Dr Polly Cheung on the set of TVB program Straight Talk with the host, Dr Eugene Chan. (PROVIDED TO CHINA DAILY)

Dr Polly Cheung, founder of the Hong Kong Breast Cancer Foundation, debunked some myths about breast cancer. She also offered important tips on diagnosis and treatment during a TV interview this week.

Check out the full transcript of Cheng’s interview with Dr Eugene Chan, host of TVB’s program Straight Talk, to learn more. 

Chan: Good evening and welcome to Straight Talk. I'm your host Eugene Chan. Our guest tonight is Dr Polly Cheung, who is a medical specialist in general surgery and has vast experience on breast cancer treatment in Hong Kong. She graduated from the University of Hong Kong, and went on to undertake a surgical fellowship at the University of Michigan in breast and endocrine surgery. She's also a fellow of surgical colleges in Glasgow, Australasia, America, and of course here in Hong Kong. She has pioneered the management of breast cancer, and also founded the Hong Kong Breast Cancer Foundation, which supports patients and their families. 

Welcome, Dr Cheung. We are indeed honored to have you here tonight to share with us the perspectives on breast cancer. We seem to be hearing more and more about breast cancers, and I'm sure most of the viewers, including myself will know someone who has had breast cancer. So is the incidence of breast cancer increasing in Hong Kong? 

Cheung: Yes, in fact, breast cancer has been the number one cancer affecting women in Hong Kong since 1994. So over the last quarter of a century, it is still the number one cancer and at present time, one in 14 women stand their lifetime risk of breast cancer. And every day we have 14 people being diagnosed with breast cancer.

Chan: Right, they are quite high numbers. 

Cheung: It’s true.

Chan: And how do men get affected as well? 

Cheung: Oh, sure, yes. 0.5% of the breast cancer cases we see are men.

Chan: So how does the... this incidence, as you said, is quite high compared to other cancers in Hong Kong, or more specifically to women. 

Cheung: Well, in fact, breast cancer tops the incidence in Asian countries, with Hong Kong's incidence at 65.5 per 100,000 women being affected by breast cancer. And we know that in women in Hong Kong, when you're talking about colon cancer, the chance is one in 32. So one in 14 for breast cancer is very high. 

Chan: How does that incidence compare to the mainland, I mean you just mentioned Asia, to Mainland and Western communities. 

Cheung: Well, in western communities, the highest incidence is one in eight in America, and also in some Western European countries. In China, with the opening up of China, the coastal cities, run a higher risk of breast cancer for the women living in cities in the rural areas it’s still not as much as those in cities. But we are seeing patients increase in numbers in Shanghai, in Beijing and also in Guangzhou.

Chan: Well, you mentioned different cities, I'm sure the viewers are going to ask you, is it because of the city where they live in or because of the ethnic background? 

Cheung: I think it's the lifestyle because we know that Chinese women who moved to America, the second generation incidence of breast cancer is the same as Caucasian. So it must be something in our living lifestyle, or our dietary changes that caused the difference. And also in China it is very different. In city people, they run a higher risk than the rural people. So there must be something in our city life that caused the problem. 

Chan: So about what you're saying is in Hong Kong, we have like 14 cases diagnosed a day.

Cheung: Yes. 

Chan: That means Hong Kong as a city. We have, I'm sure we have some high-risk factors associated, so I'm sure the viewers are going to ask you, what causes breast cancers? 

Cheung: Well, in fact, from our research, we found that breast cancer patients, over 75% of breast cancer patients do not have enough exercise per week. The standard is for at least three hours per week as a routine. And now we're seeing more and more people moving into jogging or racing,

Chan: Yoga...

Cheung: …and a lot more exercise-oriented, but still 50% of the people in Hong Kong as a normal population do not have enough exercise as what is quoted as the standard. 

Chan: Right. So maybe with COVID, when people spend more time walking to the mountain trails, all that is going to help, isn't it? 

Cheung: Yes, certainly. 

Chan: Yes. I'm going to ask you some common myths about breast cancers. Is it something that we eat, say papaya, I mean, if you have papaya...

