In this episode, Max Hansen welcomes Dr. Mikael Hartman from the National University of Singapore and Professor Cynthia Chou, a medical anthropologist from University of Iowa to discuss the Breast Cancer Prevention Program, a multifaceted research initiative aimed at improving breast cancer screening, care, and prevention in Southeast Asia.

The views and opinions expressed in this podcast are solely those of the student hosts, guests, and contributors, and do not necessarily reflect the views or opinions of the University of Iowa or the College of Public Health.

Lauren Lavin:

Hello everybody and welcome back to Plugged In To Public Health. Today we’re going to be diving into a fascinating and deeply human conversation about breast cancer care across cultures, communities, and different countries. We’re going to explore how research, anthropology and public health intersect to improve care and understanding for women navigating a breast cancer diagnosis, especially in Southeast Asia.

I’m Lauren Lavin, but today’s episode is hosted by Maxwell Hansen. And if it’s your first time with us, welcome. We’re a student-run podcast that discusses nature issues in public health and how they relate to everyone, whether you’re in the field or just curious about how health shapes our world. This episode features Dr. Hartman, a surgical oncologist and principal investigator of the Breast Cancer Prevention Program at the National University of Singapore’s School of Public Health. That’s a mouthful. Dr. Hartman is joined by his research assistant and program manager, Jenny, as well as Professor Cynthia Chou, a medical anthropologist from University of Iowa.

Together, they share insights from BCPP’s unique approach to culturally responsive breast cancer screening and care, and how collaboration between medicine and social science can lead to real world change. We’ll explore how anthropology shapes healthcare delivery, what makes screening programs effective across borders, and what we can learn by listening to the communities we serve. Now, let’s get Plugged In To Public Health. Plugged In To Public Health is produced and edited by students of the University of Iowa College of Public Health. The views and opinions expressed in this podcast are solely those of the student hosts, guests and contributors. They do not necessarily reflect the views opinions of the University of Iowa or the College of Public Health.

Max Hansen:

All right. Well, thank you guys very much for joining me today. I just want to quickly ask for our audience if you could introduce both of yourselves and a little bit of your work that you guys are doing.

Mikael Hartman:

Thanks for having us. I’m Mikael Hartman. I’m a clinician scientist, originally from Sweden, practicing as a surgeon and scientist at National University of Singapore for the last 16 plus years.

Jenny:

Hi, I am Jenny. Thank you for having me here. I work for Prof. Mikael Hartman. I started 15 years ago as a research assistant, and this has been very interesting and adventurous for me, and eventually I move on to be the program manager to manage and execute ideas that Prof. have.

Max Hansen:

Awesome. Awesome. Thank you guys very much. We appreciate it. So just to kick things off, you guys are a part of the Breast Cancer Prevention Program in Singapore, and that is relatively new. It sounds like it was established in 2015. I’m curious if you guys could give me a bit of a breakdown of the primary objectives of the program and where those objectives were formed.

Mikael Hartman:

Okay, so maybe I’ll start by taking a step back. It used to be that breast cancer was primarily a disease that we would see in the North Americas and in Europe. But because of demographic shifts and changing in risk profile, it’s becoming an Asian disease, but Asian breast cancer has been poorly characterized or incompletely characterized. So we started an initiative which initially started back in 2010 and has evolved into the breast cancer prevention program to better understand why you get the disease. And I think maybe Jenny can elaborate a little bit more on its components.

Jenny:

Like Mikael has said, we started in 2010. I mean, there’s so many things that we want to know about breast cancer, from understanding the pain and difficulty that the patients are going through, which is the quality of life part. To all the way, Mikael has found that there’s a lot of delayed presentation and we didn’t understand why.

