Treating breast cancer: Doctors often focus on the medical and physical – what about the emotional?

How are you feeling? What are you fearful about? Do you need clarification on something a doctor once told you or a piece of advice offered by a friend?

These are questions practically unheard of in doctors’ consultation rooms and it’s not for a lack of concern. 

Healthcare systems around the world are overstretched, according to a 34-country survey conducted by global research firm Ipsos in 2022.

And even though Singapore was not among the countries studied, medical professionals here have reported feeling overwhelmed and burnt out.

This can result in doctors' consults becoming a “get-in-and-get-out” situation, with the precious minutes they have with their patients being dedicated solely to the medical aspect of their treatment journey.

‘TALK THERAPY’ AIDS RECOVERY

This is concerning to Dr Michelle Tseng, a female radiation oncologist who is perhaps the only one of her kind practising in the private healthcare sector. 

There needs to be some form of “talk therapy” and that need is especially acute in cases of breast cancer – an affliction whose devastating effects can last long after recovery, said Dr Tseng, who is part of Asian Alliance Radiation and Oncology (AARO), a specialist oncology group.

She studied medicine at Imperial College London and returned to Singapore in 2010 to do her internship at the National University Hospital (NUH), Tan Tock Seng Hospital and KK Women’s and Children’s Hospital.

In 2011, fewer than two years after her return to Singapore to practise medicine, she decided to specialise in radiation oncology at NUH.

Dr Tseng said she knew of no other female radiation oncologist in private practice at the time, except for Dr Susan Loong, a senior radiation oncology expert who used to work at the National Cancer Centre before going into private practice. Dr Loong has since retired. 

Last year, the Raffles Junior College alumna was asked by a peer if she would consider joining the private healthcare sector, where she would have the time and space to impact not just what breast cancer treatment looks like, but also what it feels like.  

Dr Tseng, whose parents are both doctors, took on the challenge – bent on her mission to “normalise the idea that the mental and emotional health of a breast cancer patient ought to be considered alongside the management and treatment of their disease”.

“Having worked in government restructured hospitals for more than 10 years now, I understand the resource and manpower limitations that such hospitals face and it’s not always feasible to fully address the mental and emotional wellbeing of each and every patient,” she explained.

But this holistic approach is a principal one because breast cancer has a particularly harsh emotional impact on a woman and can negatively affect her physical recovery, said the mother of two.  

And it is at AARO, which has clinics in major private hospitals and medical centres across Singapore, that she has been able to set an example.

“A holistic treatment plan is different in that it is not just a one-time check-in with the patient. The entire process, from investigation and diagnosis to treatment is a journey of ups and downs that patients need support for.

“Many patients are unable to voice their concerns for fear of taking up too much of their doctor’s time. They keep to themselves and maintain a brave front for their family and friends.

“They need time, and they need a safe space in which to share their worries and concerns with their treatment team without fear of judgement or time pressure, said Dr Tseng.

A CHECK-IN, AN EDUCATION & EVEN CELEBRATION

Dr Tseng, who runs an all-women team at AARO that specialises in female disease sites, consults with patients who have been diagnosed and advises them on their prognosis, before recommending and discussing with them a treatment plan. 

AARO, which is among the largest of its kind in Singapore, studies all bodily disease sites, including those in men, with each specialist focusing on specific disease sites. “This is how oncology is practised in academic institutions and we’re proud to have introduced this to the private sector,” Dr Tseng said.

“I make it a point to give my patients, most of whom are women suffering from breast cancer, more time to tell me about the impact the diagnosis has had on them.

“At government restructured hospitals, doctors have many patients to see – we are allocated at most half an hour to explain everything about radiation therapy to a patient.

“I don’t find that to be enough time and I am often rushing through my consultation. That’s not the kind of consultation that I would want for my patients,” said the 39-year-old.

“Now that I’m in private practice, I have more time. And with this time, I get to ask my patients the questions that I’m pretty sure no other doctor had asked them before.

