Empowering Change - Remarkable Strides in Breast Cancer Survival

Article By Dr. Donald Greig

October is Breast Cancer Awareness Month, a time when pink ribbons, public campaigns and community events remind us of a disease that has touched almost every family in some way.

But awareness should be more than a colour or a slogan. It should be a prompt to understand risk, recognise symptoms, make informed screening decisions, support those going through treatment, and celebrate the remarkable progress that has been made.

Over the past four decades, breast cancer care has changed dramatically. In many high-income countries, mortality rates have fallen substantially, largely because cancers are being found earlier and treatments have become far more precise. In Hong Kong, breast cancer remains the most common cancer among women, but outcomes have improved greatly compared with previous generations.

A diagnosis of breast cancer is still frightening. It still brings uncertainty, difficult decisions and emotional strain. But today, it is also a diagnosis surrounded by more knowledge, more treatment options and more hope than ever before.

Breast cancer in Hong Kong

Breast cancer is the most common cancer among women in Hong Kong. The Hong Kong Breast Cancer Foundation notes that approximately one in 14 women in Hong Kong may develop breast cancer during her lifetime, and that risk increases with age.

This is why awareness matters.

Breast cancer is not one single disease affecting one single type of woman. It can occur in younger women, older women, women with a strong family history, and women with no obvious risk factors at all. Some cancers are slow-growing and hormone-sensitive. Others are more aggressive and require intensive treatment. Some are detected because a woman feels a lump. Others are found through screening before they can be felt.

The good news is that earlier detection and modern treatment have transformed outcomes for many patients.

Why survival has improved

The improvement in breast cancer survival has not come from one discovery alone. It is the result of many advances working together:

• better public awareness

• earlier presentation

• improved mammography and imaging

• more precise surgery

• safer radiotherapy

• better chemotherapy

• hormone treatment

• HER2-targeted therapy

• immunotherapy for selected cancers

• molecular testing

• multidisciplinary care

• survivorship support

Forty years ago, breast cancer treatment was often more radical and less individualised. Today, treatment is increasingly tailored to the biology of the tumour and the needs of the individual patient.

That is one of the great shifts in modern cancer medicine.

Finding cancers earlier

One of the most important reasons breast cancer outcomes have improved is that more cancers are being detected at an earlier stage.

Early breast cancer is generally more treatable. A cancer detected at Stage 0 or Stage I is often managed with less extensive treatment and has a much better prognosis than a cancer found after it has spread to lymph nodes or distant organs.

Mammography remains the main screening tool for detecting breast cancer before symptoms appear. It can identify small cancers, clusters of microcalcification and early changes that may not yet be felt as a lump.

In Hong Kong, the Government has adopted a risk-based approach to breast cancer screening. Women aged 44 to 69 with certain combinations of personalised risk factors are advised to consider mammography screening every two years. These factors include family history of breast cancer among first-degree relatives, previous benign breast disease, never having given birth, later age at first live birth, early age at first period, higher body mass index and physical inactivity. (breastscreen.gov.hk)

The Government’s Breast Cancer Risk Assessment Tool is designed to help women aged 44 to 69 better understand their own risk profile. It asks about factors such as age, age of menarche, age at first live birth, family history, benign breast disease, height, weight and physical activity. Women assessed as being at increased risk are recommended to consider mammography screening every two years.

Separately, the Hong Kong Breast Cancer Foundation also provides screening services and states that women aged 40 and above should consider regular mammography screening every two years. Its Free Breast Cancer Screening Programme provides approved applicants with breast self-examination education, clinical breast examination and mammography, although follow-up tests such as ultrasound, doctor consultation or biopsy may involve additional payment.

In our own clinic at The New Clinic, my practice is to use three pillars of screening to detect early breast cancer using a combination clinical examination, mammography and ultrasound, starting from aged 40-years, although earlier if family history or other factors dictate otherwise.

For patients, the practical message is this: know your risk, know your breasts, and do not delay seeking advice if something changes.

Breast awareness: what to look for

Screening is important, but it does not replace breast awareness.

Every woman should become familiar with what is normal for her breasts. This does not have to mean a rigid monthly ritual, but it does mean noticing changes and seeking medical advice promptly.

Symptoms that should be checked include:

• a new lump or thickening in the breast or armpit

• a change in breast size or shape

• nipple inversion or a nipple that suddenly pulls in

• blood-stained or persistent nipple discharge

• dimpling, puckering or tethering of the skin

• redness, scaling or eczema-like change around the nipple

• persistent breast pain in one area

• swelling, warmth or skin changes resembling inflammation

• any new asymmetry that does not settle

Most breast changes are not cancer. Cysts, fibroadenomas, hormonal changes, infections and benign breast conditions are common. But it is never wise to assume. A timely examination and appropriate imaging can provide reassurance or allow early treatment.

Gentler, more precise surgery

Surgery for breast cancer has also changed enormously.