And so, we wanted to look at screening, because he can only heal those patient that comes in, but he can bring them into for treatment earlier, and which is why we thought it should be a holistic approach, looking at different aspects. So like what Mikael has actually mentioned before, that it’s a journey of the patients cancer journey, from screening, to treatment, to prognosis, to survivorship. So our objective is actually to reduce the breast cancer mortality rates without increasing the burden to the healthcare system, as well as dedicate the research to prevention of breast cancer, by understanding the causes and the genetic of the disease.

Max Hansen:

You mentioned briefly there, Dr. Hartman, about how there’s differences between the burden of breast cancer amongst this population compared to the western world. And you also just mentioned as well, Jenny, that there’s a genetic factor to it. I guess I’m a little curious, if you guys could touch a bit on the differences in the timeline of that disease development between the two populations.

Mikael Hartman:

One mindset one can have is adapt, adopt, or something new. So in many ways, we can adopt already existing strategies that we’ve known for the last 30 years into the diagnostic process and how we treat. Sometimes we need to adapt it a little bit because of cultural differences and differences in sensitivity to chemotherapy agents. And every now and then we need something new where there are ways to diagnose and to establish risks that are unique for an Asian heritage.

Max Hansen:

Thank you for that. Okay. BCPP emphasizes various aspects of breast cancer. I mean, breast cancer as a disease requires a lot of specialized fields to truly affect an individual’s disease outcomes. I’m curious, when thinking about screening, genomics, personalized medicine and survivor quality of life, how does the program integrate all of these diverse areas into a cohesive research strategy?

Mikael Hartman:

At a first glance, it may look like it’s a bit piecemealish, where we have five plus different areas. But if you think of a journey of a woman being healthy, to having an image abnormality that gets biopsied, that gets characterized as a cancer, gets treated and then turns into a survival patient. So the BCPP, the Breast Cancer Prevention Program aims to mimic that journey and to add data at each step.

Jenny:

An example of how we integrate all these diverse areas would be we actually came up with a pilot risk-based screening approach in Singapore where it’s not only looking at how dense the breast is. Usually the screening program just ask the woman to do a mammogram. Dense, then okay, go for a further check. Not dense, no particular finding, and then they’re cleared. But from our research, we actually find that there’s a lot of overlapping components to the risk factor of breast cancer. So if we add in bit of genetic and reproductive factors, family history, it will allow us to better predict the risk of a woman, an individual risk of a woman. And we feel that the higher the risk, they should be screened more frequently than a woman with lower risk. So that’s how we gather all the finding we have and then integrate it into one program, one project.

Max Hansen:

I have a quick question about that just in terms of the rural areas of the country. I know that in this state in particular, we have an issue with trying to collect information about risk in those rural areas. It’s hard to capture. I’m curious if you guys have ran into any similar problems to that in Singapore?

Mikael Hartman:

I guess there are two aspects to that. I mean, we’re an urban country. Singapore is a city-state. It’s marathon from coast to coast. It’s not that big. I think it’s like the Iowa City is pretty much the size of Singapore, where we have then close to 6 million people that live there. I think if you break it down into two different aspects, one is how do you capture the information of women? And the other one is how do you reach them? So the capturing, you can use technology. Most data that you would need for risk assessment would be available to you just using different online versions. The only one that requires a lab, really, would be the genetic information, but that can also be solved by means of mailing, meaning that you can do a buckle swap or similar and get DNA from the patient, put it in a small container, and then just ship it to the closest genetic lab. So that, I think, could solve risk-based screening also in a very rural setting like Iowa, I imagine that it is.

Jenny:

And something that I would like to add is that on top of Mikael’s idea, it’s important to know that we have many different ethnicities in Singapore. So to get accurate data, the best way will be to translate the question into their native language, so then we will be able to get more accurate data in that sense.

Max Hansen:

I really appreciate the emphasis put on just really trying to understand the community that you’re trying to reach first. I feel like that’s super important to acknowledge there. The program collaborates at many different levels of global collaboration, I guess. They collaborate at the local, regional, and international level, assembling multi-ethnic cohorts like the Singapore-Malaysia Hospital-Based breast cancer Registry and the Singapore breast cancer cohort. How have these collaborations enhanced your research capabilities and the findings from that research?

