Breast cancer - What we can do

Breast cancer has become the leading cause of cancer death for women in South Africa, superseding cervical cancer in the recent years. The global risk of developing breast cancer has increased significantly over the last decade, such that today one in nine women will be diagnosed with this disease in their lifetime.

Risk factors for breast cancer are numerous and include early age at first menstruation, smoking, previous history of benign breast diseases and later age at first child. This is becoming increasingly relevant as more and more women postpone child-bearing on account of other competing interests like careers and travel. The use of oral contraceptives increases the risk minimally; however, the risk does tend to decline steadily over time following cessation of use.

Family history is perhaps the most important risk factor for breast cancer. Certain genetic mutations are known to be responsible for increasing the risk of breast cancer manifold. Among these are the BRCA mutations, known in medical literature as BRCA 1 and BRCA 2.Women with these mutations have a lifetime risk of 70% for developing breast cancer and 30% for ovarian cancer.

It is however important to realise that having a positive family history does not necessarily imply a genetic mutation as familial clustering is also fairly common.
Factors that may suggest a genetic mutation in a woman with breast cancer include younger age at diagnosis,(Younger than 50),a family history of bilateral breast cancer, where both breasts get involved with cancer, either simultaneously or at different time points, or a family history of ovarian cancer. Family members of such women need to be screened for mutations to exclude an existing cancer and allow for closer surveillance.

This does not at all suggest that we should abandon the Pill, throw away our career aspirations and head for the maternity ward in an effort to escape this scourge.
There are simple measures that we can implement to screen for this disease and attempt to diagnose it early as the prognosis is generally better in the earlier stages of the disease. Women with documented BRCA mutations must discuss their risks with their doctors especially the issues pertaining to prophylactic mastectomies(surgical removal of the breast) and /or removal of the ovaries. These significantly drop the probability and risk of future cancer but do not eliminate it completely. Remember that, should you opt for a prophylactic mastectomy a plastic surgeon will be able do a reconstruction simultaneously, to minimise the pschycological impact of a mastectomy.

You can start by examining your breasts monthly, preferably after your menses, as this is the time when breast tissue is least dense. Postmenopausal women can elect a day at the beginning of each month for uniformity. It’s important to use the palmar aspect of your fingers and not your finger tips as you are likely to misinterpret normal breast nodularities as “lumps”, causing unnecessary alarm. In addition, annual breast examination by a clinician is recommended. Anything suspicious must be imaged, preferably by doing a mammogram.
A mammogram is a low intensity X ray of the breast.
It is recommended that you go for a baseline screening mammography from age 40, every one to two years until 50, followed then by annual mammograms until age 70 after which a mammogram can be done biennially.  However if you have a strong family history or  a documented mutation on screening  the recommendation is to do annual mammograms beginning at age 40 or five to ten years before the youngest age at which breast cancer was diagnosed in a family member, whichever is earlier.
If there are any suspicious lesions on the mammogram, the radiologist will proceed to do sonar of the breast which may better define any abnormalities on the initial study. This may be followed by a biopsy of any suspicious areas to exclude a cancer.

In the event that you are diagnosed with breast cancer you will immediately be referred to an oncologist. The treatment for breast cancer is multi disciplinary with the medical and radiation oncologists together the surgeon working closely together to ascertain the best treatment plan, tailored to your specific situation.
The treatment depends mostly on the stage of the disease at diagnosis. All localised breast cancers must be surgically removed if feasible. The final decision regarding whether you will have a mastectomy or a lumpectomy (where only the cancer is removed, leaving the breast behind) is mostly yours although your doctor will be able to provide the necessary guidance and insights to aid you in making a decision.
Taking into consideration different factors eg, the stage and biology of the cancer, the tumour size, involvement of axillary(armpit) glands with tumour, and your oncologist will be able to determine the need and extent for chemotherapy, radiation therapy or both. You may not need any chemotherapy or radiation at all especially if the cancer is low grade, the glands negative and the tumour size very small.
Breast cancer mortality has declined steadily over the years, mostly due to improved screening, awareness and better therapies. It remains our challenge as women to be informed, go for regular screenings and so attempt to turn the tide in the battle against this disease.