In the past, many women underwent radical mastectomy, involving removal of the whole breast and extensive lymph node surgery. Today, many women can safely have breast-conserving surgery, also known as a lumpectomy or wide local excision, often followed by radiotherapy.

For suitable patients, this approach can provide excellent cancer control while preserving much of the breast.

Another major advance has been sentinel lymph node biopsy. The sentinel nodes are the first lymph nodes most likely to receive drainage from the breast tumour. By identifying and testing these nodes, surgeons can often avoid removing large numbers of lymph nodes unnecessarily.

This matters because extensive lymph node removal can increase the risk of arm swelling, stiffness, discomfort and lymphoedema. Sentinel node biopsy has helped reduce these complications while still giving essential information about whether cancer has started to spread.

Modern breast surgery is therefore not just about removing cancer. It is about doing so as safely, accurately and compassionately as possible.

Better imaging and more personalised planning

Imaging has also improved. Mammography, ultrasound, breast MRI and image-guided biopsy allow clinicians to define the size, location and nature of a cancer more accurately before treatment begins.

This helps answer important questions:

• Is the cancer confined to one area?

• Are there multiple areas involved?

• Are lymph nodes suspicious?

• Is breast-conserving surgery possible?

• Is chemotherapy better given before or after surgery?

• Is MRI needed because of dense breast tissue, genetic risk or complex findings?

The more precisely we understand the cancer at the beginning, the better we can plan treatment.

Smarter systemic treatments

Systemic treatment means treatment that works throughout the body. This includes chemotherapy, hormone therapy, targeted therapy, antibody-drug conjugates and immunotherapy.

These treatments have become much more refined.

For hormone receptor-positive breast cancer, anti-oestrogen treatments such as tamoxifen or aromatase inhibitors can significantly reduce the risk of recurrence. For HER2-positive breast cancer, targeted therapies such as trastuzumab have transformed a once more aggressive subtype into one with much better outcomes for many patients.

For some women, chemotherapy remains essential. For others, modern molecular testing may show that chemotherapy can safely be avoided.

This is a major change. The question is no longer simply, “Does this patient have breast cancer?” It is also:

What kind of breast cancer is it, and what treatment does this specific tumour actually need?

The molecular biology revolution

One of the most important advances in breast cancer care has been the deeper understanding of tumour biology.

We now know that breast cancer is not one disease. It is a family of diseases.

Pathology and molecular testing help identify key features, including:

• oestrogen receptor status

• progesterone receptor status

• HER2 status

• tumour grade

• proliferation markers

• lymph node involvement

• genomic recurrence risk in selected cases

These markers help guide treatment.

A small, slow-growing, strongly hormone-sensitive cancer may be treated very differently from a fast-growing triple-negative cancer or a HER2-positive cancer. This is why two women with “breast cancer” may receive very different treatment plans.

Multi-gene tests can also help in selected early breast cancers by estimating recurrence risk and identifying patients who may gain little additional benefit from chemotherapy. This allows some women to avoid unnecessary toxicity while still receiving effective treatment.

That is precision medicine in practice: not more treatment for everyone, but better treatment for the right person.

Treatment before surgery: neoadjuvant therapy

Another important shift is the increasing use of treatment before surgery, known as neoadjuvant therapy.

This may involve chemotherapy, HER2-targeted therapy, hormone therapy or immunotherapy, depending on the cancer subtype.

There are several reasons to give treatment first:

• to shrink a tumour and make surgery easier

• to increase the chance of breast-conserving surgery

• to assess how the tumour responds

• to guide treatment after surgery

• to treat microscopic disease early

In some aggressive subtypes, such as triple-negative or HER2-positive breast cancer, the response to neoadjuvant treatment provides valuable information. If no invasive cancer remains at surgery, this is called a pathological complete response and is often associated with a better outlook.

Harnessing the immune system

Immunotherapy is another exciting area, particularly for some patients with triple-negative breast cancer.

Checkpoint inhibitors work by helping the immune system recognise and attack cancer cells more effectively. They are not suitable for every patient and can have significant immune-related side effects, but for selected patients they have added a powerful new option.

The broader lesson is that cancer treatment is no longer only about surgery, chemotherapy and radiotherapy. It is increasingly about understanding the relationship between the tumour, the immune system and the body’s wider biological environment.

Living beyond treatment

Breast cancer care does not end when active treatment finishes.

Many women live for years after breast cancer, but survivorship brings its own needs. These may include:

• fatigue

• menopausal symptoms

• anxiety about recurrence

• sexual health concerns

• body image changes

• lymphoedema prevention

• bone health monitoring

• heart health monitoring after certain treatments

• return to work and family responsibilities

• emotional recovery

A woman may look “well” on the outside while still carrying the physical and psychological weight of treatment.

Good survivorship care should include follow-up, rehabilitation, lifestyle support and emotional care. Exercise, healthy weight management, limiting alcohol, not smoking, sleep, stress management and social connection all have a role in recovery and long-term health.