Mikael Hartman:

We are trained in epidemiology. I think one way to describe an epidemiologist is if you give an epidemiologist an orange, he or she will say, “Thank you. Do you have a few more?” Give you a few more. Then it makes a basket and they’ll go, “That’s really nice. You wouldn’t happen to have an orange tree?” You give them an orange tree, they go, “That’s really nice. Would you happen to have an orchard?” And that’s how we work. We realize that there is a power in size, and because we’re small, we knew that our data would be insufficient to substantially answer many of the questions. So we went and looked for collaborators. And I think maybe Jenny, you can talk about some of these collaborators, because they’re all over the world.

Jenny:

Yes. So for instance, we have this large Singapore Malaysia hospital-based breast cancer registry. And even though the ethnicity are similar in both countries, but the same race will differ in the different country. For instance, Chinese in Malaysia and Chinese in Singapore will differ a bit by their prognosis or the stage that they present at. Yes. So quickly we find that, okay, so there are differences and many of the findings are from European or from the States data, and we find that we have different genetic component. Asians have different genetic components. So we use their finding and validate that into the Singapore and Malaysia cohort, and we find that, oh, there is a difference, like SNPs genetic treatment prognosis all differ. So that’s how we actually gather more information that is truly unique to the Asian population.

Max Hansen:

I think similar to the emphasis placed previously, but just even the small differences that can be occurring within that large umbrella group of Asian women, I think is super powerful and super important to be able to truly address the needs of each of these individual communities.

Mikael Hartman:

So maybe I can give an example of using the power of having a very large international collaborative effort where we had more than, in the end, 300,000 healthy controls in breast cancer patients where we contribute in a small way. We were able to develop genetic scores that were applicable mainly to Caucasian women. But that was a really good basis for then developing an Asian scoring system. And the scoring is based on what we call single nucleotide polymorphism. That’s a big word, but what it means is that in your DNA, you have four letters. And these letters, they constitute about 40,000 plus genes. But every now and then we have spelling errors. You replace the letter. If it’s rare, we call it a mutation, but if that spelling error is common, it’s a polymorphism. My name is Mikael, spelled M-I-K-A-E-L. You’ll still recognize it as Mikael, but you’ll realize I’m not from Iowa. This guy must be from somewhere else. And the same goes with polymorphisms. They add that nuance, and that’s how we could use these polymorphisms to develop an Asian scoring system.

Max Hansen:

Right on. Right on. It sounds like, I mean, anyone that is into cancer research is well aware of the genetic component of things. Recent studies have provided insights into early breast cancer development in individuals with BRCA2 mutations. Can you please explain to our listeners? And myself personally, I’m not entirely sure what that is. I’m curious what it is.

Mikael Hartman:

Right. If you think of why you get a disease, so we have largely, you can think of environmental factors and hereditary factors. So for the estimate we use for why you get a disease in terms of genetics would be heritability. So the heritability for breast cancer is about 30%, meaning that the occurrence of breast cancer is largely explained to 30% by genes. Now, these genes come in different shapes and forms. There are what we call high penetrant mutations, meaning that if you have an error in that gene, it’s very likely to show up as a disease-causing gene.

These are typically known for breast cancers, BRCA1 and 2. If you have the mutation, your likelihood of developing breast cancer can be somewhere between one and two, meaning 50% or as high as 80%. And then you have what we have called medium penetrant genes, and there’s about five plus of these that convey a risk of maybe a lifetime risk of somewhere between 20 to 50%. And then we have a number of low penetrant genes, meaning that if you carry the alteration, it may not show up in your phenotype. So we think of genotype, what the genes look like, phenotype is what the disease looks like.

