Even though breast cancer is the most common cancer in South African women, breast cancer treatment has evolved over the last 50 years, from a disease treated mainly in the hands of the surgeon to now being a showcase for multi-disciplinary team management.
Advancement in the understanding of oncological care has resulted in swings from large radical surgery (mastectomy) to breast-conserving surgery (lumpectomy). Greater understanding of tumour biology (behaviour of cancer cells) has seen tremendous strides in the use of oncological drugs that target the cancer cell specifically, and a paradigm shift around understanding cancer spread.
Clinical assessment breast examinations involve not just feeling the breast tissue gently but also examining the nipple and feeling for lymph nodes.
Breast ultrasounds in women under 35; and mammograms and ultrasounds in women over 35 are the standard initial radiology assessments. Today MRI scans can also be done to assess breast tissue.
If a concerning area is seen on the breast radiology, a radiology review in a multi-disciplinary meeting to determine assessment of and need for a needle biopsy is required. There is no role for surgical biopsies as an initial diagnostic tool.
Stages of breast cancer
Stage 1: Early breast cancer confined to the breast.
Stage 2: Locally advanced in either the breast or the lymph nodes.
Stage 3: Locally advanced in both the breast and the lymph nodes or extremely advanced in the breast.
Stage 4: Metastatic disease is present in any organ.
Treatment may consist of surgery (breast-conserving surgery or mastectomy), oncological treatment and radiation. Oncology treatment means drugs to treat breast cancer. There are different types which can be taken orally, intravenously, or by injection.
- Cytotoxic drugs are chemotherapy drugs.
- Target therapies target areas of the cancer cell.
- Endocrine therapies either binds selectively to hormones, or blocks hormones.
- Immunotherapies assist or manipulate the immune cells and function.
The order of treatment is dependent on the stage at which your cancer is detected as well as the behaviour of your cancer.
All young breast cancers patients should be offered a fertility service and discussion prior to starting treatment.
Radiation is recommended if there is axillary nodal disease (one or more lymph node involved).
Who gets what surgery?
Today there is little reason for you not to choose breast-conserving surgery (lumpectomy). The absolute oncological indications for a mastectomy today are: inflammatory breast cancer (always after chemotherapy) and multicentric breast cancer.
You may choose to have a mastectomy or a bilateral mastectomy, but this is a psychological choice, not an oncological choice. Before you decide on your surgery, a detailed discussion explaining the following points need to be made: Once a diagnosis of a breast cancer is made; that cancer determines the outcome, and irrespective of the BRCA or family history a bilateral mastectomy becomes choice, not an oncological decision. The survival is equal whether a mastectomy or breast-conserving surgery is performed. Please remember, breast cancer treatment doesn’t involve emergency cancer surgery ever.
Oncoplastic surgery is defined as techniques used at the time of breast-conserving surgery. Reconstructive breast surgery is the term used for reconstruction post-mastectomy, be it immediate, immediate-delayed or delayed.
Breast reconstruction and oncoplastic surgery should be discussed with you prior to surgery. The vast majority of patients can undergo immediate reconstruction at the time of their cancer surgery (thus avoiding multiple procedures).
An oncology care physician survivorship programme ensures that post-treatment you don’t need to have your follow-ups in the oncology suite. Ask your treating doctor, if they have such a programme.
Ask about onco-psychology services for you, your partner and family as most people experiencing a cancer diagnosis suffer from subclinical depression, and families can have various psychological issues around a diagnosis.
Less patients have lymphoedema today but the need for physiotherapy and when is important.
Complementary oncology and the need to understand why you, as a patient, want to use supplements with cancer medication is critical; having facilities that care about what you are taking and how this is managed is important.
FAST FACTS AND USEFUL TIPS
- For every 100 people seen in a breast health practice; only 10% will require surgery.
- Whilst history taking is important, 65% of women diagnosed with breast cancer have no significant risk factor history.
- All your information should be reviewed when you go for an opinion.
- Work out costs of treatment by asking for quotes from your treating team.
- Ensure that your treatment plan is discussed in a multi-disciplinary team to ensure safe care.
Prof Carol-Ann Benn heads up an internationally accredited, multi-disciplinary breast cancer centre at Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established The Breast Health Foundation.
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