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Demystifying Breast Cancer

Breast cancer is the commonest cancer in South Africa today. A woman has a 1:29 chance of being diagnosed with breast cancer in her lifetime. Our understanding of this disease has advanced a lot over the years and today 90% of women with early stage breast cancer can be cured with the available treatment modalities.

The hope is that after reading this article you will have a better understanding of the relevant issues surrounding the diagnosis and management of breast cancer.

Risk factors for breast cancer include but are not limited to family history smoking, alcohol, obesity, early age at first child bearing and prolonged use of hormone replacement therapy. After 5 years of HRT the risk of breast cancer rises significantly. A recent study showed that even small infrequent alcohol use increases breast cancer risk.

There are various recommendations to screening, however it s reasonable to do a mammogram every 2 years in your 40’s then annually in the 50’s until the age of 75. There is limited data of benefit in performing mammograms in the elderly, as they often have competing factors for mortality.

If the radiologist detects an abnormality on the mammogram, they will obtain your consent to perform a biopsy. The biopsy should be a core biopsy and not a Fine Needle Aspiration (FNA) which only samples a few cells and is not adequate to provide the information required to make a comprehensive assessment of the suspected cancer.

If the diagnosis is confirmed you will be referred to a breast surgeon,who will see you as well as discuss your case at a Multi Disciplinary team of Specialists.This should comprise of a medical oncologist, a plastic surgeon, a radiologist to review your films, a pathologist to explain the biology (what I like to call the “signature “ of the cancer, a radiation oncologist, as well as supportive members of the team that include a lymphedema therapist, counsellor and a dietician among others.

A word of advice: always take a family member or trusted friend to the Oncologist visit, as there is often a lot to discuss and in the state of anxiety and distress it may be difficult to remember everything.

In addition you need to prepare for the consultation with written questions to your Oncologist. I will be covering what questions to as in a column to follow.

The Oncologist will discuss the treatment with you.The cornerstone of treatment for early stage breast cancer is surgery. However depending on the stage of the cancer,you may require therapy,either chemotherapy or hormonal blockade to shrink your tumour before the surgery.

The indications for this include and are not limited to large tumour size, especially of you desire breast conservation surgery,affected lymph glands in the armpit,aggressive biology with a high risk of distant spread.

Depending on the extent of surgery, you will be introduced to a plastic surgeon to discuss the timing and type of reconstruction. In the past the adage was to wait for a year before reconstruction, but most women, except in select cases, can have an immediate reconstruction. In most cases,this means that the process of reconstruction begins immediately. You may need multiple procedures before the final result, so you will need to discuss this with the plastic surgeon beforehand.

Its important to know that the decisions regarding your treatment will be made with you. You are the most important member of the multidisciplinary team! You need to be vocal about your needs,and your expectations.

Following your surgery, a determination will be made about what treatment is needed after surgery,in order to reduce your risk of breast cancer recurrence. This is based on the final pathology result, the biology of the cancer, size, lymph node involvement, as well in select cases and where applicable the result of a genomic profiling, where the tumour is submitted for further testing of specific genes to further profile the cancer biology and determine risk of reapse.

There are variations of this test on the market, including the Oncotype DX, Mammaprit and Endopredict. Your Dr will discuss these with you if they are clincally indicated.However not all medical aids pay for these genomic tests,so you may need to explore this with your medical aid should it come up.

The treatment you receive after surgery is called adjutant therapy,and may include chemotherapy (if not administered preoperatively),hormonal blockade, or biological agents.

In addition you may require radiation therapy,which is delivery of types of rays to the breast and draining nodal areas,and this reduces the risk of local recurrences and improves survival after a diagnosis of breast cancer where indicated. The indications for radiotherapy are if you have undergone a lumpectomy, positive lymph glands in the armpit and large tumour size.

Remember that breast cancer although traumatic and distressing, is not a medical emergency. This means that you have time to see your specialists, ask questions, consider your options carefully and seek a second opinion should you not be entirely comfortable. You should never feel pressurised to make a decision, nor be referred hurriedly to a string of doctors. I would even recommend that you have at least 2 visits before you make a final decision.

Breast cancer is a curable cancer, and the “one size fits all” approach is obsolete! We are moving into the era of personalised care, with the patient in the driver’s seat!

In the next few weeks we will write more about surgery, radiation therapy, lymphedema and the questions to ask when you see your oncologist for the first time.

Breast cancer can be treated, get informed!