Max Hansen:

Piggybacking off of that, it sounds like you guys are doing a lot of genetic research as a part of this program. I’m curious, what are the implications of that research on personalized medicine for individual cases of breast cancer?

Jenny:

Okay, so you talk about prevention strategy. Mikael has talked about the polygenic risk score that derives from the single nucleotide polymorphism. This is like a rap.

So we thought if we can use that genetic component, okay, take a bucket swap. I mean, that is the pilot that we roll out into the risk space that I mentioned previously. We could also in the future draw blood, but then it wouldn’t be so easy to collect by an individual woman. So swap gave us the genes, the genetic component, we calculate the polygenic risk score. We add on if the woman went for a mammogram, add on the density score, whether they are recalled or not recalled. And then we can add on their H. [inaudible 00:17:01], reproductive history, family history.

And then we give a score. We tell the woman whether they are high risk, average, below average. And then we tell them high, risk screen every year. Average, screen according to guideline. We would actually hope for the low risk to be screened once in three years, or one is in five years. But that’s up to the Ministry of Health in Singapore. So giving that, it will actually reduce the burden of the screening program that we have now, and we will be able to pick out the cases I think in a better percentage. So that is how we plan to change the whole prevention setting in Singapore currently. But we are still at the pilot phase.

Mikael Hartman:

So when it comes to a strategy that transitions from what is done in most parts of the developed world, which is an age-based screening strategy, it means that you ask two questions. Are you a woman? Yes. Are you 40, 45 or 50? Yes. Then go and do mammograms on average every other year. So this initiative is then asking, we don’t really care about your age. We would much rather know what your risk is. And based on that risk, we would do two things. We would consider a different starting age, where some women would potentially start at the age of 35, and some may start at a much later age.

And the screening interval would be different. So for women of higher risk, they would screen more often, women of lower risk would screen less often. And the reason we say this is that if hypothetically a thousand women go for a mammogram, it’s about the same all over the world. About 900 of them are called normal. About 100 of them are recalled for some image abnormality. They have additional scans, and then 90 of them are called normal, leaving you with about 10 that have a biopsy, and you find four cancers. Which means that out of 1,000 women, 996 are normal for our cancer. You haven’t saved a life yet. You’ve just done a lot of scans. You’ve scared the living daylights out of 10%. So this initiative tries to allocate resources in a more efficient manner.

Max Hansen:

All right. All right. We just had a third guest join us just now, so please go ahead and introduce yourself to our listeners and tell them a little bit about yourself.

Cynthia Chou:

My name is Cynthia Chou and I am currently in the Department of Anthropology here at the University of Iowa. My training has been in what we call social anthropology from the University of Cambridge in England. And then I also did a study on the Malay world in which I was awarded a Dr. Phil from the University of Copenhagen later on. I’ve been working on the Malay world for about the past 30 years or so, and I was roped into this project together with breast surgeons in Singapore to do this study, because they wanted to find out about the cultural aspects of it. And one of the surgeons happened to be an old friend of mine when I was still an undergraduate student at the National University of Singapore. So it was quite by coincidence that some 30 years later on, we happened to bump into each other and he asked if I would consider doing this project, and I thought it was a very meaningful one. So that’s how I joined the team.

Max Hansen:

Awesome, awesome. Thank you very much for that introduction, Dr. Chou. We just got done talking about the multi-ethnic population that this program has been researching and processing data from. I’m curious, studies have identified barriers to breast cancer screening among Singaporean women, such as a lack of knowledge or a fear of becoming a burden to their families. How is BCPP addressing these cultural and informational challenges that these women are facing?

Cynthia Chou:

Well, first of all, there have been very few studies… Well, actually there have been studies done on Asian women, but in Western countries. And there have hardly been any kind of anthropological study done on Asian women in Asia itself. So as an anthropologist, when I joined this team together with the breast surgeons, the challenge was to carry out studies with an anthropological lens on many countries in Asia, in which no study has actually been, ethnographic study has been done on women in these parts of Asia. So from it, we produced a book, and in this book it’s for many countries, it’s the first time that they’ve gotten to know about breast cancer amongst Asian women and how Asian women actually perceive it in Asia itself.

