R0.000

Breast cancer

Home / Breast cancer

How common is breast cancer in men?

The occurrence of male breast cancer varies throughout the world. In the United Kingdom it counts for less than of all breast cancers but in North America there seems to be an increasing incidence especially amongst black males, with about a thousand cases being diagnosed per year. It is most commonly found in men over sixty. We don’t know how common it is in South Africa but we think between 1-3% of all breast cancers happen in men.

Who gets it?

The risk factors for male breast cancer are interesting; it is definitely not associated with benign male breast lumps or breast enlargement (gynaecomastia). There does appear to be an inherited component because the lifetime risk of a male to get breast cancer if his mother and his sister had breast cancer is about 2.5%.

Male breast cancer is more common in families who have the BRACA2 gene mutation and in males who have Kleinfelter’s Syndrome (which is the chromosomal abnormality XXY). It seems to be increasing in men who work on electrical lines and factors such as radiation, X-rays and electromagnetic waves have been implicated.

 What type of breast cancer do men get?

A male breast cancer is almost always a ductal carcinoma (the most common sort). Lobular carcinoma is rarely seen in men and when it is it is usually in association with Kleinfelter’s Syndrome. Any variation of ductal carcinoma can be seen in male breast cancers including Paget’s disease (cancerous eczema of the nipple). 80% to 90% of male breast cancers are responsive to hormones.

Male breast cancer is no different to female breast cancer. All people have some breast tissue but because men have less, when cancer develops it tends to be more advanced earlier, with chest wall and skin involved. The vast majority of male breast cancers present as a painless breast lump and it is usually a painless mass. They may have a nipple discharge or nipple changes, and very few are painful. About 5% of these cancers will present with spread to other organs (metastatic disease). Any unilateral breast mass that is firm, fixed or ulcerated in a man should raise suspicion.

How do we investigate it?

All potential cancers are investigated the same way, whether it is in a man or a woman. The investigations that should be done are a mammogram and sonar. Sensitivity in mammograms is the same in men as it is in women. A core needle biopsy will provide the pathological diagnosis.

Treatment

The treatment for male breast cancer is just as the same as in women. It usually involves surgery, oncology (chemotherapy and hormone therapy) and radiation therapy working as a multi-disciplinary team. Men are normally managed with a mastectomy and a lymph node dissection, followed by chemotherapy and radiation treatments if they are needed. Tumours that are greater than 2cm have twice the risk of returning than those where the lesions are less than 1cm, so it is important to make sure the margins are wide and the cancer is well-treated. Hormone therapy can improve the survival if the cancer is sensitive to hormones.

Although the prognosis is believed to be worse in male breast cancer than in female, stage for stage it is actually identical. Because men are often diagnosed at a later stage relative to the size of breast tissue they have, it gives the impression of a worse prognosis.

It is important for men with unilateral breast masses that are firm, to seek medical attention and be assessed appropriately by a breast specialist.

If you or someone you love is diagnosed with breast cancer the chances are you have to spend a lot of time in different doctors’ offices, and all the doctors will discuss different types of treatments.

Breast cancer management relies on a firm foundation of a multi-disciplinary team. What that means is that every doctor involved in cancer treatment should be speaking to every other doctor. The intention is that from the start of a patients treatment there is an individual plan, tailored to the exact stage and type of breast cancer that the patient has. This team of people involved in care includes the breast surgeon, the reconstructive (plastic) surgeon, a radiologist who carries out mammograms and biopsies, the chemotherapy and radiation specialists (oncologists) and a psychologist too.

Breast cancer management involves not just the breast but treatment of the whole body. This is because even very early on we know that cancer cells can be found in other organs. It is important to eradicate the cancer not just from the breast, but from the whole body. This is done using four different type of therapy often managed by a different member of the multi-disciplinary team (that’s why it’s so important that they talk to each other).

These can be divided into those that affect the breast, to get rid of the cancer present either there or in the nearby lymph glands, and those therapies that seek out and destroy breast cancer cells that may be present in the rest of the body. The therapies are:

  • Local treatments to the breast:
    • Surgery
    • Radiation
  • Whole body treatments to find any cancer that has spread in the body:
    • Chemotherapy
    • Receptor-dependant treatments (hormonal and target treatments)

Each type of treatment can be thought of completely separately (with one exception). During cancer management, the patient will have at least one local and one whole body treatment but they might require all of the different treatment methods, depending on the type of breast cancer and the advice of the specialists.

Let’s look at them all individually.

Surgery

In breast cancer management, surgery will take place at some point through the treatment path. Surgery can take place at more than one time, either for diagnosis, treatment or reconstruction. There are three areas of surgery every patient will experience and therefore should discuss with their doctor: Surgery to the breast, surgery to the axilla, and reconstructive surgery. Some of the operations undergone are:

Sentinel Lymph Node Biopsy

Often this is the first part of cancer treatment, carried out to see if the cancer has spread from the breast to the glands (called lymph nodes) under the arm. On the day of the operation the patient is injected with a radioactive chemical which is not harmful, and the doctor uses a special probe and blue dye to find the first gland the cancer would have spread to (the ‘sentinel’ which means the guard). The surgeon will make a small cut in the armpit under a general anaesthetic and take out this gland.

If the cancer is spread it is called ‘locally-advanced’ and this increases the risk it has spread outside the breast to the rest of the body. Cancer that has spread to the rest of the body is best treated with chemotherapy.

Wide Local Excision or Breast Conserving Surgery

This is a ‘lumpectomy’ operation that can take place if the surgeon believes it is possible to remove the cancer safely without removing the whole breast. This might be because the cancer is small, or because the breasts are large enough to allow a big area to be removed. Cancer is never taken out alone, it is always taken out with a big margin, which acts as a fire break between the cancer and normal breast tissue. It reduces the risk that the cancer may come back in the same place.

There are some important safety measures that have to happen with breast conserving treatment (BCT). The first is that the surgeon must be sure that all the cancer can be removed safely. Then the patient must be able and willing to have radiation treatment, because BCT is not safe if you do not have radiation. Finally it is important that BCT is carried out with help from a surgeon skilled in reconstructive techniques. Normally this is a different surgeon from the breast cancer surgeon.

Mastectomy

The oldest and most well-known method of surgically treating breast cancer is a mastectomy. This is a procedure where the whole breast is removed from the body, and the patient is left with a flat chest and one scar. Very often, immediate reconstructive surgery can be carried out so that the patient has only one operation, and is left with a similar breast mound to before the operation.

Sometimes a woman may decide to have both breasts removed during the operation but this is only after intense discussion of all the options, and a realistic assessment of the risk of further cancer in the other breast.

Axillary lymph node dissection

If the cancer has spread to the glands, all of the glands under the arm will need to be removed. Unfortunately this can cause some pain and stiffness around the arm after the operation, and in 1 out of 10 ladies, the arm may swell up after the operation (called lymphedema) because there is no longer a clear passage for fluid to flow from the arm back to the body. Most often an axillary dissection is done at the same time as the breast operation, through the same cut or a different one. If the sentinel lymph node biopsy is negative however, an ALND may not be required.

New data suggests that some women may not need to have an ALND; even if their glands are positive. This may change surgical practice in the future, but at present further research is required.

Reconstruction

All patients who have breast surgery should have the opportunity to have reconstruction. This surgery can restore two equal breast mounds to a woman’s chest. This may be part of breast conserving surgery or after a mastectomy, either at the same operation or at a later date. Plastic surgeons can use tissue from other parts of the body to reconstruct the breast and they may also use prostheses, made of materials such as silicon, to give the shape of a breast under the skin and muscle, if there has been a mastectomy. All women have a right to be considered for reconstructive surgery, even if your operation was a long time ago.

 

Radiation treatment

Radiation is also a method of killing rapidly dividing cells such as those in breast cancer. It works in a local area however, not throughout the body like chemotherapy.

Radiation treatment is given by directing a beam of radiation, made up of thousands of X-rays, which attacks any cells which may be cancer. It helps to reduce the risk a cancer coming back after surgery especially if the cancer is large or close to the rim of normal tissue removed. All cancer surgery, even the best, has a risk of leaving behind a few isolated cancer cells. If those cells start to divide again, the cancer can recur. Radiation ‘mops up’ any cancer cells that surgery may have left behind. There are a number of circumstances that increase the risk of cancer recurrence and in these situations we know radiation is beneficial.

These are:

  1. When a cancer is very big (greater than 5am)
  2. When a cancer has involved a lot of glands under the arm, or the glands are heavily involved
  3. When any breast tissue is left behind (radiation is always required in breast conserving treatment)
  4. When the multidisciplinary team is concerned that the margins of normal tissue around the cancer was too small (not a big enough ‘fire break’). If there is true cancer at the margin however, the cancer should be removed with surgery not radiation.

Chemotherapy

Chemotherapy uses medicines that attack cancer cells to kill the cancer in your body. These medicines may be given through a drip or in tablet form.

We know that cancer cells multiply more quickly than most of the body’s cells. Because of that, they are working very hard and are in the duplicating phase of the cell cycle almost constantly. Chemotherapy finds cancer cells by looking for all the rapidly dividing cells in the body. It then attacks them by preventing them duplicating.

This works well, but also affects normally cells in the body which divide quickly, such as the cells of the hair and the gut. Because these cells die too, patients can suffer from hair-loss or gut symptoms such as nausea, vomiting or diarrhoea.

If the breast cancer is greater than 1cm or has spread to the glands we know that the risk that the cancer is in the rest of the body is great. Only chemotherapy can find and attack cancer cells outside of the breast, and so it is given to all patients with these types of cancer. There are genetic methods of determining whether a patient will benefit from chemotherapy, which use samples of the breast cancer tissue to analyse how aggressive it is. These tests are expensive but may be beneficial in ensuring the correct patients get chemotherapy.

Receptor-dependant treatment

Breast cancer is one disease but has many faces. If you stand in a room of breast cancer survivors, the differences in the types of tumour will be as different as the sizes, shapes and personalities of the people they belong to. Some cancers talk easily to the other cells of the body, others ignore any interactions. The way that cancers ‘talk’ to the body is through hormones and receptors.

If a breast cancer has receptors on it, some of the body’s hormones and other factors can influence it. Doctors can use hormone and receptor blockers to prevent anything encouraging the cancer to grow, or encourage any other potential cancer cells to develop. There is still so much we don’t know about receptors, and lots we are learning, but there are some receptors we know how to block:

Oestrogen receptors(ER) and Progesterone receptors (PR)

If the cancer is positive for these receptors, it means that oestrogen (the female hormone) can encourage the cancer cells to grow and divide. By preventing oestrogen influencing the cells, drugs are used to block the receptor. The most common medicines are Tamoxifen and blockers called Aromatase Inhibitors.

Her2 receptor over-expression

This is the newest abnormality to be found in breast cancer, and has changed the treatment of Her2 positive cancers which were often aggressive and may be ER/PR negative. All cells have Her2 receptors which encourage growth of normal cells. Some breast cancer cells have too many Her2 receptors which mean that they promote the growth of cancer cells. Treatments that specifically target Her2 include Trastuzumab (sometimes known as Herceptin). This can be given with chemotherapy, with ER-blockers or by itself.

 

Much of the research into breast cancer care is around finding more receptors so that more medicines can be developed to block them. Often new treatments are being tried out in current cancer patients, and patients can take part in a trial of a new treatment.

 

When you have breast cancer or think you might be at risk, it is important to see a doctor who is a breast cancer specialist and can advise you on the most modern, safest and most effective ways of curing the disease.

A diagnosis of cancer can be one of the most stressful experiences of life. In addition to the worries over survival and treatment, many patients find that they have additional concerns over the cost of medical treatment. In South Africa, 80% of patients are managed within the government health service, and 20% have medical insurance that means they can be treated in private hospitals. Many people find that they have let medical aid run out, or are not covered in a way they thought they were. If you do have medical aid, there are a number of considerations to remember to check in case you have a diagnosis of breast cancer in your life.

Most importantly remember:  you cannot afford NOT to be treated for breast cancer.

I haven’t got Medical Aid

There are many excellent public hospitals and superb academic cancer specialists who work in government hospitals. As with all times of illness: knowledge is power, therefore knowing what management you should be expecting will help you navigate through the system. Books like this one and the internet can help you get more information to help you in your journey.

There are many organisations that wish to help patients who do not have the resources for travelling to a hospital or managing treatments. See our help and support page for further details.