“Typically, a doctor explains the process and indicates the patient’s next steps. No one actually acknowledges how life-changing and potentially devastating breast cancer can be,” she added.

Dr Tseng, who has 10 years of experience in radiation oncology and has specialised in breast cancer for five, pointed out that patients themselves are often “so focused on the medical treatment plan that they neglect themselves”.

“They tell people they are okay when in fact, there are extremely distressing issues unique to breast cancer,” she said.

There are also issues with navigating the expectations of others and receiving typically unsolicited advice when it comes to decisions about diagnosis and treatment.

“So, when I’m in clinic, I make it a point to let them know they can be honest with me about what they are feeling. I assure them that it’s common for doctors not to be able to explain every detail because they have run out of time or whatever, and I encourage them not to be shy to ask what they want.”

Even then, patients may hold back, for reasons such as shock, exhaustion and the fear of being a burden to their consulting doctor, who may be visibly overwhelmed.

Anticipating this, Dr Tseng makes sure a patient takes home her name card, bearing her personal contact details, so that they can take their time to carefully process the discussion and ask follow-up questions from a place of calm and clarity.

“There’s so much going on, I know, and it can be so hard to process everything right there and then, so I encourage them to take their time and come back to me when they’re ready.”

As a celebration of life, in spite of its characteristic trials and tribulations, Dr Tseng and her team take note of patients' birthdays. 

“If they’re having a birthday during their treatment period, we present them with cakes to help them celebrate. Sometimes, we surprise them with their favourite flowers when they’ve completed treatment."

'EVERY WOMAN SHOULD GET TO CHOOSE A FEMALE DOCTOR IF THEY WISH TO'

Part of the reason Dr Tseng chose to specialise in breast cancer and specifically, radiation oncology, was the fact that there was a lack of female doctors in these arenas.

She frequently received requests from patients wanting to see her alone, without the presence of her male colleagues, as they “felt more comfortable with a female doctor”, she told CNA Women.

“I wanted to give all female patients the option to choose a female doctor if they wanted to. I believe that women simply understand other women better. As a woman, I find it easier to empathise with my female patients and their experiences.

“Our male oncologists (at AARO) are very professional with their female patients and very well-respected. This is all not about who does the job better – it is simply about giving female patients the option to choose,” she said.

“Ultimately, when a patient is comfortable with her doctor, she will be able to share more openly about her symptoms and this will help the doctor treat her more effectively.”

At the AARO treatment centre – the all-women team comprises clinic assistants, nurses, radiation therapists, medical physicists and oncologists – every woman that walks through the door is attended to based on guidelines around privacy and modesty.

“Being an all-female team,” Dr Tseng said, “we are sensitive and acutely aware of patients that are suffering from or may potentially have to confront the unique and sometimes crushing effects of a breast cancer diagnosis”.

“We’re able to pre-empt some of these issues and guide them towards addressing these issues at an early stage … We don’t belittle a single issue, no matter how minor it might seem,” she said.

Dr Tseng cited an instance when a patient began crying before her first radiation treatment (often requiring the use of a machine called a linear accelerator) because she suffered from claustrophobia. 

“Our female radiation therapists sat with her, taking the time to understand her fears and encouraging her to proceed. They reassured her and they comforted her. After that first treatment, the rest of the patient’s treatment journey was seamless, probably because she knew she had a supportive team rallying for her at every stage,” she said.

“On top of tapping on our network of experts in areas like physiotherapy and psychology to provide them with more support, we have also visited a patient’s home to suggest fixture modifications to help them adjust to their drastic new circumstances, and to stay safe.

“All these are only possible because we have frequent conversations with our patients and take down the details often overlooked by others,” she added.

Ideally, said Dr Tseng, acknowledging that the patients’ mental and emotional health are important too, is a good first step for any medical institution.

“There should be resources allocated to these needs, complementary to the patient’s cancer treatment plan.

“This could be in the form of a specialist nurse clinic that is run together with the doctor’s clinic where the doctor can ensure treatment is prescribed well while the nurse focuses on the patient’s mental and emotional issues.”