Cheung: Papaya is good, in fact it's rich in vitamin A. Rich in vitamin A which is the anti-cancer chemical. 

Chan: Right, there's no specific food that you can identify that is the culprit? 

Dr Polly Cheung offers some important tips on diagnosis and treatment of breast cancer during a television interview. (PHOTO TAKEN FROM HONG KONG BAPTIST UNIVERSITY FOUNDATION WEBSITE)

Cheung: Oh, yes, certainly. There are dieticians, who have run studies that show that the content of animal fats in our diet is also the culprit for breast cancer, right? So for a westernized diet compared to the traditional Chinese diet, it is one quarter of the fatty content in the Chinese diet compared to Western diet. But you know, in Hong Kong is a cosmopolitan city, and we always follow a lot of things, which is handy food. So we are eating a lot more fatty food, then we used to or our ancestors used to have. 

Chan: So that means we have more vegetables and less fat that should be better. 

Cheung: We should have more vegetables, true. 

Chan: How about breastfeeding? Does it make a difference? 

Cheung: Oh, definitely breastfeeding protects the breast against breast cancer, it's because of changes in the pathology. We know from pathological studies that breast cells are unstable if you don't go through the whole maturation process, which means that the breast function is for lactation. So for pregnancy, there are changes in the breast cells. And then for lactation, there also are changes in the breast cells which cause the cells to become more stable. And it will protect you against changes, or cancer changes.

Chan: Right, I'm going to ask you a number of myths coming up. So we've going to do some quick answers... quick questions, quick answers. I mean, with due respect, do women with bigger breasts have a higher chance of getting breast cancer? 

Cheung: Well, in fact, women with cup A or B sizes do have breast cancer, we don't find a difference between cup A or B or cup CD. 

Chan: Well, how about women with breast implants? Does it cause cancers? 

Cheung: No breast implant or silicone implants, they themselves are medical-inert, they don't cause cancer. 

Chan: Right. Okay. And can you... as I said, food that can cause cancer, are there any supplements we can take for prevention?

Cheung: I think city people would always like to take food supplements, which is not the way we advocate. It should be natural food, fresh things, and less preservatives. And animal fat is something which we need to cut down. So dairy products go for low fat preparation. 

Chan: Okay, and how about those on contraceptive pills on hormone replacement therapy? Is it going to increase the chance of risk of breast cancer? 

Cheung: For oral contraceptive pills there's still no definite evidence that it will increase rates of breast cancer. But for hormone replacement therapy after menopause, there are studies that shows that there is an increased risk of breast cancer, especially for those who take a combined estrogen and progesterone pills. 

Chan: Oh, I see. Also, I've heard that hair dyes can cause cancer. I mean, is that true? I mean, one study said that if you have long term permanent hair dye, or even those chemical hair straighteners, if they use it every five to six weeks, they increase 30% chance of having breast cancer. Is that true? 

Cheung: I think for hair dyes, their content is really heavy metal, which we want to avoid but there's no definite proof that it will cause breast cancers. 

Chan: And how about stress I mean, we had mentioned earlier.

Cheung: Yes, stress is something inherent with city people. And we have studies that show that if you put yourself in... have stress within half of the time that you're living, this will increase your odds ratio of breast cancer by 3.4, which means 2axillary40% increase in breast cancer. 

Chan: So is breast cancer hereditary? 

Cheung: There are some way hereditary about 5% of people with breast cancer. 

Chan: You know one... I mean my famous actress Angelina Jolie. I mean Angelina Jolie, she had her double mastectomy, meaning removal of both breasts because she has the BRCA gene. 

Cheung: That's correct. 

Chan: And actually one of my medical friend, an oncologist in Singapore, also a female, had both her breasts removed. Is that something that you advocate?

Cheung: Breast cancer or BRCA gene mutation has a 80% lifetime chance of breast cancer. So people who have mutation carriers should be considering either a bilateral mastectomy, or prevention by medications or close surveillance. So all these three options for the patient. For Angelina Jolie it’s her choice.

Chan: Also, in younger women, you mentioned I mean even the cup A and cup B and stress people. So all our youngsters are very, I mean, very smart. Now they are all professionals, is the incidence increasing in the young generation? 