And so, what we got was the meanings. You see a symptom is simply a symptom, but how do you interpret the thing? And it’s a matter of social construction and the meanings that are attributed to it molds the interpretative process. And it’s from the interpretative process then people decide whether they want to pursue treatment or whether they don’t want to pursue treatment. And so, all of this impacts upon how you would design a breast cancer preventive program.

Max Hansen:

It sounds like there’s a very comprehensive approach being taken to addressing these concerns. So the Breast Cancer Meanings project involved anthropological research across eight Asian countries. Could you briefly explain what the Breast Cancer Meanings project is?

Cynthia Chou:

So as I mentioned to you, because many countries in Asia haven’t really had a study, an anthropological study or an ethnographic study on Asian women in Asia, so many of these countries, this was the first time that we had it. But the anthropological perspective also demonstrated to the biomedical practitioners such as the surgeons and the doctors that when they talk about breast cancer, they talk about breast cancer as a disease, which is a biological abnormality. The anthropological lens that came in, it shows how the regular person sees and talks about breast cancer, but they talk about it as an illness, which is more about their sociocultural experience about breast cancer and the meanings that they attribute the thing. And that’s why the book is called Breast Cancer Meanings, because we are looking at the meanings and how do those meanings get socially constructed.

And here we look at the concept of embodiment as to how outside factors get into the body that affects the health of a person. And what we also did find is that the word cancer does not mean the same thing in all cultural groups. And here, we have the Asian continent, in which it’s a cultural mosaic. There is no one size fits all answer or solution to it. And when they were doing the long, when the surgeons were doing the long, they were stopping at different Asian countries. So at the start of it, when I was pulled into the project, I was asked if I could look for an Asian solution.

And this is where the cultural perspective brought in the idea that there is no one size fits all answer to it, but you actually have to understand the culture of each society that you’re approaching or group that you’re approaching. And what’s very significant was that in the team, that from the cultural perspective, we also had linguists, anthropological linguists to look at the language itself, in which we often forget that language is a very important factor in how you perceive and understand the world. And what we looked into in analyzing the language is that in some societies, there’s not even an indigenous term for cancer. The word cancer is borrowed from English.

And also for the anthropological studies, true light on the word illness, that in many Asian societies when they talk about being ill, being ill connotes the necessity of experiencing pain. And if you don’t have any pain, then you are not ill. So that really complicates things, because in breast cancer, by the time you feel pain, you’re in mighty big trouble. And if you think about it, oftentimes when a patient goes to see a doctor, one of the questions that they asked is, “Did you experience any pain this past week? What’s the level of your pain?”

So that immediately influences patients or just normal people to think that, “Oh, I have to have pain before I can be considered to be sick,” right?

Max Hansen:

Before you can even seek that care.

Cynthia Chou:

To seek that care. So breast cancer, by the time you feel pain, you’re pretty much in the advanced stage. So they would think, “I don’t feel any kind of pain, what kind of risk would I experience in having it?” So then we say, okay, go for mammograms. What does the mammogram do? It compresses the breast and it actually causes pain. Because it causes pain, there’s also the idea from people’s perspective, that the mammogram actually causes the breast cancer because it causes pain.

Max Hansen:

That’s a very insightful perspective there, and it absolutely makes sense because it’s very, from the outside looking in someone who is unaware of what that procedure is doing, it’s very, very easy to be like, “Oh, well that is bad for me. That’s not good for me. I don’t even feel like I need anything right now, so why would I put myself through that?” So I really appreciate that.

T sounds like there’s a lot of barriers that these people are facing when it comes to preventing breast cancer and really reducing their risk. I’m curious, what community outreach initiatives the BCPP implemented to raise awareness and encourage early detection among Singaporean women?

