Breast Cancer: Risk Factors, Staging and Advanced Breast Cancer Subtypes

Breast Cancer: Risk Factors, Staging and Advanced Breast Cancer Subtypes

It’s PINKtober! October is an annual breast cancer awareness month, an annual campaign to raise awareness on the impact of breast cancer which aims to prevent breast cancer-related deaths in women across the world.

Breast Cancer in Malaysia

In Malaysia, breast cancer is the most commonly occurring cancer in women and the second most common cause of cancer death overall. It accounts for close to 33 percent of the overall frequent cancer incidents in women in 2020. The risk of breast cancer increases with age.1 The good news is that more women are surviving the disease as a result of early detection and improved treatment.


Why does one get breast cancer?

The causes of breast cancer are not fully understood and no one knows for certain why one may develop the disease. However, several risk factors affect the likelihood of developing the disease.2


Risk factors include:

Aging Being on hormone replacement therapy (HRT)
Family History Being overweight or obese
Previous breast cancer or lump Drinking too much alcohol
Dense breast tissue


Breast Cancer Staging

When someone is diagnosed with breast cancer, doctors will assess to determine if cancer has spread and to what extent. This process is called staging. The stage of cancer determines how severe the cancer is and how best to treat it.3

Doctors may refer to Stage 1 cancer as “early stage” and Stage II to Stage III as “locally advanced”.4 Stage IV is the most “advanced stage” of breast cancer also known as advanced breast cancer (aBC) as it spreads (metastasizes) from its original location in the breast, past the nearby lymph nodes, to other body organs. About 30% of women diagnosed with early-stage breast cancer will develop metastatic disease.5


Advanced Breast Cancer (aBC) Subtypes

Luminal A Triple Negative Luminal B HER2-enriched
73% of all breast cancer cases 13% of all breast cancer cases 10% of all breast cancer cases 5% of all breast cancer cases


HR = Hormone Receptor

HR + means tumor cells have receptors for the hormones estrogen or progesterone, which can promote the growth of HR+ tumors.


HER2 = Human epidermal growth factor receptor

HER2 + means tumor cells overexpress (produce high levels of) a protein, called HER2/neu, which has been shown to be associated with certain aggressive types of breast cancer.


Know Your Subtype

Knowing your breast cancer subtype can help determine your treatment and predict survival. Your doctor may perform laboratory tests such as biomarker testing to determine your subtype. A biomarker may be found or measured by testing blood (plasma) or tissue. It helps your doctor know which treatments might work best for that specific cancer type by:

Guiding treatment decisions

Predicting how the cancer may respond to treatment

Determining how cell treatment is working

Signaling if the cancer is returning

In PINKtober, we aim to create widespread awareness on breast cancer so that the disease can be diagnosed and treated at early stages.

Treatment recommendations are tailored and personalized and depend on several factors such as the stage of the tumor, tumor’s subtype, genomic markers, patient’s age, menopausal status, and the presence of BRCA1 or BRCA2 mutations. Some tests for breast cancer that can help your specialists make informed decisions that can be done at PPP are BRCA1&2, HER2 FISH, Homologous Recombinant Repair (HRR), PIK3CA Test and more.


For more information on the tests provided, please contact us at +603-42809115 (Customer Service) or email us at [email protected]




1- International Agency for Research on Cancer. (2020). Malaysia. [Fact Sheet]. World Health Organization (WHO)

2- NHS website. (2022, June 1). Causes.

3- Stages of Breast Cancer | Understand Breast Cancer Staging. (n.d.). Retrieved October 25, 2022, from

4- Breast Cancer – Stages. (2022, May 24). Cancer.Net.

5- Metastatic Breast Cancer. (n.d.). Retrieved October 25, 2022, from

Coronavirus disease 2019 (COVID-19) and Tuberculosis (TB) Coinfection

Coronavirus disease 2019 (COVID-19) and Tuberculosis (TB) Coinfection

Coronavirus disease 2019 (COVID-19) and tuberculosis (TB) are two major infectious diseases causing serious public health problems. The main route of transmission of both these diseases are through respiratory droplets and they primarily target the lungs. Their coinfection; COVID-TB, can lead to worse outcomes among the coinfected patients. Both diseases have similar signs and symptoms such as cough, fever and difficulty breathing, however, TB has a longer incubation period with a slower onset of disease.1, 2, 3


According to the World Health Organization (WHO), the COVID-19 pandemic had caused disruption of the tuberculosis control leading to an increase in the TB mortality rate, for the first time in more than a decade.4, 5 This means that patients are not receiving timely treatment and the transmission of the infection is continued as they have limited access to essential services due to the current situation.


