doctor/Pharmacist Today

Dr. Chong Yen Pau

Dr. Chong Yen Pau

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Mr. Low Yuen Ker

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I underwent Lasik surgery in Malaysia and I was able to attend follow-up consultations because I currently live in New Zealand. However, upon returning to New Zealand, I managed to consult my doctor through TeleMe’s online video consultation platform and it went smoothly. I highly recommend TeleMe’s service to everyone !

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Dr. Chong Yen Pau

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Mr. Low Yuen Ker

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Ms. Lim En Ni

Ms. Lim En Ni

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Type 2 Diabetes: Causes, Symptoms and Diagnosis

Type 2 Diabetes: Causes, Symptoms and Diagnosis

Type 2 diabetes is the most common form of diabetes in Malaysia. According to the National Health and Morbidity Survey 2015, almost one in five Malaysian adults has diabetes. The survey also revealed that 1.8 million out of 3.5 million Malaysians diagnosed with diabetes were not even aware they have the disease!

Diabetes is a lifelong condition when your blood glucose level is too high. Type 2 diabetes occurs progressively when the body becomes immune to the effects of insulin (insulin resistance) and/or the pancreas does not produce enough insulin (insulin deficiency). This results in glucose staying in the blood and unable to be utilised by the body organs to be used as energy.

 

image credit: Pixabay

 What Causes Type 2 Diabetes?

1) Overweight: Being overweight will cause our body cells to not react to insulin

 

2) Genetics: If you have a family member who has diabetes, you have a higher chance of getting diabetes

image credit: Getty Images

Symptoms of Type 2 Diabetes

Majority of diabetics do not have any symptoms until much later on when they will experience some of these:

  • feeling very thirsty
  • passing urine more often than usual especially at night
  • feeling more tired than usual
  • unexplained weight loss
  • blurred vision
  • cuts and wounds take longer to heal

image credit: Pixabay

There are a few ways to diagnose diabetes and tests should be carried out in your doctor’s clinic or a health lab prior to initiating therapy.

 

1) The Fasting Blood Glucose Test is a blood test to diagnose diabetes or pre diabetes and requires you to fast for 8 hours before performing the test.

 

2) The Random Blood Glucose Test measures your blood glucose at any time.

 

Fasting Random
Venous blood (mmol/l) >7.1 >11.1
  • In symptomatic individual, one abnormal glucose value is diagnostic.
  • In asymptomatic individual, 2 abnormal glucose values are required.

 

3) The HbA1C Test measures your average blood glucose over the past 3 months. High values mean you are at risk of vascular complications.

 

Normal Pre-diabetes Diabetes
<5.6% 5.6-6.2% >6.3%
  • A repeat HbA1c should be repeated 4 weeks after the first positive test for asymptomatic patients.
  • For symptomatic patients, a single positive test is sufficient.

 

4)  The Oral Glucose Tolerance Test measures your blood glucose level before and after you drink a syrup glucose solution (a sweet drink). Your blood will be drawn once before you drink the solution and have your blood drawn again after 2 hours.

Category 0 hour 2 hour
Normal 5.6-6.2 <7.8
Impaired fasting glucose 6.1-6.9
Impaired glucose tolerance 7.8-11.1
Diabetes ≥7 ≥11.1 

 

Next up on Healthtips by Teleme, diabetes medication and treatment.

 

Sources:
1) https://www.niddk.nih.gov
2) https://www.nhs.uk
3) www.diabetes.co.uk
4) MOH Clinical Practice Guidelines on Management of Type 2 Diabetes 2015

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Dr. Vijay Ananda

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Dr. Chong Yen Pau

Dr. Chong Yen Pau

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I underwent Lasik surgery in Malaysia and I was able to attend follow-up consultations because I currently live in New Zealand. However, upon returning to New Zealand, I managed to consult my doctor through TeleMe’s online video consultation platform and it went smoothly. I highly recommend TeleMe’s service to everyone !

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Download Teleme App and consult a doctor today on diabetes

 

Dr. Vijay Ananda

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Is There a (Virtual) Doctor in the House?

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Depression Care and Treatment: Therapies

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Things You Should Know About Diabetic Retinopathy

Things You Should Know About Diabetic Retinopathy

What is Diabetic Retinopathy?

Diabetic retinopathy (DR) is a complication of diabetes mellitus (DM) and is an important cause of avoidable blindness worldwide. Over time, diabetes causes damage to many organs in your body, including the retina. Your retina helps you see by acting as the film projector in the back of your eye, projecting the image to your brain.