Navigating Medical Aids

All medical aids, even hospital plans, have to provide some cancer cover. This will include in-patient care but may also include specialist fees, chemotherapy and cover for radiation and medications. The amount and type of treatments covered tends to depend on the medical aid plan that you are on, and it may require you to register for a cancer scheme after diagnosis. Check when you are considering starting or changing medical aids what type of treatments you are covered for.

Fortunately medical aids are not allowed to refuse cover for a patient with a pre-existing condition and that includes cancer. Remember to always mention these conditions to your medical aid so that you gain access to appropriate care and do not disqualify yourself.

Check your policy too as many companies encourage good health by funding screening mammography and Pap smears even to patients without day-to-day benefits.

Cancer policies

Even if you have medical aid, some of the initials concerns about cancer that patients suffer are not about survival or treatments, they are about whether they will be able to afford their treatments or go into debt. Because of this many insurance companies offer a policy which allows patients to unlock financial resources to cover the gap between what is covered and what is required.

Disability cover

Disability cover protects your ability to earn a living. It allows you to retrieve money from your policy when you are unable to work for certain periods of time. This may be due to temporary or permanent disability. The policy may be related to your ability to work at all or your ability to carry out your specific occupation.

Estate planning (making a will)

Nobody likes to think of a time when they will not be here, but it is said ‘death, taxes and childbirth: there is never a convenient time for any of them!’

Your estate is everything that you own, from a house and car to your jewellery and cell phone. If you do not plan for who will receive them after you die, the government will plan for you and may leave your family and dear ones without the resources they need when they need them.

Making a will is a simple exercise and shows how much you love the people around you. It is a good idea to also stipulate who should make decisions for you, if you are too ill to decide for yourself how you would like doctors to treat you.

Saving now for the future

Saving money is not easy, but if you are worried about how you can afford to cope if you get ill now is the time to start. Once you ensure that you have coverage in place for managing your expenses (such as medical aid and disability, cancer or life insurance) have a look at your monthly budget and look for ways to save a small amount into an emergency fund each month. This can act as a financial buffer when you have a significant outlay. This might not even be a medical expense but it will come in useful if you do have an unexpected medical diagnosis.

Budgeting also allows you to work towards paying off debts. Often the greatest of patients is not how to afford future treatment, but how to keep up with past debts during a period where you cannot work.

If you do get into debt or cannot afford treatments, discuss the problems with your doctor. They may have knowledge of charities that can provide financial assistance or work to find a longer but easier solution to payments.

A diagnosis of cancer can be one of the most stressful experiences of life. In addition to the worries over survival and treatment, many patients find that they have additional concerns over the cost of medical treatment. In South Africa, 80% of patients are managed within the government health service, and 20% have medical insurance that means they can be treated in private hospitals. Many people find that they have let medical aid run out, or are not covered in a way they thought they were. If you do have medical aid, there are a number of considerations to remember to check in case you have a diagnosis of breast cancer in your life.

Most importantly remember:  you cannot afford NOT to be treated for breast cancer.

I haven’t got Medical Aid

There are many excellent public hospitals and superb academic cancer specialists who work in government hospitals. As with all times of illness: knowledge is power, therefore knowing what management you should be expecting will help you navigate through the system. Books like this one and the internet can help you get more information to help you in your journey.

There are many organisations that wish to help patients who do not have the resources for travelling to a hospital or managing treatments. See our help and support page for further details.

Navigating Medical Aids

All medical aids, even hospital plans, have to provide some cancer cover. This will include in-patient care but may also include specialist fees, chemotherapy and cover for radiation and medications. The amount and type of treatments covered tends to depend on the medical aid plan that you are on, and it may require you to register for a cancer scheme after diagnosis. Check when you are considering starting or changing medical aids what type of treatments you are covered for.

Fortunately medical aids are not allowed to refuse cover for a patient with a pre-existing condition and that includes cancer. Remember to always mention these conditions to your medical aid so that you gain access to appropriate care and do not disqualify yourself.

Check your policy too as many companies encourage good health by funding screening mammography and Pap smears even to patients without day-to-day benefits.

Cancer policies

Even if you have medical aid, some of the initials concerns about cancer that patients suffer are not about survival or treatments, they are about whether they will be able to afford their treatments or go into debt. Because of this many insurance companies offer a policy which allows patients to unlock financial resources to cover the gap between what is covered and what is required.

Disability cover

Disability cover protects your ability to earn a living. It allows you to retrieve money from your policy when you are unable to work for certain periods of time. This may be due to temporary or permanent disability. The policy may be related to your ability to work at all or your ability to carry out your specific occupation.

Estate planning (making a will)

Nobody likes to think of a time when they will not be here, but it is said ‘death, taxes and childbirth: there is never a convenient time for any of them!’

Your estate is everything that you own, from a house and car to your jewellery and cell phone. If you do not plan for who will receive them after you die, the government will plan for you and may leave your family and dear ones without the resources they need when they need them.

Making a will is a simple exercise and shows how much you love the people around you. It is a good idea to also stipulate who should make decisions for you, if you are too ill to decide for yourself how you would like doctors to treat you.

Saving now for the future

Saving money is not easy, but if you are worried about how you can afford to cope if you get ill now is the time to start. Once you ensure that you have coverage in place for managing your expenses (such as medical aid and disability, cancer or life insurance) have a look at your monthly budget and look for ways to save a small amount into an emergency fund each month. This can act as a financial buffer when you have a significant outlay. This might not even be a medical expense but it will come in useful if you do have an unexpected medical diagnosis.

Budgeting also allows you to work towards paying off debts. Often the greatest of patients is not how to afford future treatment, but how to keep up with past debts during a period where you cannot work.

If you do get into debt or cannot afford treatments, discuss the problems with your doctor. They may have knowledge of charities that can provide financial assistance or work to find a longer but easier solution to payments.

The old adage that you can chose your friends but not your family holds true when looking at your cancer risks.

Today people live for longer than at any other time in history. For instance in the 19th century ,  more babies died from disease, men and children died early working in the mines, plagues carried off the frail, women died in childbirth, and 40 was considered ripe old age!

So cancer did still kill people back then but it killed less people because people died of other things long before they were ever at risk of a cancer. Today more people live until they are over 70, but 1 in 4 people over 70 will have a cancer. This is not due to an increase in cancer it is due to changes in cells and the inability of our bodies to kill or clean these abnormal cells.

It is not uncommon for more than one member of a family to have cancer. Cancer can occur in families:

  • By chance (most common)
  • Because family members have risk factors in common (such as environmental and lifestyle influences)
  • Because there is an inherited faulty gene causing an increased chance of cancer (uncommon)

 

How do I know if my family carries a faulty gene?

Trying to find information about cancers in your family and how to deal with them can be difficult. It is important to know your family history on both your mother and father side of the family. Even the faulty gene for ‘female’ cancers like breast and ovary can be inherited from your father.

Only a small amount of some cancers (up to 5%) are due to a faulty gene which is inherited from either your father or mother. This is called a familial cancer. This can also be described as an inherited risk of cancer. The faulty gene increases the risk of cancer, but it certainly does not mean every family member must develop the cancer.

Clues that the cancer that runs in your family may be due to an inherited faulty gene include:

Number of relatives from your bloodline who have had cancer: The more blood relatives who have had cancer (particularly clusters of breast, ovarian and/or bowel cancer) the more likely the cancer is due to an inherited faulty gene.

A young age when the familial cancers occur: The younger a person is when they developed cancer (compared to what is expected in the general community) the more likely it is to be due to inherited factors.

Pattern of different cancers in the family: The type of cancer a person has and who it affects in the family are important. In some families all patients may develop the same type of cancer, such as breast or bowel cancer. In other families, different sorts of cancer will cluster together (e.g. breast, ovarian or bowel cancer, and cancer of the uterus). This happens because some faulty genes can cause more than one type of cancer.

The more clues that are present, the more likely it is that there is an inherited faulty gene in the family causing the higher than usual chance of getting cancer. But this does not mean you will develop the cancer, just that you have an increased risk and need to be more vigilant with screening.

What should I do if I have a family history of cancer?

It is important to investigate your family history. You can find out what types of cancer your relatives have had and how old each person was when they developed cancer. It is also important to document a complete family history so you can see the family members not affected by cancer. Your family history of cancer can change over time as the members get older and more family is born, so it is important to keep your doctor updated about any new cancer diagnosed in your family.

Family counselling and genetic counselling services

Genetic counselling services give people information about their chance of developing cancer based on their family history. These specialists can spend time discussing ways that may help reduce the chance of you developing cancer and how you can be vigilant. It may be that genetic testing is possible, particularly if a member of the family who has cancer can be tested. This is only carried out after the advantages and disadvantages of testing for the patient and their family are discussed.

After female gender and advancing age, a positive family history of cancer is the strongest risk factor in developing breast cancer. In most cases there is not a long and extensive history of cancer present (more than four relatives in the same line). However in some families there is a strong hereditary line of cancer characterised by cancer in both breasts, young age at onset, and clustering of different cancers with breast (primarily ovarian and male breast cancer). Only less than 5% of all breast cancers will be due to these genes, which are known as BRCA1 and BRCA2. Others which are much less well known are TP53, PTEN/MMAC1, and STK11. There is testing available for the BRCA 1 and 2 genes for patients with a significant family history.

Managing these patients and families is highly specialised and requires communication between breast specialists and genetic specialists. If you think you may be at risk of carrying one of these mutations you should discuss it with your doctor and be seen in a specialist breast unit.

Studies have shown that it is possible to reduce the number of women dying from breast cancer by 45% using very simple measures. These include understanding your risk of having breast cancer based on your personal and family history, and being screened regularly for breast cancer.

What does screening involve?

Early detection is the key to better outcome with breast cancer. If a cancer is picked up very early, the risk of spread is low and there is more likelihood it can be treated with simple measure such as surgery. The later a cancer is picked up, the more aggressive treatment has to be, and the higher the likelihood of dying from the cancer.

There are many measures you can take to pick up cancer early and decrease your risk of dying. It can involve a number of different types of examinations, which include breast self-examination, clinical breast examination by your doctor or breast specialist, mammography, ultrasound (breast sonar), and magnetic resonance imaging (MRI).

Breast Self-Examination

During breast self-examination, a woman takes time to examine her breasts and get used to the way they feel and look. She checks her breast for any differences, which might include a change in the size or shape of the breast, any irregularities in the skin, any changes in the nipple and any lumps in the breast or under the arm. It is a free and easy way for women to get used to noticing any changes in the breast, and we recommend you carry out breast self-examination monthly, at the same time in your cycle if still menstruating, or on the same day each month.

Clinical Breast Examination

A clinical breast examination is an examination of the breasts which is done by a healthcare professional. It includes not only a physical examination, but time spent by the doctor listening to any symptoms or concerns the patient has, and discussing breast health. Although there is little evidence that clinical breast examination plus mammography is better than mammography alone, we believe it is important to keep close contact with your doctor or breast specialist so that you are clear about what to do if you notice a symptom.

Mammogram

Mammography is an examination of the breast using a low-dose of X-rays to look at any abnormalities within the breast. It requires you to stand beside the mammography X-ray machine and place your breast on a pad, where the X-rays will take an image of the breast from at least two views. Studies have shown that annual mammograms significantly reduce the amount of women over the age of 40 years who will die from breast cancer.

Older mammography uses photographic film to record the pictures, but newer better technology allows digital mammography, where the picture is recorded in a computer and can be more carefully looked at. This is particularly useful in women with dense breast and younger women before the menopause (still having periods).

Ultrasound

Ultrasound (breast sonar) is another imaging method to look inside the breasts. It uses high-frequency sound waves to echo back a picture of the structures inside the breast. It can be used to evaluate abnormalities found on clinical examination and mammography, and it is particularly good for looking at breasts of younger women, and looking for infections in the breast.

The accuracy of an ultrasound is highly dependent on the skill of the technician or doctor carrying out the test. That sometimes means that tests need to be repeated or errors in what is seen.

Magnetic Resonance Imaging

MRI is another method of imaging the breast using yet another modern technology. It uses a magnetic field to provide the doctor with a three-dimensional image of the breast. It also requires injection of a dye into your blood, which will help the MRI demonstrate normal from abnormal. It is an expensive test and not often necessary to diagnose abnormalities.

MRI is useful in patients who have inherited disorders such as BRCA genes or a higher than normal risk of breast cancer with ‘difficult to read’ breasts.