Mikael Hartman:

So realizing early on that we need to move outside of the hospital into the community. We worked with community centers throughout Singapore, where we had discussions with women about the condition. We also recognized that one of the largest unmet needs was in the Malay population, which is largely in Islamic community. So we then started working with the mosques and the MUIS, which is the Islamic council, to see how we can then shape our messaging in a manner that would be understandable to the Malay women.

Max Hansen:

Yeah. Like tailoring it to those people, as we have been engaged more with them through those community outreach efforts.

Mikael Hartman:

So two aspects, both tailoring it and meeting them in their setting where they would be socially more active.

Max Hansen:

Right. Awesome. We’ve talked a lot about the past and the present, so I’m curious, looking ahead, what are the key priorities and upcoming projects that the BCPP hopes to hopes to seek out in the next five years?

Mikael Hartman:

Yeah, so if you think of a prevention program, it’s good to understand that prevention comes in largely three different shapes. Primary prevention, secondary and tertiary prevention. Primary prevention is typically vaccines where you do something not to get a condition. Secondary prevention is finding things early, and tertiary prevention is completing things most effectively so that you don’t die from the condition. So where we think we have the most to offer is in secondary prevention. So what we’re trying to launch within five years is what we describe as mammography screening 2.0, which then incorporates the messaging to the communities with the unmet needs. It’s transitioning from an age-based screening solution to a risk-based screening solution, and then scaling it up. So at the moment, we’ve done studies on about 5,000 women. Our next step is to scale it up by tenfold to 50,000, and if that works, then we, with the blessing of our Ministry of Health, we’ll try to make it national.

Max Hansen:

Awesome. That sounds awesome. I mean, just the whole idea of scaling things up and just really trying to be more comprehensive with the population at hand. I’m curious with that in mind, how do you envision the program evolving to meet the challenges of breast cancer prevention in the broader Asian context?

Mikael Hartman:

That’s a really difficult question because breast cancer screening requires a society and a nation that is able to handle the screening program. And most Asian countries, actually, they’re not. So the countries that could potentially handle and are handling national screening programs is Japan, Korea, Taiwan, Singapore, parts of China, while other countries don’t have the infrastructure to run the screening program. So we need to think of other ways of getting a halo effect, which is why the work by Cynthia and her team is understanding the barriers to health seeking behavior, how we can alleviate those barriers so that we can get secondary prevention by allowing them to come earlier.

Max Hansen:

Awesome. Right on. All right, well, thank you all very much for coming in and having this discussion with me today. I know that there are five of you, and unfortunately we were only able to talk to three of the five. However, I feel like we were able to cover a lot today and it was very, very insightful. So thank you all.

Jenny:

Oh, thank you having us.

Mikael Hartman:

Yeah. Thanks for having us.

Max Hansen:

Absolutely.

Lauren Lavin:

That’s it for our episode this week. A big thank you to Dr. Hartman, Jenny, and Dr. Chou for sharing their perspective stories and lessons from the Breast Cancer Prevention program in Singapore. We learned how cultural context matters in breast cancer care, how public health research can be enriched by anthropological insight, and how trust-building and community engagement are essential for making healthcare more accessible and more effective across diverse populations. This episode was hosted and written by Maxwell Hansen and edited and produced by Lauren Lavin. You can learn more about the University of Iowa College of Public Health on Facebook and check out the Breast Cancer Prevention program for more on today’s topic. Our podcast is available on Spotify, Apple Podcasts and SoundCloud. If you enjoyed this episode, it would like to help support the podcast. Please share it with friends, colleagues, or anyone interested in public health. Have a suggestion for a team? You can reach out at CPH-[inaudible 00:33:21].edu. This episode is brought to you by the University of Iowa College of Public Health. Until next time, stay healthy, stay curious, and take care.