Diabetes damages the tiny blood vessels that nourish the retina. In the early stages, known as non-proliferative or background retinopathy, the vessels in the retina weaken and begin to leak, forming small, dots of bleeding. When retinopathy advances, the decreased blood circulation deprives areas of the retina of oxygen.

Diabetic retinopathy can lead to severe visual loss or blindness in 2 ways. The first is when it affects your macula, the central part of your retina that provides you with sharp, central vision. When this part becomes swollen, it is called diabetic maculopathy.

At the same time, blood vessels can also become blocked or closed, and parts of the retina die. New, abnormal, blood vessels may then start to grow along the retina and surface of the vitreous (the transparent gel that fills the inner part of the eye).

Unfortunately, these delicate vessels can bleed easily. Blood may leak into the retina and vitreous, causing “floaters” (spots that appear to drift in front of the eyes), along with decreased vision. This is called proliferative diabetic retinopathy, and it can even cause scar tissue which can pull off the retina, causing what’s called a tractional retinal detachment (TRD).

In the later phases of the disease, continued abnormal vessel growth and scar tissue may cause a total retinal detachment and glaucoma. The result of either problem, if left untreated, is loss of sight and potentially blindness.

Signs of leakage and bleeding in DR
Figure 1: Signs of leakage and bleeding in DR

Symptoms of Diabetic Retinopathy

You may not be aware the symptoms of DR in the initial stages of the condition, unless it progresses quickly to the more severe stages. The symptoms of DR include:

• Blurred vision
• Sudden loss of vision in one eye
• Seeing rings around lights
• Dark spots or flashing lights

The symptoms described above may not necessarily mean that you have diabetic retinopathy. However, if you experience one or more of these symptoms, contact your ophthalmologist for a comprehensive eye examination.

The following are the risk factors for accelerating DR:

• Poorly-controlled diabetes
• A long duration of diabetes
• High blood pressure
• Elevated blood cholesterol levels
• Sleep apnea
• Gestational diabetes (diabetes during pregnancy)

Tests for Diabetic Retinopathy

A dilated retinal examination will be recommended by your ophthalmologist to examine the retina and detect the presence of any diabetic changes in the eye.

In addition to this, your ophthalmologist may also recommend certain diagnostic procedures such as a fundus fluorescein angiogram (FFA) or optical coherence tomography (OCT) to assess the severity of DR and to determine the best mode of treatment.

The angiogram test involves the injection of fluorescein (a yellow dye) into your arm. The dye can then be seen coursing through the blood vessels in your retina and photos are taken.

Normal, healthy blood vessels do no leak, however, damaged blood vessels like in DR do, thus helping to target treatment. An OCT scan uses reflected light to build a cross sectional image of the retina. Maculaedema is noted when areas of your retina are shown to contain spaces filled with fluid.

Treatment of Diabetic Retinopathy

In mild cases, treatment is not necessary. Regular eye exams are critical for monitoring progression of the disease. Strict control of blood sugar and blood pressure levels can greatly reduce or prevent DR. In more advanced cases, treatment is recommended to stop the damage of DR, prevent vision loss, and potentially restore vision.

Treatment options include:

1. Intravitreal Anti-VEGF injections
Anti-VEGF therapy involves the injection of the medication into the back (vitreous cavity) of your eye. The medication is an antibody designed to bind to and remove the excess VEGF (vascular endothelial growth factor) present in the eye that is causing the disease.

2. Laser Therapy

Laser retinal treatment is often helpful in treat- ing DR. To reduce macularedema, a laser is focused on the damaged retina to seal leak- ing retinal vessels. For abnormal blood vessel growth (neovascularization), the laser treatment is targeted over the peripheral retina (Panretinal Photocoagulation). The small laser scars that result will reduce abnormal blood vessel growth. Laser retinal therapy may be performed in outpatient clinic and greatly reduces the chance of severe visual impairment.

3. Vitrectomy

A vitrectomy may be recommended in advanced proliferative diabetic retinopathy. During this microsurgical procedure that is performed in the operating room, the vitreous is removed and replaced with a clear solution. Your ophthalmologist may wait several weeks to see if the blood will clear on its own before going ahead with surgery. In addition to a vitrectomy, retinal repair may be necessary if scar tissue has detached the retina from the back of your eye. Severe loss of vision or even blind- ness can result if surgery is not performed to reattach the retina.

Proliferation of new blood vessels with scar tissue forming on the retina and in the vitreous

Figure 2. Proliferation of new blood vessels with scar tis- sue forming on the retina and in the vitreous

How to Prevent Diabetic Retinopathy

• Visit your ophthalmologist or optometrist at least once a year. You may be recommended to visit more or less frequently depending on your situation.
Maintain optimal blood glucose levels, blood pressure and blood cholesterol.
• Know your HbA1c (a test of your average blood glucose level over three months). Most people with diabetes should aim for a target of lower than 7%. Talk to your healthcare team about what your target should be.