When you feel a lump or have a concern that you have developed a breast symptom, the first way to put your mind at risk is to know that more than 70% of all patients with breast problems do not have cancer. The only way to be sure of what is the problem is to be seen by a specialist and ensure correct imaging and diagnosis.

What will happen when I am seen by a doctor?

When you visit a general practitioner or breast specialist you are not just going to discuss your current problem, but chat about your general health and history. It is important to identify risk factors and potential health issues for the future, not just focus on one part of your health. The way to know exactly what type of lump it is or the cause of your symptom is to have your general practitioner or breast specialist to carry out triple assessment. This means that every lump or symptoms is investigated and managed in the same rational manner.

What is triple assessment?

Clinical examination

You doctor will spend some time examining you in order to determine if there is an abnormality. They will look at you to see if there are any breast changes you can see such as skin thickening, nipple changes, or dimples in the breast. After that your doctor will feel the breasts, in the same way as in breast self-examination. They will feel into the axilla and all over the breast looking for lumps or pains. It is also important to look at the nipple carefully, looking for any discharges or abnormalities. Often your doctor will do a full clinical examination to check for any other changes or abnormalities, including taking your blood pressure.

If you do have a lump or abnormality identified your doctor will discuss what that means. No doctor has X-ray fingers, so any clinical examination is always accompanied by imaging which is the next step.

Radiology examination

This is imaging done by a specialist radiologist, and double read by a second radiologist to ensure nothing is missed. Normally this includes a mammogram with at least two views (but sometimes more) and an ultrasound of the breast and armpit. Often in women under 35 years the breast is often too dense to rely on mammograms to see problems so an ultrasound is done alone. Newer methods of diagnosis such as MRI scan may also be useful in some cases.

Pathological diagnosis

If there is a lump present, the radiologist may wish to do a core needle biopsy. This is best done by the radiologist because they use X-ray or sonar guidance. The old technique of Fine Needle Aspiration (FNA) should not normally be used because it can be inaccurate and not give enough information to the doctor. It is also rare to require a full surgical biopsy in theatre and it is often not the best method of diagnosing cancer as it affects further treatment.

This sample will be sent to a pathologist who will cut the sample into small slices and stain them especially to allow easy identification of any abnormalities or cancers.

How soon will I be told if its cancer?

The specialist breast surgeon or radiologist may be concerned about the lump or mass they see, but no diagnosis can be made for certain without a tissue sample taken by biopsy. This takes 48 hours to test at least. The most important thing to remember is that breast cancer is not a death sentence, nor is it an emergency. By the time a cancer is palpable (at 1cm) it has been present in your breast for at least five years.

There is never a requirement for an emergency mastectomy, and sometimes the best treatment for breast cancer is to begin with chemotherapy rather than considering immediate surgery. So even if there is cancer present, you have time to consider your options, time to take advice or seek another opinion.

Breast Cancer staging

Patients often ask what stage their cancer has been diagnosed and how advanced it is. Although this might seem very important, in actual fact the character of the cancer, the way it behaves and reacts to treatment, is more important. For instance, an early stage but aggressive cancer may progress more quickly than a large but laid-back tumour.

Staging is made on clinical and laboratory findings. Staging systems are used to classify breast cancer, so that the doctor can treat the disease with a logical basis and all breast cancers doctors have a common base on which to base treatment plans. The most commonly used staging system is the TNM staging system. It allows doctors at particular centres to compare their results with other centres all over the world. Thus treatment regimens in South Africa can be compared with those in the United Kingdom and United States of America.

The most commonly used staging system is the TNM staging system, with T referring to tumour size, N referring to nodal status and M being used to determine metastatic disease which is when cancer has spread beyond the breast and regional lymph nodes to the rest of the body. Metastases are little islands of tumour cells that have spread from the primary cancer and taken root in distant tissues and organs. It is these metastases that eventually cause death. Doctors detect metastases with various methods.

Part of the staging is to perform certain tests to determine whether the cancer has spread (M):

  • X-ray chest for lung spread
  • X-ray bones and bone scan for bony spread
  • Brain scan for brain metastases (MRI)
  • Abdominal ultrasound (sonar and CAT scan for liver spread)
  • Blood tumour markers (these should be used as a serial assessment, not as individual values).

There are four stages of cancer:

  • stage one and two cancers are early;
  • stage three cancers are locally advanced (large breast cancers greater than 5cm) and
  • Stage four cancers have spread to elsewhere (M+).

It is your right to know as much as you want about the cancer, ask about new treatments and remember that your time with your doctor is just that: YOUR TIME so take as much time as you need during a consultation. It is your body and your life so become involved with your health.

It is estimated that 80% of women are wearing the wrong bra. Are you one of them?

Wearing the wrong size bar can lead to increased pain in the neck and shoulders as the breasts are inadequately supported. One of the most common causes of breast pain is poor support and women are often shy to look for the correct size of bra. As a result their bust is unsupported from below and all the support comes from the shoulder straps which causes welts and indentations in the shoulders.

This lack of support can also lead to large breast hanging down on the skin below the breast causing an area of warm moisture through the day. This results in a fantastic breeding ground for bacteria and funguses to grow- often seen as a white or red discolouration under the breasts and eventually leading to darker discolouration in dark skins. An inappropriately tight bra can also cause problems. There is constriction of the respiratory muscles (the muscles that helps us breathe well) causing breathing problems, and back and should aches too.

So what is the wrong bra and how do you find the right one for you? Look in the mirror with your bra on and see if it fits

It doesn’t fit properly if…

The underband is riding up at the back: If the underband bows up at the back or lifts up when you raise your arms it is too loose.

The shoulder straps are digging in: A vast majority of the support for your breasts should come from the underband, support from below not suspension from above. If you have too loose a band you will feel the straps dig into your shoulders and be left with red marks there.

The centre between the cups lifts away from the body: The centre should lie flat against your body supporting and separating your breasts. If it does not, your cup size is probably too small.

The straps do not lie in parallel to each other but stretch outwards: This normally means that your underband is too tight and is overstretching at the fastening.

Some of your breast spills out over the top of your bra: The classic ‘four breast’ look! The cup is dividing your breast tissue because your cup size is too small. Often women are alarmed to find they are actually a DD, E or F rather than a C cup.

 

It will fit properly if…

…you follow this easy plan to correct bra size.

Get some help: Most lingerie shops and departments offer a bra-sizing service and you should take them up on it. There should be no obligation to buy.

Budget for a good bra: If you are worried about the cost of a bra, take some time to see how much you have spent on clothes in the last six months, and how many times a week you wear the items. Your bras are the most often worn items in most women’s wardrobes, but the item they are most reluctant to spend money on. Spoil yourself and your bosom!

If you want to have an idea of your size before your shop: you will need to know your underband size and cup size. Even though South Africa follows metric measurements, bra sizes are still measured in inches. To convert centimetres to inches, multiply by 2.5.

First, take a soft measuring tape and put it around your body just underneath your breasts. Take a deep breath in and pull it snug to your skin. Record this measurement (e.g. 31 inches) and then add 5 to it, rounding up to the next even number (31 +5= 36 inches). This is your band size

Next, measure round your over the fullest part of your breasts (normally at the nipples) when you are wearing a bra. Record this measurement (e.g. 38 inches) and subtract this measurement from your band size (38-36=2). This will correspond to the cup size you should try first.

If the number is:           0=AA cup

1=A cup

2=B cup

3=C cup

4=D cup

5=DD cup

6=E cup

Remember that this is only a rough guide of your size. You should then shop and try on sizes one above and below. As you adjust the band size up (e.g. 36 to 38) come down by one on the cup size (e.g. 36D to 38C).

 

Not all styles will suit all breast shapes, so it may take some time to find a bra that suits and fits you. When you find the right bra, it should not be uncomfortable or dig into your skin. It should hold your breasts well and give you a good shape. A good bra can give you as much shape and lift as expensive plastic surgery.

Why do we do reconstruction?

The psychological impact of losing a breast varies but for most women it means some form of grieving. Breast reconstruction can alleviate the sense of deformity that may develop after a mastectomy. It is considered an integral part of the management of patients with breast cancer and this option should be discussed prior to any breast surgery. Remember rather a delay of a day or two to determine what your surgical options as opposed to a lifetime with one or no breast. Cancer diagnosis does not mean that you need surgery that very day. There is no such thing as an emergency mastectomy, and there is always time to get advice or a second opinion and be sure of your options.

When do we do it?

Breast reconstruction can be done immediately after the mastectomy or lumpectomy. It can also be delayed for a few months or even longer. The benefits of having reconstructive surgery at the time of the mastectomy are obvious in that it helps to preserve body image. Having this procedure depends on the patient’s age, the size and location of the tumour and the stage of the disease.

How do we do reconstruction?

The most common reconstructive techniques involve using the woman’s own tissue to rebuild the breast (autologous flap) or having a silicone or saline implant. Despite the bad publicity silicone implants have had in the past, there is no scientific evidence that they may cause cancer and certain immune system disorders. The goal of reconstructive surgery is to obtain symmetry for the breasts therefore this can involve surgery to the other breast too, in the form of reduction, augmentation, mastopexy or prophylactic mastectomy and reconstruction. Even breast conserving procedures should be done so as to achieve the best cosmetic result. All women are entitled to a cosmetic result whether they have surgery for benign breast problems or cancer.

Because cancer is part of your body, it is difficult to find and kill cancer cells without harming your own body. Most cancer treatments have some side-effects, but just as each patient has an individualised treatment plan, each patient may have different responses to the different treatments.

If you are undergoing cancer treatment it is important to keep in close contact with your family doctor and your specialist doctors. They will help you manage the side-effects more easily.

Side Effects of Breast Cancer Surgery

 

Pain in the region of your operation

Any operation can cause pain in the region surrounding the operation site. This pain should be short lasting and you should speak to your specialist doctor or nurse to help you with painkillers for a limited time. Pain can sometimes be a sign of infection so it is important if the pain is getting worse and not better to seek advice.

After a mastectomy, women can sometimes experience ‘phantom breast pains’ which means they experience feelings of pain or tenderness that appear to come from the breast that is no longer there. This is because the nerves to that breast have been cut as part of the mastectomy operation. Sometimes it takes some time for the body to learn that the breast is no longer there and adjust to the sensation of no longer having a breast. This may still happen even when the breast has been immediately reconstructed.

Loss of sensation

In order to remove a breast, the nerves in the skin and tissues below must be cut. This will lead to a feeling of numbness in the area the nerve supplied, normally over the skin of the chest area, and often in the inner aspect of the upper arm. It is normal to lose some sensation in these regions and it can take a number of years for sensation to return.

It is also important to remember if you have reconstruction of the nipple, that this nipple will not have the sensation of your previous nipple.

Feeling of imbalance

When a woman undergoes mastectomy it can take some time for her to adjust to the new feeling of weight distribution in her chest, particularly if she is large breasted. There may be feelings of imbalance, which can cause compensation in the muscles of the back and shoulders leading to pain. This can often be avoided with the consideration of immediate reconstruction of the breast or breast reduction on the other side. An external prosthesis in the bra can also require getting used to.

Lymphedema

When a woman undergoes operation and removal of some of the glands under the arm, it can cause swelling in the arm from retained water. This is called lymphedema. The risk of lymphedema is increased when cancer treatment also includes radiation to the armpit. Approximately one in ten women who have gland surgery will get lymphedema, and this can range from mild swelling to a debilitating condition. A specialist physiotherapist can help with exercises to improve the drainage of the arm, and there are many implements and garments to wear which can also aid the condition. Patients with lymphedema can prevent the situation from getting worse by avoiding lifting heavy weights, exercising the arm and alerting their doctor to any signs of infection in the arm

Stiffness in the shoulder

Following any major breast surgery the pain of the operation, together with difficulty moving the arm due to drains and bandages, can lead to stiffness in the shoulder and pain on moving the arm. At its worst this can lead to a frozen shoulder, which may require orthopaedic treatment. Many years ago patients were advised not to move the arm and shoulder for a long time after a breast operation and this made the problem far more common and more severe.

Side effects of Radiation therapy

 

Skin changes

During radiation treatment the skin on and around the breast can become very sensitive and tender. It can be itchy or red too. This is because of the radiation, and will settle down after the treatment ends. Sometimes the skin colour can change or fine veins (‘telangiectasia’) develop over the skin around a mastectomy scar. These are small changes which may be permanent. It is important to discuss any skin lotions or creams a patient might wish to use during treatment with the radiation therapist before using them.