TB is curable and preventable. About 85% of people who develop TB disease can be successfully treated and treatment has the additional benefit of curbing onward transmission of infection.4 Therefore, to reduce the prevalence of both these infectious diseases and the burden of coinfection, essential services should actively engage in ensuring an effective and rapid response to COVID-19 while ensuring that TB testing and care are maintained.1


Simultaneous and integrated testing for COVID-19 and TB which includes COVID-19 screening for all patients diagnosed with TB and TB screening for all patients with confirmed COVID-19 can be done to improve the detection of both diseases. It is especially important in the care of people who are vulnerable to unfavorable outcomes, including death like the older age group and people with certain comorbidities like diabetes mellitus and chronic obstructive pulmonary disease. This approach can also help to mitigate the gap caused by the pandemic in diagnosing and controlling tuberculosis.6, 7


Together we can defeat COVID-19 and TB.


At Pantai Premier Pathology, we provide Tuberculosis (TB) and Coronavirus disease 2019 (COVID-19) Tests :

  1. Mycobacterium TB QuantiFERON test
  2. AFB-sputum test
  3. COVID-19 RTK antigen testing
  4. RT-PCR testing



  1.  Song, W. M., Zhao, J. Y., Zhang, Q. Y., Liu, S. Q., Zhu, X. H., An, Q. Q., … & Li, H. C. (2021). COVID-19 and Tuberculosis Coinfection: An Overview of Case Reports/Case Series and Meta-Analysis. Frontiers in medicine, 8.
  2. Nikolayevskyy, V., Holicka, Y., van Soolingen, D., van der Werf, M. J., Ködmön, C., Surkova, E., … & Cirillo, D. (2021). Impact of the COVID-19 pandemic on tuberculosis laboratory services in Europe. European Respiratory Journal, 57(1).
  3. Global Tuberculosis Programme. (n.d.). World Health Organization (WHO). Retrieved March 22, 2022, from\
  4. Global tuberculosis report 2021. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO.
  5.  Pai, M., Kasaeva, T., & Swaminathan, S. (2022). Covid-19’s Devastating Effect on Tuberculosis Care—A Path to Recovery. New England Journal of Medicine.
  6. Ruhwald, M., Hannay, E., Sarin, S., Kao, K., Sen, R., & Chadha, S. (2022). Considerations for simultaneous testing of COVID-19 and tuberculosis in high-burden countries. The Lancet. Global Health.
  7.  World Health Organization (WHO). (2020). Tuberculosis and COVID-19.

Treatment Planning for Breast Cancer

Treatment Planning for Breast Cancer

Breast cancer is the most common form of cancer among women in Malaysia. According to the Statistics report made by Global Cancer Observatory in 2020, Breast cancer has been ranked first in the incidence and prevalence rate of cancer among Malaysians.1 In addition, Chinese women in Malaysia seemed to be at the greatest risk among breast cancer patients, with and incidence rate of 40.7 per 100,000 population; followed by Indian women (38.1 per 100,000) and Malay women (31.5 per 100,000), as reported by Malaysia National Cancer Registry Report 2012-2016.2, 3


Breast cancer is a type of cancer that develops in the breast when the cells in the lobules (milk producing glands) or the ducts becomes abnormal and divide uncontrollably. Breast cancer cells typically would form a tumour that can be seen on an x-ray or felt as a lump. It occurs almost entirely in women, but men can get breast cancer too.4, 5


It is important to understand that most breast lumps are benign and non-cancerous. Non-cancerous breast tumours are abnormal growths which do not spread outside of the breast and are usually non-life-threatening. However, some types of benign breast lumps are able to increase the incidence risk of woman getting breast cancer. Any breast lump or changes needs to be examined by a health care professional to determine if it is benign or malignant (cancerous) and whether it may contribute to the risk of developing cancer in the future.4


As with most cancers, the earlier the breast cancer is detected and diagnosed, the better the chances for a successful treatment. The treatment for breast cancer depends on the diagnosis which includes local treatment that comprises of surgery and radiotherapy or an adjuvant therapy (additional to surgery) that comprises of combinations of radiation therapy, hormone therapy, targeted therapy, or biological therapy.


Learn about the different types of treatments available for your cancer by seeking your consultants for a better understanding and to make an informed choice about your treatment options. Most importantly, remember to be positive and to lead a normal life after your breast cancer treatment. Cancer is not the end, but the beginning of a new life with proper treatment!


Treatment recommendations are tailored and personalized and depends on several factors such as stage of the tumour, tumour’s subtype, genomic markers, patient’s age, patient’s menopausal status, the presence of BRCA1 or BRCA2 mutations. Some of the test for breast cancer that can help your specialists to make informed decisions which can be done at PPP are BRCA1&2, HER2 FISH, Homologous Recombinant Repair (HRR), PIK3CA Test and more.