Prevention and risk reduction

Not all breast cancers are preventable, but some risk factors can be modified.

Women can reduce risk by:

• maintaining a healthy body weight

• being physically active

• limiting alcohol

• avoiding smoking

• breastfeeding where possible

• discussing hormone replacement therapy carefully with a doctor

• knowing their family history

• attending screening when appropriate

• seeking advice promptly for symptoms

For women with a strong family history or known genetic mutation, additional strategies may be needed. These may include genetic counselling, earlier screening, MRI surveillance, medication to reduce risk or, in selected high-risk cases, preventive surgery.

This is why family history matters. Breast cancer in a mother, sister or daughter, breast cancer at a young age, ovarian cancer, bilateral breast cancer or male breast cancer in the family may all be relevant.

Access and equity

As we celebrate progress, we must also recognise that it has not reached everyone equally.

Globally, many women still present with advanced breast cancer because they lack access to screening, diagnostic imaging, biopsy, surgery, radiotherapy or essential medicines. Even within wealthy cities, financial hardship, language barriers, caring responsibilities, fear, stigma and lack of awareness can delay diagnosis.

In Hong Kong, community programmes are helping to close this gap.

The Hong Kong Breast Cancer Foundation’s Free Breast Cancer Screening Programme supports eligible applicants aged 40 or above who hold a Hong Kong ID card, have not had a mammogram in the previous two years and meet specified application categories. Approved applicants may receive breast self-examination education, clinical breast examination and mammography.

The Government’s Breast Cancer Screening Pilot Programme has also expanded from risk-based screening for women aged 44 to 69 to include subsidised screening services for high-risk female Hong Kong residents aged 35 to 74 under Phase II. The Department of Health announced that eligible women may access services through designated NGO clinics, with a capped co-payment for mammogram or ultrasound breast examination. (info.gov.hk)

These initiatives matter because early detection only works if women can actually reach the services they need.

A practical Hong Kong screening guide

For women in Hong Kong, the following is a useful starting point:

If you are aged 44 to 69: Use the Government’s Breast Cancer Risk Assessment Tool to estimate your risk. If you are assessed as increased risk, discuss mammography every two years with your doctor.

If you are aged 40 or above: Consider discussing mammography and ultrasound screening with your doctor as well as clinical examination, especially if you have risk factors or would like an individualised assessment. The Hong Kong Breast Cancer Foundation supports regular mammography screening from age 40.

If you have a strong family history or known genetic mutation: Seek medical advice about high-risk screening. You may need earlier screening, more frequent screening, MRI, genetic counselling or specialist assessment.

If you have symptoms at any age: Do not wait for a routine screening appointment. Symptoms should be assessed promptly.

If you are unsure: Speak to your family doctor. Screening decisions should consider age, breast density, risk factors, family history, previous breast disease and personal preferences.

A note on screening benefits and harms

Mammography screening can save lives by detecting cancer earlier. However, like all screening tests, it also has limitations.

Possible harms include:

• false positives

• anxiety while awaiting further tests

• additional imaging or biopsy

• overdiagnosis of cancers that may never have caused harm

• radiation exposure, although the dose is low

This does not mean screening should be avoided. It means screening should be informed.

The best approach is not fear-based screening, but thoughtful, risk-based screening with proper explanation of benefits and limitations.

My view

Breast Cancer Awareness Month is not just about reminding women that breast cancer exists. It is about empowering women with knowledge, access and confidence.

The progress in breast cancer survival is real. We now detect many cancers earlier. We operate more precisely. We treat more intelligently. We understand tumour biology better. We can spare some women unnecessary chemotherapy and offer others treatments that did not exist a generation ago.

But the most important message remains simple:

Know your breasts. Know your risk. Do not delay seeking advice.

I advocate screening from 40-years onward annually, younger as indicated, through the 3 pillars of screening: breast examination, mammography and adjuvant ultrasound.

If you are eligible for screening, consider it. If you have a family history, discuss it. If you notice a change, get it checked. And if you are going through treatment or recovery, know that you are not alone.

The improvements we see today are the result of researchers, clinicians, nurses, radiographers, advocates, charities, patients and families all contributing to the same goal: earlier diagnosis, better treatment and longer, fuller lives.

This October, let awareness become action.

Helpful Hong Kong resources

• Government Breast Cancer Screening Pilot Programme

• Cancer Online Resource Hub Breast Cancer Risk Assessment Tool

• Hong Kong Breast Cancer Foundation screening services

• Family Health Service women’s health information

Disclaimer: This article is intended for general information only and should not be taken as personal medical advice. Breast cancer screening recommendations vary according to age, symptoms, family history, genetic risk, previous breast disease, breast density and personal medical history. Please consult your doctor or healthcare provider for individual advice, especially if you notice any breast symptoms or have a strong family history of breast or ovarian cancer.