Changes in the size or shape of the breast

In most women, radiation does not affect the breast shape in any way. Sometimes however, when radiation therapy is used after a lumpectomy or breast conserving surgery, the treatment can result in the breast changing in density or size. The breast can become larger due to swelling within the breast during treatment, and in the long term the breast can become smaller or firmer.

Fatigue

Many women find radiation can leave them feeling tired and fatigued after treatment, particularly later on in cancer management. The fact that the regime requires daily hospital visits can also leave a patient suffering from exhaustion.

 

Side effects from chemotherapy

The side-effects of chemotherapy drugs depend heavily on which of the drugs are used and in what combination. Most of the side-effects of chemotherapy occur because, along with killing the cancer cells in your body, the chemotherapy can damage some of your ordinary cells. The cells that are most frequently damaged are those that divide and multiple often. These include the cells of the hair and skin, and cells of the gut and intestine. More serious side-effects can include a depressed immune system with an increased risk of infection, and easy bruising or bleeding.

Nausea, vomiting, mouth ulcers and diarrhoea

These occur as the cells of the gut are damaged or killed by the chemotherapy agents and take time to replenish. Most of these side-effects can be managed well by your doctor and most of them go away during the recovery part of the chemotherapy cycle.

Hair loss

Many patients fear losing their hair and are surprised to find that many chemotherapy agents do not cause this side-effect. Even if the hair is lost, it will most commonly grow back after the treatment is finished. The selection of wigs and scarves available for women who have lost their hair is extensive, and many charities will support women in looking their best even during chemotherapy.

Numbness and tingling of the hands and feet

The sensation of numbness can be uncomfortable or frustrating for a patient. It is a side-effect of some of the chemotherapy agents given in breast cancer. Oncology doctors work hard to prevent this becoming a problem in the long term.

 

Side effects of Hormonal treatments

Hormonal treatments are designed to starve breast cancer of the female hormones it feeds on. It does this by preventing the body making the hormone or preventing it getting to the cancer. This can simulate the menopause in most women who take these treatments. The side-effects are therefore effects of the menopause.

Hot flushes, night sweats and vaginal dryness

A hot flash is a sudden rush of blood to the face and neck that can last for anything between a few seconds and an hour. It is difficult to treat with medication but relaxation and loose clothing can often help to cope with these events. The same hormone deprivation that causes this can also cause your vagina to be dry which may cause increased infections in the bladder and painful intercourse.

Increased risk of clotting

Some hormonal medications can increase your risk of developing clots (‘thrombosis’) in the veins of the legs and arms. It is important if you take hormone medications to tell doctors if this has ever happened to you before as it may affect the medication you are given.

Bone and joint pains

Most of the hormone medications given to patients can affect the joints and bones in some way. They can cause arthritic pains in the joints or muscular aches that can be difficult to tolerate. Some of the medications can also cause thinning of the bones which should be monitored by your doctor.

There is no definite symptom which means that you definitely have breast cancer. Most of the symptoms which are related to breast cancer are also present with non-cancer problems, so it is important not to panic if you develop a problem but to ensure you get it checked out.

If you have breast cancer will you feel a lump?

Most breast cancer present as a lump in the breast. Often women are surprised by the unexpected appearance of a lump and are unsure whether to get it investigated. No matter how sudden or how the lump feels, it is very important to see your doctor. Cancer lumps often feel hard and craggy and grow steadily in the breast. Eventually the cancer will spread to the lymph glands causing hard lumps to be felt under the arm too.

Approximately ten per cent of breast cancers present without a lump, and in fact when you do feel a lump in your breast, around 80-85% of those are benign. Most lumps felt in the breast are not cancers but might be cysts or masses known as fibroadenomas.

Cancer can show up without a lump, and if you experience some of these other symptoms you should also get checked out:

  1. Change in the size and shape of the breast
  2. Thickening of the skin of the nipple or ulceration
  3. Eczema of the nipple, itching or scaly patches
  4. Nipple turning inwards
  5. Thickening or dimpling of the skin of the breast
  6. Lumps noticed under the arm

Is breast cancer is painful?

Unlike most cancers, breast cancer does not present with pain. That doesn’t mean that if you have a painful lump it can’t be cancer, but it is unusual for pain to be the first thing a women with breast cancer notices. The most common way that women find a breast cancer is when they feel a lump in the breast or notice a discharge from the nipple. In the future, we want breast cancer to be found on mammogram, before there is even a lump, because we know that the earlier a cancer is detected, the better it can be treated.

Is a nipple discharge normal?

It is true that some nipple discharges are very normal- take breast feeding for instance! It is also quite common to get a discharge after breast feeding for a while. Not all nipple discharges are normal however, and they can mean different things. Breast specialists worry particularly with one sided nipple discharges that come from just one place on the nipple what every colour they are, and we also don’t like nipple discharges that have blood in them. The best plan is to get every nipple discharge checked out by a specialist who can help you understand what the problem is, and help you solve it too. Remember not to squeeze your nipples- they can respond by producing or increasing a discharge. If you have been squeezing, the first step to preventing a discharge is by stopping.

What changes in the nipple are related to breast cancer?

There are two particular changes on the nipple which are concerning for breast cancer. The first is an itchy scaly eczematous rash which can develop on the areolar (the coloured part of skin around the nipple) or on the nipple itself. This kind of rash can cause the skin to peel or become red and raw. It is termed ‘Paget’s disease’ and is a spread of cancerous or pre-cancerous cells along the ducts to the nipple where they cause rash or an ulcer.

The second symptom that can develop is an inversion and in-drawing of the nipple. Many women have inverted nipples which are completely normal, but if a nipple suddenly becomes inverted, particularly on one side only, it is cause for concern and should be investigated.

 

Whilst all cancer is treatable and potentially curable it is better to pick up cancer as early as possible. Remember to go for screening mammography and sonar after the age of forty every year, and get your GP or a breast specialist to examine you once a year too. Being breast aware also means learning to love your breasts, and getting to know your body. You may be the best person to pick up when something is wrong with your body if you learn what is normal for you and what is not.

Any woman (and even men) can get breast cancer which is why it is so important to know about the disease and know about all potential treatments. It is often not clear why some people get cancer and others do not, and the more we learn about the disease, the better we get at curing it.

What is cancer?

It is natural in life that we are all born, we grow and we all eventually die. The cells that make up our bodies are just the same. They have a life cycle which involves multiplying, growing and eventually dying in a process called ‘apoptosis’. In cancer, some of the cells of the body will misbehave and do not carry out the normal cycle. They will continue to grow and multiply but they will not die. Eventually they will spend all of their time multiplying and none of their time working as a normal cell does so that they grow into a tumour. This tumour invades the normal cells and makes new blood cells to feed its growth. It is out of control.

Eventually the tumour decides to break up and uses the bloodstream and lymphatic cleaning system of the body to travel to distant parts of the body, such as the brain and the bones, the liver and the lungs. There these small cancer cells will settle and begin to multiply in their new position, destroying the normal functional tissue in that area. These are called ‘metastases’ and the increase in these tumours will eventually lead to death.

Is breast cancer common?

Breast cancer is the most common cancer to affect women worldwide. There is no adult woman, population or culture that is free from the risk of getting breast cancer. The rates of cancer vary throughout the world, from one in 8 women in the United States to much less in Japan and the Far East. There are not accurate statistics for the prevalence of breast cancer in South Africa, but we think they may be similar to those in the United States because we have a similar diet and lifestyle.

Breast cancer is also the most common cause of cancer death for women in the world today although there has been a dramatic decrease in cancer deaths over the past forty years due to increased awareness and increased screening of women.

Who gets breast cancer?

Anyone with breast tissue can suffer from breast cancer, it even affects men. Women of every age are at risk, even including young women in their 20s or 30s. Breast cancer has been seen in girls of nine years old. Your risk of getting breast cancer increases with your age, so as you get older you become more and more likely to get breast cancer. A woman less than 40 has approximately 1 in 230 risk of getting breast cancer rising to 1 in 29 after the age of 65.

It doesn’t matter what race or culture you are, all groups suffer from breast cancer. Women of all walks of life are at risk, whether rich or poor, healthy or unhealthy, insured or uninsured. Most women (more the three quarters) do not even have risk factors that put them at high risk of breast cancer. It depends on whether your cells decide to stop behaving and start multiplying irregularly and progressively.

Many women who get breast cancer ask “Why me? What did I do to cause this?” It is very normal to ask this type of question, but the answer is: Nothing. There is no single cause of breast cancer and no single event that will bring it on. There is nothing any women does or doesn’t do which causes breast cancer. It is an unfortunate event of life which we work to lessen through early diagnosis and treatment.

How treatable is breast cancer if caught early?

All cancer is treatable and there are good options for management and cure irrespective of the size when it is found. When breast cancer is detected early, before it invades tissues outside the breast, the survival rate is as high as 95%.

Breast cancer that has not invaded into the breast tissue but is still in the ducts (known as carcinoma in-situ) has a 99% cure rate. Often surgery alone is appropriate treatment. If a small cancer invades into the breast tissue but does not spread to the glands it also has a very good prognosis. The treatment of cancer is tailored more and more to the ‘personality’ of the cancer: how it behaves and what it responds to, not the size alone.

Do chances of survival drop (by how much?) if caught later?

When cancer is confined to the breast it is easier to treat and be sure of a cure. Patients do not die of cancer when it is confined to the breast. It is the spread of cancer of the brain, bones, liver and lungs which will eventually cause problems. The aim of breast cancer awareness and screening is to catch cancer early before it can escape the breast, breakthrough the lymph glands under the arm (the security guards of the breast) and spread from there to the rest of the body like a wave of terrorists that can hide away and reappear in the future.

Many of the more aggressive types of treatment for breast cancer such as chemotherapy are based around catching and killing these spreading cells. Even if the cancer has spread to bones, up to 75% of patients will be alive in five years after diagnosis.

All women are at risk from breast cancer, which affects one in eight women in the world today. Many risk factors are things that you have no or little control over, such as your family history or your race.

It is important to remember that three-quarters of women who get breast cancer were not at increased risk, and we don’t fully understand why different women get cancer yet. Even if you have all these risk factors, it only highlights the need to be careful and check your breasts regularly. It does not mean you are going to get breast cancer.

So what are the risk factors for breast cancer and how can you deal with them? You can separate risk factors into three groups:

Risk factors you can’t avoid:

Ethnicity: White women have more of a risk of getting cancer than black or Asian women. There is very little you can do to change a risk factor like this.

Age: The risk of getting breast cancer increases with age. At thirty your risk of breast cancer is 1 in 2000, that increases to 1in 50 at age fifty and by eighty years it is 1 in 10. That is why it is recommended to start checking for breast cancer above the age of 40 with a yearly breast exam by your doctor and a yearly mammogram.

Family history: There are breast cancers that run in families and in different minorities. Some families carry a gene that specifically increases the risk of breast and ovarian cancer (BRCA1 and 2) and we know that these are commonly seen in Ashkenazi Jews and Afrikaans women. In other families clusters of cancers like bowel and prostate through the generations point to an increased risk of breast cancers too.

Risk factors you can’t help:

Pregnancy: Nulliparity (not having children) or having children when you are over thirty is a significant risk factor for breast cancer. We know that a lot of breast cancers are driven by the hormones, and the hormones changes that occur during pregnancy have a lasting effect on your chances of getting breast cancer. Having one child at a young age does help protect against cancer, but after the age of 30 the risk is the same whether you have children or not.

Breastfeeding: After birth, breast-feeding of a considerable length of time has a protective effect on your breasts, but it is a marginal effect which is present if you breast-feed for one year or more. Having said that, the effect on your child is much much more with increased immunity, good bonding and long-term effects on weight control and intelligence also suggested. Breast feeding is one of the greatest gifts you can give to your child.

Early age starting your periods and late menopause:  the length of time your body is under the effects of female hormones during your lifetime also affects your risk of breast cancer. If you have started your periods before 12 years, or had a late menopause after 55 years, you have an increased risk.

 

Risk factors you can change:

Obesity: Having an increased body mass index (BMI) greater than 30 after the menopause puts a woman at increased risk of getting breast cancer. At any point in life it also put you at increased risk of a number of other conditions such as diabetes, high blood pressure and joint problems. It is never too late to change your diet, increase your daily exercise amount and make it a target to lose a few kilos.