For more information on the tests provided, please contact us at +603-42809115 (Customer Service) or email us at [email protected]



  1. International Agency for Research on Cancer. (2020). Malaysia. [Fact Sheet]. World Health Organization (WHO)
  2. Cancer Cases Rise In Malaysia, Chinese Most Prone. (2020, January 3). Code Blue.
  3. Ministry of Health Malaysia. (2019, June). Malaysia National Cancer Registry Report 2012–2016 (No. 5). National Cancer Registry, NCI.
  4. What Is Breast Cancer? (2018, September 18). American Cancer Society.

Have you tested for TB?

Testing for TB is critical prior to anti-TNF-α therapy

TNF-α inhibitor recipients face an increased risk of developing active TB

Autoimmune disorders such as rheumatoid arthritis, inflammatory bowel disease and Crohn’s disease are commonly treated with biologics to slow progression of the disease. Unfortunately, biologics such as TNF-α inhibitors can also increase the likelihood that patients carrying latent TB infection will progress to active TB (1–3). As a result, many biologic treatments carry a warning stating that TB infection should be investigated and treated prior to initiating therapy.

  • More than one third of the world’s population is believed to carry latent TB infection (4)
  • Patients receiving TNF-α inhibitor therapy face up to a 9-fold increased relative risk of developing active TB (5)
  • TB reactivation risk should be evaluated in all patients prior to biologic therapy (2, 6)


Published data indicate that QuantiFERON technology may provide more accurate detection of TB infection prior to start anti-TNF-α treatment

Studies performed among patients with chronic immune diseases have reported improved performance by detecting TB infection with QuantiFERON technology compared to the tuberculin skin test (TST) (1, 2, 7, 8).


“In a TB-endemic population, the QuantiFeron-TB Gold In-Tube assay seemed to be a more accurate test for detection of LTBI in RA patients compared with the TST, and may potentially improve the targeting of prophylactic therapy before treatment with anti-TNF agents.” – Ponce de Leon (2008)


Before you initiate TNF-α inhibitor therapy, get tested with QuantiFERON-TB Gold Plus for accurate TB detection. For more information on the tests provided, please contact us at +603-42809115 (Customer Service) or email us at [email protected]



  1. Matulis, G., Juni, P., Villiger, P.M., and Gadola, S.D. (2008) Detection of latent tuberculosis in immunosuppressed patients with autoimmune diseases: performance of a Mycobacterium tuberculosis antigen-specific interferon gamma assay. Ann. Rheum. Dis. 67, 84–90.
  2. Cantini, F., et al. (2017) Risk of tuberculosis reactivation in patients with Rheumatoid Arthritis, Ankylosing Spondylitis, and Psoriatic Arthritis receiving non-anti-TNF-targeted biologics. Mediators Inflamm. 2017:8909834
  3. Swaminath,A. Bhadelia, N., and Wang, Y.C. (2013) Cost-effectiveness of QuantiFERON testing before initiation of biological therapy in inflammatory bowel disease. Inflamm. Bowel Dis. 19, 2444–2449.
  4. World Health Organization. Tuberculosis Fact Sheet. http://www.who. int/mediacentre/factsheets/fs104/en/. Accessed Sept 18 2017.
  5. Lobue, P. and Menzies, D. (2010) Treatment of latent tuberculosis infection: An update. Respirology. 15, 603.
  6. World Health Organization. (2015) Guidelines on the management of latent tuberculosis infection. WHO/HTM/TB/2015.01.
  7. Ponce de Leon, D., et al. (2008) Comparison of an interferon-gamma assay with tuberculin skin testing for detection of tuberculosis (TB) infection in patients with rheumatoid arthritis in a TB-endemic population. J. Rheumatol. 35, 776–781.
  8. Mariette, X., et al. (2012) Influence of replacing tuberculin skin test with ex vivo interferon γ release assays on decision to administer prophylactic antituberculosis antibiotics before anti-TNF therapy. Ann. Rheum. Dis. 71, 1783–1790.

Liquid biopsy for detection of EGFR T790M mutation in Non-Small Cell Lung Cancer (NSCLC)

Liquid biopsy for detection of EGFR T790M mutation in Non-Small Cell Lung Cancer (NSCLC)

About Non-Small Cell Lung Cancer (NSCLC)

Lung cancer is the leading cause of cancer death among both men and women, accounting for about one-quarter of all cancer deaths combined.1


First-line Standard of Care

Epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) is a substance that blocks the activity of a protein called epidermal growth factor receptor (EGFR), that is found on the surface of some normal cells and is involved in cell growth. This protein can also be present in increased levels in some types of cancer including lung cancer, which allows these cells to grow and divide uncontrollably.2

These cancer cells can be hindered from growing by blocking the EGFR using EGFR-TKI, making this therapy a first-line standard of care.3, 4