Cheung: Well, it is not. In fact, I think the younger generation if they go for healthy living and a healthy diet, we hope the incidence will drop in future.

At the present time, about 8% of people are below the age of 40. For those young patients, then we look out for hereditary gene mutation carriers. 

Chan: Yes, in the second part of the first part, I'm going to ask you about how to detect such an increasing cancer in women. What do you look for? I mean, we know that do you check yourselves every day? Is it adequate? 

Cheung: Well, checking yourself every day. It's something which is good, a good practice to be aware of your own breast changes. But it can only detect palpable cancer, we want to catch breast cancer early enough before it can be felt by yourself. 

Chan: Right? So are all the lumps cancerous? 

Cheung: No. In fact for young people and lumpy breasts are quite a common problem, especially those with associated pain. This is called benign breast change or fibrocystic change.

Chan: And also, we mentioned earlier, men do get breast cancer as well. How do we check? 

Cheung: Well for men because there's no breast development, it is only a breast bud underneath the nipple. So, if you find anything, which is hard, underneath the nipple, then you should see a doctor. 

Chan: Right. And I've heard the government had launched a breast cancer screening pilot scheme in September. Can you tell us briefly, I mean, does it apply to all the women and does it cost them anything? 

Cheung: Well, for the policy in breast screening, the Department of Health has issued guidelines, which divides people into increased-risk or average-risk. So obviously, we know that for increased risk people who have families' history who carry a mutation carrier, they should have a yearly mammogram screening. For the average risk women without family history of breast cancer, they are still at risk for breast cancer. For people who are in the age of 44 to 69, which is recommended by the Department Health, those with high risk factors like obesity, lack of exercise, first childbirth being more than the age of 30. Having a history of benign breast disease, they should also consider undergoing a mammogram every two year. They are subsidized if they belong to a higher score, under this risk factor profile. 

Chan: I'm going to ask one last question before the break. Since you're doing self checking, why do you still need to do mammograms? 

Cheung: Well, mammograms can detect things which are not palpable...

Chan: How regular should they go for mammograms? 

Cheung: They should go for two-yearly mammograms from an age of 44. Recommended by the Department of Health. 

Chan: Okay, well, all right. We'll go for a break and don't go away.

Chan: Welcome back. We have been talking with Dr. Polly Cheung about breast cancer. She has been debunking some of the common myths for us and advising our viewers on how it can be detected earlier. So Polly, in the first part we were talking about some myths of breast cancer, you mentioned the importance of self checking, and also mammogram every 2 years. Some questions about mammogram that our viewers asked me to ask you.

Cheung: Okay.

Chan: They said that, they complained that during the mammogram it can be quite uncomfortable or someone used the word painful. What will be your message to them?

Cheung: Well, I think they should go for experienced centre, so dedicated breast screening centres because occasional radiographers, if they are not familiar or they are not used to doing it, then you will feel more pain. Basically the breasts are compressed between 2 plates until it is tight, that they are not moving, then they can take a picture.

Chan: Right.

Cheung: And in fact, the advance of 3D mammogram helps in that aspect as well because they don’t need to compress all the way down.

Chan: Some claims, one of the myths is, the radiation from the mammogram can cause cancer or even by the pressing of breast when we’re doing the mammogram, as you said, can actually cause the cancer to spread. Are these 2 myths true or not?

Cheung: Definitely not. Mammogram is like taking 3 chest x-rays in a row. So the radiation exposure to mammogram is 0.3 millisieverts, and our body annual tolerance for any radiation exposure is more than 3 millisieverts, so it is like 1/10 or 1/8 of the total annual exposure. Exposure means that you are watching TV, you are flying in the air, all these will give you radiation exposure as well.

Chan: So it is quite minimal?

Cheung: That is true. 

Chan: But actually pressing it, will it cause cancer to spread?

Cheung: No, in fact not. Because even if there is somebody who has higher chance of a lump being breast cancer, we do more evasive procedures, like putting a true cut needle inside. So this will not give you spread of breast cancer.