Alcohol: Women who classify themselves as heavy drinkers are also at increased risk for breast cancer. This means that they are consistently drinking more than four drinks (units) a day or seven drinks per week. Remember that heavy drinking is not the same as problem drinking and that a nice glass of wine in the evening is normally classed as two or even three units, and a bottle of beer is 1 ½ units. It becomes very easy to become a heavy drinker without realising.

Hormone Replacement Therapy: Studies in the USA and in the UK have shown that women are at increased risk of breast cancer if they are taking most types of HRT for more than five years. It is also true that the closer to the menopause you start taking HRT the higher the risk of breast cancer. In real terms if 30 in 10,000 menopausal women get breast cancer, 38 in 10,000 women taking HRT will get it. This has to be weighed against the potential benefits so it is important to speak to a sympathetic gynaecologist who may suggest other more natural methods of dealing with your menopause.

It is not just about changing your lifestyle to decrease your risk of cancer. It is also important to change your attitude and start to get wise about breast health.

had a diagnosis of atypical hyperplasia or any other type of benign breast disease, or lobular carcinoma-in-situ

There is no direct family history of breast cancer in first generation (sisters or parents) or suggestions of hereditary forms of cancer.

No history of mantle radiation for lymphoma (a type of upper body radiation given for lymph gland cancer)

You are at above average risk if:

There is a close family history of breast cancer

This means that your parents, grandparents or children have had breast cancer. It also may include your aunts, cousins and other relatives if there are many in the family who have breast cancer, all from the same side of the family.

You have had a diagnosis of atypia on a previous breast biopsy. This is a form of benign breast disease but can be associated with an increased risk of later cancer

You had mantle radiation before the age of 32

 

Screening guidelines

Screening guidelines are intended to increase the chance of picking up a cancer or worrying area of cells once they have developed in your breast. There is no test or method that prevents cancer developing in the breast but we can pick it up as early as possible to ensure the best outcome for you. These guidelines are taken from the American

Average risk patients

Examine your own breasts each month and get to know what is normal for you

After the age of 40 see your doctor or breast specialist every six months for a clinical breast examination

After the age of 40 get a mammogram and sonar at least every two years

After the age of 50 get a mammogram and sonar every year

 

Above average risk patients

Examine your own breasts each month and get to know what is normal for you so it is easier to spot something abnormal if it happens

See your doctor or breast specialist every three to six months for a clinical breast examination, starting when you are ten years younger than the youngest age a breast cancer was diagnosed in your family (but not earlier than 25 years or later than 40)

Go for an annual mammogram and sonar starting no later than ten years before the youngest member of your family was diagnosed with breast cancer

If you have atypia diagnosed, you should start annual mammograms irrespective of age, and see your doctor for a clinical breast examination every three months

You may want to consider an MRI scan, which helps with the differentiation of normal and abnormal breast tissue in some difficult to diagnose patients.

 

Simple measure can reap great rewards. Getting to know your breasts and getting into the habit of checking them regularly is important. Consider booking your next mammogram and sonar for the week after your birthday- that way you will be reminded every year that it is time for a check-up!

Your doctor will discuss the plan for your breast cancer treatment throughout your care. Often the plan may change as new information is obtained- such as the results of a sentinel lymph node biopsy or the receptor status of your cancer. Every plan is likely to include surgery and at least one other modality of treatment. There are many different but equally good ways of treating breast cancer. Your doctor will discuss with you the way she thinks is best, based on the discussions within the multidisciplinary team and new evidence or new treatments which are always being developed.

The most important person in the discussion is you, or your loved one with cancer, and all the decisions around treatment are ultimately made by you. Doctors can give you the evidence and advice based on years of training and experience, but the patient must decide what is best for her.

Here are a couple of tips when considering your management:

Take your time

By the time a breast cancer is picked up by a clinician or on a mammogram, it has been developing in the breast for 2-6 years. There is no such thing as emergency treatment for breast cancer, and whilst it is important to seek treatment immediately, there is time to discuss with your family and friends, with previous cancer survivors and with support groups, what you feel about your cancer and your treatment.

Get a second opinion if you want one

There are different ways in which a breast cancer may be treated with equally good results. In different parts of the world the four pillars of treatments may be used in a different order. You own health and previous history of illnesses may influence the kind of treatment you can be offered. No doctor will consider it an insult if you ask for a second opinion.

Read around the subject wisely

The internet is wonderful at opening doors to a world of knowledge and it is important that you research as much as you want into your treatment. Many large cancer organisations around the world have excellent and trustworthy information for patients. Some of these are:

  1. Netcare Breast Care Centre of Excellence(SA): www.breasthealth.co.za
  2. CANSA (SA): www.cansa.org.za
  3. Breast Health Foundation (SA): www.mybreast.org.za
  4. National Cancer Institute (USA): www.cancer.gov
  5. Susan G Komen for the Cure (USA): www.komen.org
  6. Breakthrough Breast Cancer (UK): www.breakthrough.org.uk
  7. Macmillan Cancer Care (UK): www.macmillan.co.uk
  8. American Cancer Society (USA): www.cancer.org

There is also a lot of advice and treatments offered on the internet that are not based on good scientific evidence, and many well-meaning people who have sought other methods of treating cancer. When you read all sources of information, it is important to read critically and not to trust everything you read or hear of. Discuss any concerns or reading you have done with your doctor as they can often help you discern the true and trustworthy from the fraudulent.

Get support

You do not have to survive cancer alone. In every part of the country there are networks of breast cancer survivors who are ready to support you from diagnosis onward. Some of these organisations are:

  1. Bosum Buddies: www.bosombuddies.cfsites.org
  2. Reach for Recovery: www.reach4recovery.org.za
  3. Look Good… Feel Better…: www.lgfb.co.za
  4. People Living With Cancer: www.plwc.org.za

Many of these organisations hold meetings, for support and for gaining information about their disease. They also get involved in fundraising for breast cancer charities. Most organisations are committed to helping you fight your cancer and walking with you every step of the way. You never stop being a breast cancer survivor, and in time you will be able to support others too.

How will I cope?

Most patients experience psychological problems following the diagnosis of breast cancer and the most difficult period is between diagnosis and surgery or treatment. Breast cancer patients will experience the following emotions:

  • Anger
  • Depression
  • Anxiety
  • A sense of helplessness
  • A sense of powerlessness
  • Vulnerability
  • A sense of unfairness

Breast cancer patients will also experience certain fears around their treatment such a fear of being sick, fear of being in pain, fear of the side effects of treatment and fear of disfigurement. It is important for all these fears to be discussed because many side effects of treatment and surgery can be alleviated. Knowing more about the treatment and realistic expectations of the course of management and the future will help. Anxiety about disfigurement after mastectomy can be allayed by remembering that reconstructive surgery is an option in most breast cancer cases.

What about my family?

Breast cancer affects not only the patient but also the patient’s family and friends. Open communication between family members is important. Family may need time to understand and support their loved one undergoing such a difficult time. They may also have feelings of helplessness, shock and confusion. They may find it difficult to cope with these emotions and determine how best to support their loved ones.

Children and Teenagers

Children whose close relative (mother, sister or grandmother) has cancer are often aware of a change in their lives and those surrounding them. Even young children can sense that something is wrong and this may frighten them. There may be a change in the daily routine or absence of a loved one, and this can cause fear which manifests as anger or tantrums. They may consider that they are responsible and require reassurance that this is not the case. Open and honest communication is best, addressing all fears and discussing their feelings. They may have lots of questions which should be encouraged and answered in a way they will understand.

Telling children and young people the truth about illnesses and cancer, at a level they can understand and cope with, will reduce the stress, guilt or fear they may feel. Spend additional time with them and ensure that they have opportunity to spend quality time with the cancer survivor. Older children and teenagers may be expected to take on additional responsibilities in the family and it is important to remember they are still children who need loving support.

Partners

One of the hardness life events is coping with illness in your intimate partner. There may be feelings of fear, confusion or helplessness and an overwhelming concern which prevents communication. The key to navigating this difficult time is to maintain open and honest communication between partners with time protected to spend alone and discuss feelings. Loving words and physical touch will remind your partner of your care. Another source of stress may be a change of role and responsibilities within the family, and concerns over financial well-being.

When a breast cancer patient requires spending a long period of time in hospital, there can also be difficulty maintaining good contact and communication, and the supporting partner may have a feeling of isolation or uselessness in their contribution to the treatment of their loved one. Often unrealistic expectations may need to be addressed, and it is important try and maintain life in the same way as it was before the diagnosis.

Intimacy issues between the patient and her partner should be addressed. It can be problematic because each partner must attempt to cope with their feelings. It may be difficult to express love physically in the same way as before, due to physical changes or emotional preoccupations. Finding new ways to express love and gain satisfaction is part of new methods of communication.

Some sexual problems may stem from the treatments for cancer themselves and others may be a result of emotional changes. Communication between partners and involvement of healthcare providers can often help identify problems which can be solved. Understanding unrealistic expectations or unhelpful feelings of anxiety or guilt will help the situation immeasurably, and there are many healthcare workers who wish to give help and advice.

 

The more someone knows about breast cancer and the treatment options available the better equipped they will be to deal with it. It is important for a partner, family, friends and health care practitioners to speak openly rather than pretending there are no problems or concerns. Sometimes it may be helpful to speak to breast cancer survivors, a psychologist or a social worker.

How common is breast cancer in men?

The occurrence of male breast cancer varies throughout the world. In the United Kingdom it counts for less than of all breast cancers but in North America there seems to be an increasing incidence especially amongst black males, with about a thousand cases being diagnosed per year. It is most commonly found in men over sixty. We don’t know how common it is in South Africa but we think between 1-3% of all breast cancers happen in men.

Who gets it?

The risk factors for male breast cancer are interesting; it is definitely not associated with benign male breast lumps or breast enlargement (gynaecomastia). There does appear to be an inherited component because the lifetime risk of a male to get breast cancer if his mother and his sister had breast cancer is about 2.5%.

Male breast cancer is more common in families who have the BRACA2 gene mutation and in males who have Kleinfelter’s Syndrome (which is the chromosomal abnormality XXY). It seems to be increasing in men who work on electrical lines and factors such as radiation, X-rays and electromagnetic waves have been implicated.

 What type of breast cancer do men get?

A male breast cancer is almost always a ductal carcinoma (the most common sort). Lobular carcinoma is rarely seen in men and when it is it is usually in association with Kleinfelter’s Syndrome. Any variation of ductal carcinoma can be seen in male breast cancers including Paget’s disease (cancerous eczema of the nipple). 80% to 90% of male breast cancers are responsive to hormones.

Male breast cancer is no different to female breast cancer. All people have some breast tissue but because men have less, when cancer develops it tends to be more advanced earlier, with chest wall and skin involved. The vast majority of male breast cancers present as a painless breast lump and it is usually a painless mass. They may have a nipple discharge or nipple changes, and very few are painful. About 5% of these cancers will present with spread to other organs (metastatic disease). Any unilateral breast mass that is firm, fixed or ulcerated in a man should raise suspicion.

How do we investigate it?

All potential cancers are investigated the same way, whether it is in a man or a woman. The investigations that should be done are a mammogram and sonar. Sensitivity in mammograms is the same in men as it is in women. A core needle biopsy will provide the pathological diagnosis.

Treatment

The treatment for male breast cancer is just as the same as in women. It usually involves surgery, oncology (chemotherapy and hormone therapy) and radiation therapy working as a multi-disciplinary team. Men are normally managed with a mastectomy and a lymph node dissection, followed by chemotherapy and radiation treatments if they are needed. Tumours that are greater than 2cm have twice the risk of returning than those where the lesions are less than 1cm, so it is important to make sure the margins are wide and the cancer is well-treated. Hormone therapy can improve the survival if the cancer is sensitive to hormones.

Although the prognosis is believed to be worse in male breast cancer than in female, stage for stage it is actually identical. Because men are often diagnosed at a later stage relative to the size of breast tissue they have, it gives the impression of a worse prognosis.

It is important for men with unilateral breast masses that are firm, to seek medical attention and be assessed appropriately by a breast specialist.

If you or someone you love is diagnosed with breast cancer the chances are you have to spend a lot of time in different doctors’ offices, and all the doctors will discuss different types of treatments.