Acquired EGFR T790M mutation

However, patients treated with EGFR-TKIs inevitably develop acquired resistance and tumor progression due to secondary mutation, EGFR T790M, after approximately 9-13 months.3, 5, 6, 7 The EGFR mutation-positive NSCLC, occurs in 30-40% of patients in Asia.8

The T790M mutation is an acquired resistance that produces a drug-resistant variant of the targeted kinase which confers growth advantage and survival of lung cancer cells. This mutation is present in about half of lung cancer patients following first- or second- generation EGFR-TKI therapy. 9, 10, 11


Second-line Treatment

As mutational subclones may evolve over time, liquid biopsy allows for real-time monitoring of clonal changes to guide the second-line treatment in patients and to determine T790M mutation status to maximize the number of patients who are able to receive subsequent treatment with the third-generation EGFR TKI. 11, 12


Future Treatment Paradigm

Other exploratory strategies (e.g., bypass pathways, downstream signaling, histologic transformation, and others) are under development to identify patients that are suitable for molecular targeted therapy to overcome the resistance mechanisms which may change the future treatment paradigm based on preclinical and clinical studies.11


At Pantai Premier Pathology, we provide Lung Cancer Tests:

  1. EGFR Mutation Testing (Tissue)
  2. EGFR T790M mutation Liquid Biopsy Testing
  3. 170 Genes Next Generation Sequencing Testing
  4. 523 Genes Next Generation Sequencing with Tumour Mutational Burden Testing


For more information on the tests provided, please contact us at +603-42809115 (Customer Service) or email us at [email protected]




1- Key Statistics for Lung Cancer. (n.d.). American Cancer Society. Retrieved August 2, 2021, from

2- epidermal growth factor receptor tyrosine kinase inhibitor. (n.d.). National Cancer Institute (NIH). Retrieved August 2, 2021, from

3- Bursac, D., Zarić, B., Kovačević, T., Stojšić, V., Vagionas, A., Boukovinas, I., … & Sekerus, V. (2021). Personalized Approach to Tissue and Liquid Biopsy after Failure of First-Line EGFR-TKIs: Is There an Issue When Tissue Is Not the Issue? A Case Series. Case Reports in Oncology, 14(2), 716-724.

4- Planchard, D., Boyer, M., Lee, J. S., Dechaphunkul, A., Cheema, P., Takahashi, T., … & Ohe, Y. (2018). 128O Osimertinib vs standard of care (SoC) EGFR-TKI as first-line therapy in patients (pts) with untreated EGFRm advanced NSCLC: FLAURA post-progression outcomes. Journal of Thoracic Oncology, 13(4), S72-S73.

5- Helena, A. Y., Arcila, M. E., Rekhtman, N., Sima, C. S., Zakowski, M. F., Pao, W., … & Riely, G. J. (2013). Analysis of tumor specimens at the time of acquired resistance to EGFR-TKI therapy in 155 patients with EGFR-mutant lung cancers. Clinical cancer research, 19(8), 2240-2247.

6-  Suda, K., Onozato, R., Yatabe, Y., & Mitsudomi, T. (2009). EGFR T790M mutation: a double role in lung cancer cell survival?. Journal of Thoracic Oncology, 4(1), 1-4.

7- Wu, W. S., & Chen, Y. M. (2014). Re-Treatment with EGFR-TKIs in NSCLC Patients Who Developed Acquired Resistance. Journal of personalized medicine, 4(3), 297–310.

8- Ellison, G., Zhu, G., Moulis, A., Dearden, S., Speake, G., & McCormack, R. (2013). EGFR mutation testing in lung cancer: a review of available methods and their use for analysis of tumour tissue and cytology samples. Journal of clinical pathology66(2), 79–89.

9- Suda, K., Onozato, R., Yatabe, Y., & Mitsudomi, T. (2009). EGFR T790M mutation: a double role in lung cancer cell survival?. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 4(1), 1–4.

10- Choo, J. R., Tan, C. S., & Soo, R. A. (2018). Treatment of EGFR T790M-Positive Non-Small Cell Lung Cancer. Targeted oncology, 13(2), 141–156.

11- Liao, B. C., Griesing, S., & Yang, J. C. (2019). Second-line treatment of EGFR T790M-negative non-small cell lung cancer patients. Therapeutic advances in medical oncology, 11, 1758835919890286.

12- Hochmair, M. J., Buder, A., Schwab, S., Burghuber, O. C., Prosch, H., Hilbe, W., Cseh, A., Fritz, R., & Filipits, M. (2019). Liquid-Biopsy-Based Identification of EGFR T790M Mutation-Mediated Resistance to Afatinib Treatment in Patients with Advanced EGFR Mutation-Positive NSCLC, and Subsequent Response to Osimertinib. Targeted oncology, 14(1), 75–83.