Chan: Right. I understand that there is something called the needle aspiration.

Cheung: Yes, correct. That will be part of the biopsy procedure you can do as well. It will not cause the spread of cancer.

Chan: All right, okay. So we have talked about what is breast cancer, we talked about how to detect it. Let’s talk about how to treat it. See, I am sure any women or men, when they are told they are having cancer, especially breast cancer, to them it is like the end of the world. Is that true?

Cheung: Yes, to many of them, it is the uncertainty that they are facing. But in fact if you detect a breast cancer early, the chance of cure is very high. The average survival is 85% in 10 years. So if you detect the cancer at stage 1, it is more than 90%. 

Chan: So it is, in a way, quite a curable, treatable disease?

Cheung: Correct.

Chan: And you know, as you said, another reason why ladies are afraid of diagnosis, is quite obvious. They might be worried that they might lose their breast, which is a very important part of a body.

Cheung: Yes, it is true.

Chan: Is that still the case? Does surgical advances help with better to preserve whatever we have?

Cheung: Yes.

Chan: And still have a good prognosis?

Cheung: That is why early detection is important. If you can detect the cancer in a non-palpable stage or they are small, then they only need to remove the lump. 

Chan: Right.

Cheung: And you don’t have to remove the whole breast. And lumpectomy coupled with radiation already have the same survival as mastectomy. So nowadays it is not a taboo anymore with breast cancer.

Chan: Right. You know, as you know, all options, all treatment options for cancer are inevitably include surgery, chemotherapy, and radiation. Any advances recently for breast cancer?

Cheung: Right, this is called a multimodality treatment or we call it multidisciplinary treatment, with a combination of all these tools, we can save the woman’s life by increasing the survival. Radiation, as I mentioned, if you are doing a lumpectomy, it is an integral part of the cancer treatment. But advances are a lot more in medical treatment. Nowadays we identify the tumor biology and we will undergo medical treatment according to the tumor biology. In tumor biology, it means that there are 3 types of cancer, one is hormone sensitive cancer, which is 2/3 of the patients, the other 1/3 is either triple-negative cancer or HER2 positive cancer. And now the advance is that we can give, if the patient is required to have chemotherapy, give it up front before the surgery. That will help to shrink down the tumor so that the woman can enjoy lumpectomy instead of mastectomy as well.

Chan: So all these are recent advances, so they minimize the impact of surgery to the lady. And with chemotherapy, we all know that people do feel unwell or they lose their hair. Is it the same type of chemotherapy drugs you use for breast cancer as other cancers? Do you still have the side effects?

Cheung: We do have side effects because chemotherapy kills rapid growing cells, so hair is something that is rapidly growing, so you may have hair loss. Fortunately, now we are developing some cool caps which will help to reduce the temperature of the scalp so that hair loss may be a bit less. And white blood cells is also something which is rapidly being used and also destroyed and replaced by the bone marrow. So you may run into a white blood count, low count. But there are a lot of medication, supportive drugs which will help the patient go through chemotherapy. 

Chan: Right. You mentioned cool caps, I have heard that before, is it you putting some icy caps over your hair? How does that work?

Cheung: Over the head. It is like a cushion that you put on the head as a cap. It is a pre-cooled cap, so you have to cool the scalp before you start chemotherapy, and the afterwards that you are slowly warmed up. So that is something which is quite promising but I see it will still need to have more research into it.

Chan: And how about traditional Chinese medicine? I mean we often hear about patients taking WanZhi or Lingzhi and all those. What is your opinion as you have been treating that for so long?

Cheung: I consider those as health food if you want to label it. There is no definite level 1 medical evidence that they are active against breast cancer. But having said that I can tell you that one drug which we often use in breast cancer, which is called taxane. It is derived from the bark of a tree, so this from the medical literature in Chinese medicine, it has been used before in Chinese medicine. But this medication or this chemical combine has been extracted from the tree bark and become a medically usable chemotherapy agent, which is very effective against breast cancer. 

Chan: Okay. So we had a brief overview of the treatment. Let’s look at some challenges and future advances. You founded the Hong Kong Breast Cancer Foundation in 2005. What is the purpose of the foundation?