Breast cancer management relies on a firm foundation of a multi-disciplinary team. What that means is that every doctor involved in cancer treatment should be speaking to every other doctor. The intention is that from the start of a patients treatment there is an individual plan, tailored to the exact stage and type of breast cancer that the patient has. This team of people involved in care includes the breast surgeon, the reconstructive (plastic) surgeon, a radiologist who carries out mammograms and biopsies, the chemotherapy and radiation specialists (oncologists) and a psychologist too.

Breast cancer management involves not just the breast but treatment of the whole body. This is because even very early on we know that cancer cells can be found in other organs. It is important to eradicate the cancer not just from the breast, but from the whole body. This is done using four different type of therapy often managed by a different member of the multi-disciplinary team (that’s why it’s so important that they talk to each other).

These can be divided into those that affect the breast, to get rid of the cancer present either there or in the nearby lymph glands, and those therapies that seek out and destroy breast cancer cells that may be present in the rest of the body. The therapies are:

  • Local treatments to the breast:
    • Surgery
    • Radiation
  • Whole body treatments to find any cancer that has spread in the body:
    • Chemotherapy
    • Receptor-dependant treatments (hormonal and target treatments)

Each type of treatment can be thought of completely separately (with one exception). During cancer management, the patient will have at least one local and one whole body treatment but they might require all of the different treatment methods, depending on the type of breast cancer and the advice of the specialists.

Let’s look at them all individually.

Surgery

In breast cancer management, surgery will take place at some point through the treatment path. Surgery can take place at more than one time, either for diagnosis, treatment or reconstruction. There are three areas of surgery every patient will experience and therefore should discuss with their doctor: Surgery to the breast, surgery to the axilla, and reconstructive surgery. Some of the operations undergone are:

Sentinel Lymph Node Biopsy

Often this is the first part of cancer treatment, carried out to see if the cancer has spread from the breast to the glands (called lymph nodes) under the arm. On the day of the operation the patient is injected with a radioactive chemical which is not harmful, and the doctor uses a special probe and blue dye to find the first gland the cancer would have spread to (the ‘sentinel’ which means the guard). The surgeon will make a small cut in the armpit under a general anaesthetic and take out this gland.

If the cancer is spread it is called ‘locally-advanced’ and this increases the risk it has spread outside the breast to the rest of the body. Cancer that has spread to the rest of the body is best treated with chemotherapy.

Wide Local Excision or Breast Conserving Surgery

This is a ‘lumpectomy’ operation that can take place if the surgeon believes it is possible to remove the cancer safely without removing the whole breast. This might be because the cancer is small, or because the breasts are large enough to allow a big area to be removed. Cancer is never taken out alone, it is always taken out with a big margin, which acts as a fire break between the cancer and normal breast tissue. It reduces the risk that the cancer may come back in the same place.

There are some important safety measures that have to happen with breast conserving treatment (BCT). The first is that the surgeon must be sure that all the cancer can be removed safely. Then the patient must be able and willing to have radiation treatment, because BCT is not safe if you do not have radiation. Finally it is important that BCT is carried out with help from a surgeon skilled in reconstructive techniques. Normally this is a different surgeon from the breast cancer surgeon.

Mastectomy

The oldest and most well-known method of surgically treating breast cancer is a mastectomy. This is a procedure where the whole breast is removed from the body, and the patient is left with a flat chest and one scar. Very often, immediate reconstructive surgery can be carried out so that the patient has only one operation, and is left with a similar breast mound to before the operation.

Sometimes a woman may decide to have both breasts removed during the operation but this is only after intense discussion of all the options, and a realistic assessment of the risk of further cancer in the other breast.

Axillary lymph node dissection

If the cancer has spread to the glands, all of the glands under the arm will need to be removed. Unfortunately this can cause some pain and stiffness around the arm after the operation, and in 1 out of 10 ladies, the arm may swell up after the operation (called lymphedema) because there is no longer a clear passage for fluid to flow from the arm back to the body. Most often an axillary dissection is done at the same time as the breast operation, through the same cut or a different one. If the sentinel lymph node biopsy is negative however, an ALND may not be required.

New data suggests that some women may not need to have an ALND; even if their glands are positive. This may change surgical practice in the future, but at present further research is required.

Reconstruction

All patients who have breast surgery should have the opportunity to have reconstruction. This surgery can restore two equal breast mounds to a woman’s chest. This may be part of breast conserving surgery or after a mastectomy, either at the same operation or at a later date. Plastic surgeons can use tissue from other parts of the body to reconstruct the breast and they may also use prostheses, made of materials such as silicon, to give the shape of a breast under the skin and muscle, if there has been a mastectomy. All women have a right to be considered for reconstructive surgery, even if your operation was a long time ago.

 

Radiation treatment

Radiation is also a method of killing rapidly dividing cells such as those in breast cancer. It works in a local area however, not throughout the body like chemotherapy.

Radiation treatment is given by directing a beam of radiation, made up of thousands of X-rays, which attacks any cells which may be cancer. It helps to reduce the risk a cancer coming back after surgery especially if the cancer is large or close to the rim of normal tissue removed. All cancer surgery, even the best, has a risk of leaving behind a few isolated cancer cells. If those cells start to divide again, the cancer can recur. Radiation ‘mops up’ any cancer cells that surgery may have left behind. There are a number of circumstances that increase the risk of cancer recurrence and in these situations we know radiation is beneficial.

These are:

  1. When a cancer is very big (greater than 5am)
  2. When a cancer has involved a lot of glands under the arm, or the glands are heavily involved
  3. When any breast tissue is left behind (radiation is always required in breast conserving treatment)
  4. When the multidisciplinary team is concerned that the margins of normal tissue around the cancer was too small (not a big enough ‘fire break’). If there is true cancer at the margin however, the cancer should be removed with surgery not radiation.

Chemotherapy

Chemotherapy uses medicines that attack cancer cells to kill the cancer in your body. These medicines may be given through a drip or in tablet form.

We know that cancer cells multiply more quickly than most of the body’s cells. Because of that, they are working very hard and are in the duplicating phase of the cell cycle almost constantly. Chemotherapy finds cancer cells by looking for all the rapidly dividing cells in the body. It then attacks them by preventing them duplicating.

This works well, but also affects normally cells in the body which divide quickly, such as the cells of the hair and the gut. Because these cells die too, patients can suffer from hair-loss or gut symptoms such as nausea, vomiting or diarrhoea.

If the breast cancer is greater than 1cm or has spread to the glands we know that the risk that the cancer is in the rest of the body is great. Only chemotherapy can find and attack cancer cells outside of the breast, and so it is given to all patients with these types of cancer. There are genetic methods of determining whether a patient will benefit from chemotherapy, which use samples of the breast cancer tissue to analyse how aggressive it is. These tests are expensive but may be beneficial in ensuring the correct patients get chemotherapy.

Receptor-dependant treatment

Breast cancer is one disease but has many faces. If you stand in a room of breast cancer survivors, the differences in the types of tumour will be as different as the sizes, shapes and personalities of the people they belong to. Some cancers talk easily to the other cells of the body, others ignore any interactions. The way that cancers ‘talk’ to the body is through hormones and receptors.

If a breast cancer has receptors on it, some of the body’s hormones and other factors can influence it. Doctors can use hormone and receptor blockers to prevent anything encouraging the cancer to grow, or encourage any other potential cancer cells to develop. There is still so much we don’t know about receptors, and lots we are learning, but there are some receptors we know how to block:

Oestrogen receptors(ER) and Progesterone receptors (PR)

If the cancer is positive for these receptors, it means that oestrogen (the female hormone) can encourage the cancer cells to grow and divide. By preventing oestrogen influencing the cells, drugs are used to block the receptor. The most common medicines are Tamoxifen and blockers called Aromatase Inhibitors.

Her2 receptor over-expression

This is the newest abnormality to be found in breast cancer, and has changed the treatment of Her2 positive cancers which were often aggressive and may be ER/PR negative. All cells have Her2 receptors which encourage growth of normal cells. Some breast cancer cells have too many Her2 receptors which mean that they promote the growth of cancer cells. Treatments that specifically target Her2 include Trastuzumab (sometimes known as Herceptin). This can be given with chemotherapy, with ER-blockers or by itself.

 

Much of the research into breast cancer care is around finding more receptors so that more medicines can be developed to block them. Often new treatments are being tried out in current cancer patients, and patients can take part in a trial of a new treatment.

 

When you have breast cancer or think you might be at risk, it is important to see a doctor who is a breast cancer specialist and can advise you on the most modern, safest and most effective ways of curing the disease.

A diagnosis of cancer can be one of the most stressful experiences of life. In addition to the worries over survival and treatment, many patients find that they have additional concerns over the cost of medical treatment. In South Africa, 80% of patients are managed within the government health service, and 20% have medical insurance that means they can be treated in private hospitals. Many people find that they have let medical aid run out, or are not covered in a way they thought they were. If you do have medical aid, there are a number of considerations to remember to check in case you have a diagnosis of breast cancer in your life.

Most importantly remember:  you cannot afford NOT to be treated for breast cancer.

 

I haven’t got Medical Aid

There are many excellent public hospitals and superb academic cancer specialists who work in government hospitals. As with all times of illness: knowledge is power, therefore knowing what management you should be expecting will help you navigate through the system. Books like this one and the internet can help you get more information to help you in your journey.

There are many organisations that wish to help patients who do not have the resources for travelling to a hospital or managing treatments. See our help and support page for further details.

 

Navigating Medical Aids

All medical aids, even hospital plans, have to provide some cancer cover. This will include in-patient care but may also include specialist fees, chemotherapy and cover for radiation and medications. The amount and type of treatments covered tends to depend on the medical aid plan that you are on, and it may require you to register for a cancer scheme after diagnosis. Check when you are considering starting or changing medical aids what type of treatments you are covered for.

Fortunately medical aids are not allowed to refuse cover for a patient with a pre-existing condition and that includes cancer. Remember to always mention these conditions to your medical aid so that you gain access to appropriate care and do not disqualify yourself.

Check your policy too as many companies encourage good health by funding screening mammography and Pap smears even to patients without day-to-day benefits.

 

Cancer policies

Even if you have medical aid, some of the initials concerns about cancer that patients suffer are not about survival or treatments, they are about whether they will be able to afford their treatments or go into debt. Because of this many insurance companies offer a policy which allows patients to unlock financial resources to cover the gap between what is covered and what is required.

 

Disability cover

Disability cover protects your ability to earn a living. It allows you to retrieve money from your policy when you are unable to work for certain periods of time. This may be due to temporary or permanent disability. The policy may be related to your ability to work at all or your ability to carry out your specific occupation.

 

Estate planning (making a will)

Nobody likes to think of a time when they will not be here, but it is said ‘death, taxes and childbirth: there is never a convenient time for any of them!’

Your estate is everything that you own, from a house and car to your jewellery and cell phone. If you do not plan for who will receive them after you die, the government will plan for you and may leave your family and dear ones without the resources they need when they need them.

Making a will is a simple exercise and shows how much you love the people around you. It is a good idea to also stipulate who should make decisions for you, if you are too ill to decide for yourself how you would like doctors to treat you.

 

Saving now for the future

Saving money is not easy, but if you are worried about how you can afford to cope if you get ill now is the time to start. Once you ensure that you have coverage in place for managing your expenses (such as medical aid and disability, cancer or life insurance) have a look at your monthly budget and look for ways to save a small amount into an emergency fund each month. This can act as a financial buffer when you have a significant outlay. This might not even be a medical expense but it will come in useful if you do have an unexpected medical diagnosis.

Budgeting also allows you to work towards paying off debts. Often the greatest of patients is not how to afford future treatment, but how to keep up with past debts during a period where you cannot work.

If you do get into debt or cannot afford treatments, discuss the problems with your doctor. They may have knowledge of charities that can provide financial assistance or work to find a longer but easier solution to payments.

A diagnosis of cancer can be one of the most stressful experiences of life. In addition to the worries over survival and treatment, many patients find that they have additional concerns over the cost of medical treatment. In South Africa, 80% of patients are managed within the government health service, and 20% have medical insurance that means they can be treated in private hospitals. Many people find that they have let medical aid run out, or are not covered in a way they thought they were. If you do have medical aid, there are a number of considerations to remember to check in case you have a diagnosis of breast cancer in your life.

Most importantly remember:  you cannot afford NOT to be treated for breast cancer.