Who should be screened

All individuals with either Type I or Type II diabetes should be screened annually.
• The interval for follow-up assessments should be tailored according to the severity of the retinopathy. In those with no or minimal retinopathy, the recommended interval is one to two years.
Women with type I or type II diabetes or women who plan to become pregnant should be screened before conception, during the first trimester, as needed during pregnancy and within the first year postpartum

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Dr. Manoharan

Dr. Manoharan

Ophthalmologist (Retina)

Dr. Kenneth Fong

Dr. Kenneth Fong

Ophthalmologist (Retina)

Dr. Alan Ang

Dr. Alan Ang

Ophthalmologist (Retina)

I underwent Lasik surgery in Malaysia and I was able to attend follow-up consultations because I currently live in New Zealand. However, upon returning to New Zealand, I managed to consult my doctor through TeleMe’s online video consultation platform and it went smoothly. I highly recommend TeleMe’s service to everyone !

Jenny Cheng

Patient, From New Zealand

Need To Refill Your Prescription Meds/Get Prescription Meds?

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Talk to a specialist today!

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Dr. Manoharan

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Dr. Alan Ang

Ophthalmologist (Retina)

Everything you wanted to know about breast cancer but afraid to ask

Everything you wanted to know about breast cancer but afraid to ask

Statistics of breast cancer

In the USA 1 in 8 women will get breast cancer.  In Malaysia, the incidence has been discovered to be 1 in 19 women and accounts for around 30% of all new cancers. Around 5,000 Malaysian women are diagnosed with breast cancer every year, most of them aged between 30 and 60 years, where nearly half of those affected are under 50-years of age. Malaysian patients have poor survival rate due to lack of awareness of the signs and symptoms fear of screening and delay in medical treatment when traditional alternative is preferred.

High risk factors

  • Family history of breast or ovarian cancers
  • BRCA gene positive (more than 50% chance of getting breast cancer)

Lifestyle Risk Factors

  • Smoking
  • Alcohol consumption
  • Overweight (BMI more than 25)
  • Lack of exercise
  • Early menarche or 1st pregnancy at a late age in life.

Breast cancer

Breast cancer either begins in the cells of the lobules (known as the milk-producing glands) or the ducts (known as milk passages) and rarely from fatty and fibrous tissue of the breast.  It can spread via the lymph nodes into other parts of the body. The breast cancer’s stage refers to how far the cancer has spread beyond the original tumour.

 

Symptoms or signs of breast cancer

There may be no symptoms at all.  Usually there is a breast lump, breast pain, skin dimpling, changes at the nipple such as in-turning, discharge, rash or redness.

Breast screening

  • Mammogram is recommended every 2 years for women age 50 to 74 years
  • Should not be denied in women between 40-49 even if they are low or intermediate risk,
    Malaysian Clinical Practice Guidelines (2010)

Treatment of breast cancer

Breast cancer is treated with a combination of surgery, chemotherapy or radiation and the choice depends on the cell type and stage of cancer.  Surgery aims to remove the entire cancer with a some surrounding normal tissue and lymph nodes where necessary.

What are the risks for recurrence?

  • Stage of cancer at the time of diagnosis (more advanced stage has worse prognosis)
  • Grade of cancer (higher grade with more undifferentiated cells have worse prognosis)
  • Cancer cell type (invasive cells have worse prognosis)
  • ER / PR hormone receptor positive (amenable to hormone therapy)
  • HER2 gene positive (worse prognosis)

Follow up schedule after breast cancer treatment

  • After initial surgery/chemotherapy/radiotherapy, you are recommended to see the doctor Every 3 months for the first 2 years
  • After that, every 6 months for 3 years
  • After that, every year for 5 years
  • After that, as advised by the doctor

For more references:
www.moh.gov.my | www.acadmed.org.my | www.cancer.org.my |
http://www.cancerresearch.my/research/breast-cancer/ |
http://www.nationalbreastcancer.org/early-detection-of-breast-cancer 

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Dr. Azlina Firzah

Dr. Azlina Firzah

Breast Surgeon

Dr. Mastura Md Yusof

Dr. Mastura Md Yusof

Oncologist

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Genetic Counsellor

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Dr. Azlina Firzah

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Breast Surgeon

 

Dr. Mastura Md Yusof

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Oncologist

 

Ms. Juliana Lee

Ms. Juliana Lee

Genetic Counsellor

 

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