Cheung: Well, it is something that medical doctors are inadequate in handling, like patients’ emotional stress during the treatment, and also paramedical supports. A lot of patients who have undergone axillary dissection with lymphedema or arm swelling afterward. So these are things which we are unable to handle of all these things. So a holistic cancer care is not just the medical treatment that we give, it is the emotional support and also the paramedical support. And so Hong Kong Breast Cancer Foundation is run by survivors together with the help of healthcare professionals to fulfil this gap, which is lacking between.

Chan: But it is more than just a support group to the patients?

Cheung: Not just peer support, which is very important still.

Chan: Yes. We mentioned about the actors Angelina Jolie, and seems that I am sure she has to go through reconstruction.

Cheung: Yes.

Chan: How successful is reconstruction and in your experience when you talk to your patients, the ones who are well, I mean how much can they get back to normal life? I mean because it is completely new, what are their general feedback?

Cheung: Well, they have to be counselled very carefully before the surgery.

Chan: Right.

Dr Polly Cheung is a pioneer in the treatment of breast cancer in Hong Kong. (PROVIDED TO CHINA DAILY)

Cheung: Immediately reconstruction offers the best aesthetic result.

Chan: Immediate.

Cheung: Yes. And also the best psychological outcome because you don’t have a period of loss of breasts. 

Chan: right. 

Cheung: And the sensation can be better than a delayed reconstruction. So reconstruction helps a lot of women going through mastectomy with the hope of going back to normal.

Chan: Right. Is the cosmetic result satisfactory in your eyes?

Cheung: Oh, yes, yes. If the tumor can be detected early and we can do a nipple-sparing mastectomy, which means that we save the whole skin envelop together with the nipple, and just replace something on the inside with fat from the tummy or some of the implants, then the result is so good that even in follow-up I have to look at the notes before I can tell whether the patient has real breasts or a reconstructed breasts.

Chan: It is quite reassuring and encouraging, even taking the fat tissues from the tummy, that means they reduce their tummy as well at the same time.

Cheung: Yes.

Chan: You have been treating breast cancer for the last 20-30 years. In your opinion, what is the best way to reduce the incidence and the impact of breast cancer in Hong Kong?

Cheung: I think primary prevention from young age or teenagers, they should start to have healthy living with a healthy diet and also lifestyle changes, with more exercise, these are important. Stress is something we have to learn how to cope with stress, even in the city life. This is primary prevention. Secondary prevention is early detection. We have to go to a center for screening, which is mammogram, still now. For dense breast we may add on ultrasound just to supplement the inadequacy of mammogram in dense breasts. So secondary prevention is very important. And hopefully, in the future, we can have other ways to detect any DNA damage in the cells and we can do DNA repair. So this will be leading to medical advancement in the development of more medicine for treatment of breast cancer.

Chan: When you talk about the future, I mean as you just said, DNA therapy or DNA detection looks like a very promising way to go forward. How likely or how cost-effective is it going to be? I mean if you have 40 new cases a day diagnosed to you, do you do DNA testing on every patient or just find the ones at risk?

Cheung: No. That is what I mean, it is really for a small minority of people who may have DNA mutation like the carriers. So those we have guidelines for who to look for genetic counseling before they do genetic testing. So in the market there are too many genetic tests which are free, you can just get your saliva and get it done.

Chan: Right.

Cheung: I think it is quite dangerous because there is no counseling on what to see. And I do have patients who have undergone such tests and they don’t know what to do with it and they have to well-informed or counseled before they do any genetic testing.

Chan: Last question for you - when are we going to find the cure for breast cancer?

Cheung: I think like TB, previously tuberculosis is a very common disease and we don’t know how to treat them, and then we have drugs to tackle them. And so now it’s been trickling down to a minority of patients only. So I do have hope that in the future, with the molecular development on the understanding of cancer biology, we will have a day where we will mitigate it. 

Chan: Right. Thank you, Dr. Cheung for coming to share with us all the perspectives of breast cancer. I hope that our viewers will take note of all the recommendations you have given us. And thank you for joining us. Have a good week. And good night!