 

I haven’t got Medical Aid

There are many excellent public hospitals and superb academic cancer specialists who work in government hospitals. As with all times of illness: knowledge is power, therefore knowing what management you should be expecting will help you navigate through the system. Books like this one and the internet can help you get more information to help you in your journey.

There are many organisations that wish to help patients who do not have the resources for travelling to a hospital or managing treatments. See our help and support page for further details.

 

Navigating Medical Aids

All medical aids, even hospital plans, have to provide some cancer cover. This will include in-patient care but may also include specialist fees, chemotherapy and cover for radiation and medications. The amount and type of treatments covered tends to depend on the medical aid plan that you are on, and it may require you to register for a cancer scheme after diagnosis. Check when you are considering starting or changing medical aids what type of treatments you are covered for.

Fortunately medical aids are not allowed to refuse cover for a patient with a pre-existing condition and that includes cancer. Remember to always mention these conditions to your medical aid so that you gain access to appropriate care and do not disqualify yourself.

Check your policy too as many companies encourage good health by funding screening mammography and Pap smears even to patients without day-to-day benefits.

 

Cancer policies

Even if you have medical aid, some of the initials concerns about cancer that patients suffer are not about survival or treatments, they are about whether they will be able to afford their treatments or go into debt. Because of this many insurance companies offer a policy which allows patients to unlock financial resources to cover the gap between what is covered and what is required.

 

Disability cover

Disability cover protects your ability to earn a living. It allows you to retrieve money from your policy when you are unable to work for certain periods of time. This may be due to temporary or permanent disability. The policy may be related to your ability to work at all or your ability to carry out your specific occupation.

 

Estate planning (making a will)

Nobody likes to think of a time when they will not be here, but it is said ‘death, taxes and childbirth: there is never a convenient time for any of them!’

Your estate is everything that you own, from a house and car to your jewellery and cell phone. If you do not plan for who will receive them after you die, the government will plan for you and may leave your family and dear ones without the resources they need when they need them.

Making a will is a simple exercise and shows how much you love the people around you. It is a good idea to also stipulate who should make decisions for you, if you are too ill to decide for yourself how you would like doctors to treat you.

 

Saving now for the future

Saving money is not easy, but if you are worried about how you can afford to cope if you get ill now is the time to start. Once you ensure that you have coverage in place for managing your expenses (such as medical aid and disability, cancer or life insurance) have a look at your monthly budget and look for ways to save a small amount into an emergency fund each month. This can act as a financial buffer when you have a significant outlay. This might not even be a medical expense but it will come in useful if you do have an unexpected medical diagnosis.

Budgeting also allows you to work towards paying off debts. Often the greatest of patients is not how to afford future treatment, but how to keep up with past debts during a period where you cannot work.

If you do get into debt or cannot afford treatments, discuss the problems with your doctor. They may have knowledge of charities that can provide financial assistance or work to find a longer but easier solution to payments.

The old adage that you can chose your friends but not your family holds true when looking at your cancer risks.

Today people live for longer than at any other time in history. For instance in the 19th century ,  more babies died from disease, men and children died early working in the mines, plagues carried off the frail, women died in childbirth, and 40 was considered ripe old age!

So cancer did still kill people back then but it killed less people because people died of other things long before they were ever at risk of a cancer. Today more people live until they are over 70, but 1 in 4 people over 70 will have a cancer. This is not due to an increase in cancer it is due to changes in cells and the inability of our bodies to kill or clean these abnormal cells.

It is not uncommon for more than one member of a family to have cancer. Cancer can occur in families:

  • By chance (most common)
  • Because family members have risk factors in common (such as environmental and lifestyle influences)
  • Because there is an inherited faulty gene causing an increased chance of cancer (uncommon)

 

How do I know if my family carries a faulty gene?

Trying to find information about cancers in your family and how to deal with them can be difficult. It is important to know your family history on both your mother and father side of the family. Even the faulty gene for ‘female’ cancers like breast and ovary can be inherited from your father.

Only a small amount of some cancers (up to 5%) are due to a faulty gene which is inherited from either your father or mother. This is called a familial cancer. This can also be described as an inherited risk of cancer. The faulty gene increases the risk of cancer, but it certainly does not mean every family member must develop the cancer.

Clues that the cancer that runs in your family may be due to an inherited faulty gene include:

Number of relatives from your bloodline who have had cancer: The more blood relatives who have had cancer (particularly clusters of breast, ovarian and/or bowel cancer) the more likely the cancer is due to an inherited faulty gene.

A young age when the familial cancers occur: The younger a person is when they developed cancer (compared to what is expected in the general community) the more likely it is to be due to inherited factors.

Pattern of different cancers in the family: The type of cancer a person has and who it affects in the family are important. In some families all patients may develop the same type of cancer, such as breast or bowel cancer. In other families, different sorts of cancer will cluster together (e.g. breast, ovarian or bowel cancer, and cancer of the uterus). This happens because some faulty genes can cause more than one type of cancer.

The more clues that are present, the more likely it is that there is an inherited faulty gene in the family causing the higher than usual chance of getting cancer. But this does not mean you will develop the cancer, just that you have an increased risk and need to be more vigilant with screening.

What should I do if I have a family history of cancer?

It is important to investigate your family history. You can find out what types of cancer your relatives have had and how old each person was when they developed cancer. It is also important to document a complete family history so you can see the family members not affected by cancer. Your family history of cancer can change over time as the members get older and more family is born, so it is important to keep your doctor updated about any new cancer diagnosed in your family.

Family counselling and genetic counselling services

Genetic counselling services give people information about their chance of developing cancer based on their family history. These specialists can spend time discussing ways that may help reduce the chance of you developing cancer and how you can be vigilant. It may be that genetic testing is possible, particularly if a member of the family who has cancer can be tested. This is only carried out after the advantages and disadvantages of testing for the patient and their family are discussed.

After female gender and advancing age, a positive family history of cancer is the strongest risk factor in developing breast cancer. In most cases there is not a long and extensive history of cancer present (more than four relatives in the same line). However in some families there is a strong hereditary line of cancer characterised by cancer in both breasts, young age at onset, and clustering of different cancers with breast (primarily ovarian and male breast cancer). Only less than 5% of all breast cancers will be due to these genes, which are known as BRCA1 and BRCA2. Others which are much less well known are TP53, PTEN/MMAC1, and STK11. There is testing available for the BRCA 1 and 2 genes for patients with a significant family history.

Managing these patients and families is highly specialised and requires communication between breast specialists and genetic specialists. If you think you may be at risk of carrying one of these mutations you should discuss it with your doctor and be seen in a specialist breast unit.

Studies have shown that it is possible to reduce the number of women dying from breast cancer by 45% using very simple measures. These include understanding your risk of having breast cancer based on your personal and family history, and being screened regularly for breast cancer.

What does screening involve?

Early detection is the key to better outcome with breast cancer. If a cancer is picked up very early, the risk of spread is low and there is more likelihood it can be treated with simple measure such as surgery. The later a cancer is picked up, the more aggressive treatment has to be, and the higher the likelihood of dying from the cancer.

There are many measures you can take to pick up cancer early and decrease your risk of dying. It can involve a number of different types of examinations, which include breast self-examination, clinical breast examination by your doctor or breast specialist, mammography, ultrasound (breast sonar), and magnetic resonance imaging (MRI).

Breast Self-Examination

During breast self-examination, a woman takes time to examine her breasts and get used to the way they feel and look. She checks her breast for any differences, which might include a change in the size or shape of the breast, any irregularities in the skin, any changes in the nipple and any lumps in the breast or under the arm. It is a free and easy way for women to get used to noticing any changes in the breast, and we recommend you carry out breast self-examination monthly, at the same time in your cycle if still menstruating, or on the same day each month.

Clinical Breast Examination

A clinical breast examination is an examination of the breasts which is done by a healthcare professional. It includes not only a physical examination, but time spent by the doctor listening to any symptoms or concerns the patient has, and discussing breast health. Although there is little evidence that clinical breast examination plus mammography is better than mammography alone, we believe it is important to keep close contact with your doctor or breast specialist so that you are clear about what to do if you notice a symptom.

Mammogram

Mammography is an examination of the breast using a low-dose of X-rays to look at any abnormalities within the breast. It requires you to stand beside the mammography X-ray machine and place your breast on a pad, where the X-rays will take an image of the breast from at least two views. Studies have shown that annual mammograms significantly reduce the amount of women over the age of 40 years who will die from breast cancer.

Older mammography uses photographic film to record the pictures, but newer better technology allows digital mammography, where the picture is recorded in a computer and can be more carefully looked at. This is particularly useful in women with dense breast and younger women before the menopause (still having periods).

Ultrasound

Ultrasound (breast sonar) is another imaging method to look inside the breasts. It uses high-frequency sound waves to echo back a picture of the structures inside the breast. It can be used to evaluate abnormalities found on clinical examination and mammography, and it is particularly good for looking at breasts of younger women, and looking for infections in the breast.

The accuracy of an ultrasound is highly dependent on the skill of the technician or doctor carrying out the test. That sometimes means that tests need to be repeated or errors in what is seen.

Magnetic Resonance Imaging

MRI is another method of imaging the breast using yet another modern technology. It uses a magnetic field to provide the doctor with a three-dimensional image of the breast. It also requires injection of a dye into your blood, which will help the MRI demonstrate normal from abnormal. It is an expensive test and not often necessary to diagnose abnormalities.

MRI is useful in patients who have inherited disorders such as BRCA genes or a higher than normal risk of breast cancer with ‘difficult to read’ breasts.

When you feel a lump or have a concern that you have developed a breast symptom, the first way to put your mind at risk is to know that more than 70% of all patients with breast problems do not have cancer. The only way to be sure of what is the problem is to be seen by a specialist and ensure correct imaging and diagnosis.

What will happen when I am seen by a doctor?

When you visit a general practitioner or breast specialist you are not just going to discuss your current problem, but chat about your general health and history. It is important to identify risk factors and potential health issues for the future, not just focus on one part of your health. The way to know exactly what type of lump it is or the cause of your symptom is to have your general practitioner or breast specialist to carry out triple assessment. This means that every lump or symptoms is investigated and managed in the same rational manner.

What is triple assessment?

Clinical examination

You doctor will spend some time examining you in order to determine if there is an abnormality. They will look at you to see if there are any breast changes you can see such as skin thickening, nipple changes, or dimples in the breast. After that your doctor will feel the breasts, in the same way as in breast self-examination. They will feel into the axilla and all over the breast looking for lumps or pains. It is also important to look at the nipple carefully, looking for any discharges or abnormalities. Often your doctor will do a full clinical examination to check for any other changes or abnormalities, including taking your blood pressure.

If you do have a lump or abnormality identified your doctor will discuss what that means. No doctor has X-ray fingers, so any clinical examination is always accompanied by imaging which is the next step.

Radiology examination

This is imaging done by a specialist radiologist, and double read by a second radiologist to ensure nothing is missed. Normally this includes a mammogram with at least two views (but sometimes more) and an ultrasound of the breast and armpit. Often in women under 35 years the breast is often too dense to rely on mammograms to see problems so an ultrasound is done alone. Newer methods of diagnosis such as MRI scan may also be useful in some cases.

Pathological diagnosis

If there is a lump present, the radiologist may wish to do a core needle biopsy. This is best done by the radiologist because they use X-ray or sonar guidance. The old technique of Fine Needle Aspiration (FNA) should not normally be used because it can be inaccurate and not give enough information to the doctor. It is also rare to require a full surgical biopsy in theatre and it is often not the best method of diagnosing cancer as it affects further treatment.

This sample will be sent to a pathologist who will cut the sample into small slices and stain them especially to allow easy identification of any abnormalities or cancers.

How soon will I be told if its cancer?

The specialist breast surgeon or radiologist may be concerned about the lump or mass they see, but no diagnosis can be made for certain without a tissue sample taken by biopsy. This takes 48 hours to test at least. The most important thing to remember is that breast cancer is not a death sentence, nor is it an emergency. By the time a cancer is palpable (at 1cm) it has been present in your breast for at least five years.

There is never a requirement for an emergency mastectomy, and sometimes the best treatment for breast cancer is to begin with chemotherapy rather than considering immediate surgery. So even if there is cancer present, you have time to consider your options, time to take advice or seek another opinion.

Breast Cancer staging

Patients often ask what stage their cancer has been diagnosed and how advanced it is. Although this might seem very important, in actual fact the character of the cancer, the way it behaves and reacts to treatment, is more important. For instance, an early stage but aggressive cancer may progress more quickly than a large but laid-back tumour.

