Speech by Director of Medical Services, Professor K Satku, at The Breast Screen Singapore (BSS) Multidisciplinary Seminar

Dr Ong Kong Wee, Chairman of the BSS Organising Committee,

Distinguished Guests, Ladies and Gentlemen, Good morning

BACKGROUND: THEN AND NOW

1.         Over the last 40 years, Singapore has seen three-fold increase in the age-standardized incidence of breast cancer, from 22 per 100,000 in the early 1970s to 61 per 100,000 in the period 2006 to 2010. This trend is thought to be due to lifestyle factors such as having the first pregnancy at an older age, having fewer children, weight gain after menopause and a sedentary lifestyle. Breast cancer is now the most common cancer in Singaporean women, accounting for almost 30% of all cancers diagnosed and is also the most common cause of cancer death in women, accounting for 18% of cancer deaths in women¹. In the 80’s and 90’s, few countries, only the Scandinavian countries, UK and Canada, offered national screening programs for breast cancer².

2          Here in Singapore, while there was an increasing amount of education on screening for breast cancer it was not practised on a large scale. So, when BreastScreen Singapore was launched 10 years ago, only about 50% of Singaporean women knew about the importance of screening. Today, awareness is over 90%. BSS has been busy, screening close to 250,000 women in the last 10 years, and detecting over 1,800 cases during this time³. 70% of these were invasive cancers and 30% were DCIS cases.

ACKNOWLEDGING STAKEHOLDERS’ COMMITMENT

3.         The BSS program would not have been possible without our many partners: I would like to take this opportunity to commend NHG diagnostics, Medi-Rad Associates Ltd, Singapore General Hospital, Tan Tock Seng Hospital, Changi General Hospital, National University Health System, and the National Cancer Centre. With your highly skilled professionals – doctors, nurses, radiographers and other healthcare professionals – you have shown much dedication in ensuring the best outcomes for the women participating in BSS.

4.         Our partners have been instrumental in ensuring the two unique features of the program:

Robust quality assurance and improvement framework

5.         Firstly, the program has established a robust quality assurance and quality improvement framework. This includes standards and guidelines for mammography screening, reading and assessment. Double reading of films is one of such required standards, and if there is a discrepancy, a third reading is done by an independent radiologist. The approach is developed and adopted as one of continuous quality improvement. Thus far, 90% of the centres have met the QA requirements fully, and the program is working with the remaining providers to ensure that their compliance is also 100%. To ensure that women receive good quality screening services regardless of where they attend for their screening mammogram, this QA  framework  has also been extended to non-BSS, private X-ray centres which are registered under the Medisave scheme and can extend Medisave use to their clients.

Continuing medical education & training

6.         Secondly, the program affords opportunities for continuing professional education and training, such as regular clinical reviews for the radiologists, surgeons and pathologists; workshops for all breast screening healthcare professionals, and regular customer service training programs for front-line staff.

7.         Just this year, the program introduced a specific training track for our primary care physicians. This is vital, since they have the best opportunity to educate and counsel women on the risks of breast cancer and the benefits of screening.

THE GOAL

8.         So far we have discussed screening as if there were only benefits. But this is not true for any screening program. Breast screening is no different.

9.         Allow me to explain: We need to acknowledge the controversies surrounding breast cancer screening which have arisen in recent years; specifically, the polarised arguments about the harms of breast cancer screening. While there is no consensus on this, we would do a disservice to our patients if we ourselves do not understand what the issues are.

10.       Various studies have documented mortality reduction of between 15-30% from breast cancer screening. This is a significant benefit. Based on this, we have encouraged as many women to come forward to be screened, and have their breast cancers detected early so that they can be treated early on in the disease.

11.       Mortality reduction notwithstanding, screening is not just about benefit. The most commonly discussed harm in a doctor’s office is probably focused on false-positive screening tests.

False positives are more common in younger women, those in their 40’s, due to denser breast tissue, and are associated with much anxiety while the women concerned wait for the results of further tests.

12.       In actual fact, false-positive results are not the most important harm of screening, overdiagnosis is. This is when women are diagnosed, and undergo treatment for something detected during screening that may never have presented clinically in their lifetime.

13.  I would like to emphasize that I am in no way discouraging people from coming forward for screening. Far from it. With our currently low screening rates of 40%, more can be done to improve uptake, facilitate early diagnosis, and improve survival. However it is important to realize that ultimately, we as healthcare professionals have a duty of care to be current and fully informed ourselves, to provide sound advice to our patients, and to encourage frank discussions on screening and possible outcomes. Our patients would appreciate the balanced information, and if our discussions are done right, it should not deter them from making the right choice with regard to screening.

 14.      More research needs to be done to address the scientifically challenging issue of potential overdiagnosis and we will continue to watch the horizon for emerging evidence.

15.       As BSS enters its second decade, allow me to congratulate you all on a job well done. On this note let me thank you all, guests, faculty and participants for joining us at this seminar. I wish you an enjoyable time of sharing your knowledge and learning more.

[1] Singapore Cancer Registry Interim Annual Registry Report: Trends in cancer incidence in Singapore 2006 – 2010, National Registry of Diseases Office (NRDO)

[2] National breast cancer screening programs started in 1986-1988 (Finland, Iceland, UK, Canada)

[3] 1,881 cases have been detected, of which 70% were invasive, and 30% were DCIS cases