Staging is made on clinical and laboratory findings. Staging systems are used to classify breast cancer, so that the doctor can treat the disease with a logical basis and all breast cancers doctors have a common base on which to base treatment plans. The most commonly used staging system is the TNM staging system. It allows doctors at particular centres to compare their results with other centres all over the world. Thus treatment regimens in South Africa can be compared with those in the United Kingdom and United States of America.

The most commonly used staging system is the TNM staging system, with T referring to tumour size, N referring to nodal status and M being used to determine metastatic disease which is when cancer has spread beyond the breast and regional lymph nodes to the rest of the body. Metastases are little islands of tumour cells that have spread from the primary cancer and taken root in distant tissues and organs. It is these metastases that eventually cause death. Doctors detect metastases with various methods.

Part of the staging is to perform certain tests to determine whether the cancer has spread (M):

  • X-ray chest for lung spread
  • X-ray bones and bone scan for bony spread
  • Brain scan for brain metastases (MRI)
  • Abdominal ultrasound (sonar and CAT scan for liver spread)
  • Blood tumour markers (these should be used as a serial assessment, not as individual values).

There are four stages of cancer:

  • stage one and two cancers are early;
  • stage three cancers are locally advanced (large breast cancers greater than 5cm) and
  • Stage four cancers have spread to elsewhere (M+).

It is your right to know as much as you want about the cancer, ask about new treatments and remember that your time with your doctor is just that: YOUR TIME so take as much time as you need during a consultation. It is your body and your life so become involved with your health.

It is estimated that 80% of women are wearing the wrong bra. Are you one of them?

Wearing the wrong size bar can lead to increased pain in the neck and shoulders as the breasts are inadequately supported. One of the most common causes of breast pain is poor support and women are often shy to look for the correct size of bra. As a result their bust is unsupported from below and all the support comes from the shoulder straps which causes welts and indentations in the shoulders.

This lack of support can also lead to large breast hanging down on the skin below the breast causing an area of warm moisture through the day. This results in a fantastic breeding ground for bacteria and funguses to grow- often seen as a white or red discolouration under the breasts and eventually leading to darker discolouration in dark skins. An inappropriately tight bra can also cause problems. There is constriction of the respiratory muscles (the muscles that helps us breathe well) causing breathing problems, and back and should aches too.

So what is the wrong bra and how do you find the right one for you? Look in the mirror with your bra on and see if it fits

It doesn’t fit properly if…

The underband is riding up at the back: If the underband bows up at the back or lifts up when you raise your arms it is too loose.

The shoulder straps are digging in: A vast majority of the support for your breasts should come from the underband, support from below not suspension from above. If you have too loose a band you will feel the straps dig into your shoulders and be left with red marks there.

The centre between the cups lifts away from the body: The centre should lie flat against your body supporting and separating your breasts. If it does not, your cup size is probably too small.

The straps do not lie in parallel to each other but stretch outwards: This normally means that your underband is too tight and is overstretching at the fastening.

Some of your breast spills out over the top of your bra: The classic ‘four breast’ look! The cup is dividing your breast tissue because your cup size is too small. Often women are alarmed to find they are actually a DD, E or F rather than a C cup.

 

It will fit properly if…

…you follow this easy plan to correct bra size.

Get some help: Most lingerie shops and departments offer a bra-sizing service and you should take them up on it. There should be no obligation to buy.

Budget for a good bra: If you are worried about the cost of a bra, take some time to see how much you have spent on clothes in the last six months, and how many times a week you wear the items. Your bras are the most often worn items in most women’s wardrobes, but the item they are most reluctant to spend money on. Spoil yourself and your bosom!

If you want to have an idea of your size before your shop: you will need to know your underband size and cup size. Even though South Africa follows metric measurements, bra sizes are still measured in inches. To convert centimetres to inches, multiply by 2.5.

First, take a soft measuring tape and put it around your body just underneath your breasts. Take a deep breath in and pull it snug to your skin. Record this measurement (e.g. 31 inches) and then add 5 to it, rounding up to the next even number (31 +5= 36 inches). This is your band size

Next, measure round your over the fullest part of your breasts (normally at the nipples) when you are wearing a bra. Record this measurement (e.g. 38 inches) and subtract this measurement from your band size (38-36=2). This will correspond to the cup size you should try first.

If the number is:           0=AA cup

1=A cup

2=B cup

3=C cup

4=D cup

5=DD cup

6=E cup

Remember that this is only a rough guide of your size. You should then shop and try on sizes one above and below. As you adjust the band size up (e.g. 36 to 38) come down by one on the cup size (e.g. 36D to 38C).

 

Not all styles will suit all breast shapes, so it may take some time to find a bra that suits and fits you. When you find the right bra, it should not be uncomfortable or dig into your skin. It should hold your breasts well and give you a good shape. A good bra can give you as much shape and lift as expensive plastic surgery.

Why do we do reconstruction?

The psychological impact of losing a breast varies but for most women it means some form of grieving. Breast reconstruction can alleviate the sense of deformity that may develop after a mastectomy. It is considered an integral part of the management of patients with breast cancer and this option should be discussed prior to any breast surgery. Remember rather a delay of a day or two to determine what your surgical options as opposed to a lifetime with one or no breast. Cancer diagnosis does not mean that you need surgery that very day. There is no such thing as an emergency mastectomy, and there is always time to get advice or a second opinion and be sure of your options.

When do we do it?

Breast reconstruction can be done immediately after the mastectomy or lumpectomy. It can also be delayed for a few months or even longer. The benefits of having reconstructive surgery at the time of the mastectomy are obvious in that it helps to preserve body image. Having this procedure depends on the patient’s age, the size and location of the tumour and the stage of the disease.

How do we do reconstruction?

The most common reconstructive techniques involve using the woman’s own tissue to rebuild the breast (autologous flap) or having a silicone or saline implant. Despite the bad publicity silicone implants have had in the past, there is no scientific evidence that they may cause cancer and certain immune system disorders. The goal of reconstructive surgery is to obtain symmetry for the breasts therefore this can involve surgery to the other breast too, in the form of reduction, augmentation, mastopexy or prophylactic mastectomy and reconstruction. Even breast conserving procedures should be done so as to achieve the best cosmetic result. All women are entitled to a cosmetic result whether they have surgery for benign breast problems or cancer.

Because cancer is part of your body, it is difficult to find and kill cancer cells without harming your own body. Most cancer treatments have some side-effects, but just as each patient has an individualised treatment plan, each patient may have different responses to the different treatments.

If you are undergoing cancer treatment it is important to keep in close contact with your family doctor and your specialist doctors. They will help you manage the side-effects more easily.

Side Effects of Breast Cancer Surgery

 

Pain in the region of your operation

Any operation can cause pain in the region surrounding the operation site. This pain should be short lasting and you should speak to your specialist doctor or nurse to help you with painkillers for a limited time. Pain can sometimes be a sign of infection so it is important if the pain is getting worse and not better to seek advice.

After a mastectomy, women can sometimes experience ‘phantom breast pains’ which means they experience feelings of pain or tenderness that appear to come from the breast that is no longer there. This is because the nerves to that breast have been cut as part of the mastectomy operation. Sometimes it takes some time for the body to learn that the breast is no longer there and adjust to the sensation of no longer having a breast. This may still happen even when the breast has been immediately reconstructed.

Loss of sensation

In order to remove a breast, the nerves in the skin and tissues below must be cut. This will lead to a feeling of numbness in the area the nerve supplied, normally over the skin of the chest area, and often in the inner aspect of the upper arm. It is normal to lose some sensation in these regions and it can take a number of years for sensation to return.

It is also important to remember if you have reconstruction of the nipple, that this nipple will not have the sensation of your previous nipple.

Feeling of imbalance

When a woman undergoes mastectomy it can take some time for her to adjust to the new feeling of weight distribution in her chest, particularly if she is large breasted. There may be feelings of imbalance, which can cause compensation in the muscles of the back and shoulders leading to pain. This can often be avoided with the consideration of immediate reconstruction of the breast or breast reduction on the other side. An external prosthesis in the bra can also require getting used to.

Lymphedema

When a woman undergoes operation and removal of some of the glands under the arm, it can cause swelling in the arm from retained water. This is called lymphedema. The risk of lymphedema is increased when cancer treatment also includes radiation to the armpit. Approximately one in ten women who have gland surgery will get lymphedema, and this can range from mild swelling to a debilitating condition. A specialist physiotherapist can help with exercises to improve the drainage of the arm, and there are many implements and garments to wear which can also aid the condition. Patients with lymphedema can prevent the situation from getting worse by avoiding lifting heavy weights, exercising the arm and alerting their doctor to any signs of infection in the arm

Stiffness in the shoulder

Following any major breast surgery the pain of the operation, together with difficulty moving the arm due to drains and bandages, can lead to stiffness in the shoulder and pain on moving the arm. At its worst this can lead to a frozen shoulder, which may require orthopaedic treatment. Many years ago patients were advised not to move the arm and shoulder for a long time after a breast operation and this made the problem far more common and more severe.

Side effects of Radiation therapy

 

Skin changes

During radiation treatment the skin on and around the breast can become very sensitive and tender. It can be itchy or red too. This is because of the radiation, and will settle down after the treatment ends. Sometimes the skin colour can change or fine veins (‘telangiectasia’) develop over the skin around a mastectomy scar. These are small changes which may be permanent. It is important to discuss any skin lotions or creams a patient might wish to use during treatment with the radiation therapist before using them.

Changes in the size or shape of the breast

In most women, radiation does not affect the breast shape in any way. Sometimes however, when radiation therapy is used after a lumpectomy or breast conserving surgery, the treatment can result in the breast changing in density or size. The breast can become larger due to swelling within the breast during treatment, and in the long term the breast can become smaller or firmer.

Fatigue

Many women find radiation can leave them feeling tired and fatigued after treatment, particularly later on in cancer management. The fact that the regime requires daily hospital visits can also leave a patient suffering from exhaustion.

 

Side effects from chemotherapy

The side-effects of chemotherapy drugs depend heavily on which of the drugs are used and in what combination. Most of the side-effects of chemotherapy occur because, along with killing the cancer cells in your body, the chemotherapy can damage some of your ordinary cells. The cells that are most frequently damaged are those that divide and multiple often. These include the cells of the hair and skin, and cells of the gut and intestine. More serious side-effects can include a depressed immune system with an increased risk of infection, and easy bruising or bleeding.

Nausea, vomiting, mouth ulcers and diarrhoea

These occur as the cells of the gut are damaged or killed by the chemotherapy agents and take time to replenish. Most of these side-effects can be managed well by your doctor and most of them go away during the recovery part of the chemotherapy cycle.

Hair loss

Many patients fear losing their hair and are surprised to find that many chemotherapy agents do not cause this side-effect. Even if the hair is lost, it will most commonly grow back after the treatment is finished. The selection of wigs and scarves available for women who have lost their hair is extensive, and many charities will support women in looking their best even during chemotherapy.

Numbness and tingling of the hands and feet

The sensation of numbness can be uncomfortable or frustrating for a patient. It is a side-effect of some of the chemotherapy agents given in breast cancer. Oncology doctors work hard to prevent this becoming a problem in the long term.

 

Side effects of Hormonal treatments

Hormonal treatments are designed to starve breast cancer of the female hormones it feeds on. It does this by preventing the body making the hormone or preventing it getting to the cancer. This can simulate the menopause in most women who take these treatments. The side-effects are therefore effects of the menopause.

Hot flushes, night sweats and vaginal dryness

A hot flash is a sudden rush of blood to the face and neck that can last for anything between a few seconds and an hour. It is difficult to treat with medication but relaxation and loose clothing can often help to cope with these events. The same hormone deprivation that causes this can also cause your vagina to be dry which may cause increased infections in the bladder and painful intercourse.

Increased risk of clotting

Some hormonal medications can increase your risk of developing clots (‘thrombosis’) in the veins of the legs and arms. It is important if you take hormone medications to tell doctors if this has ever happened to you before as it may affect the medication you are given.

Bone and joint pains

Most of the hormone medications given to patients can affect the joints and bones in some way. They can cause arthritic pains in the joints or muscular aches that can be difficult to tolerate. Some of the medications can also cause thinning of the bones which should be monitored by your doctor.

There is no definite symptom which means that you definitely have breast cancer. Most of the symptoms which are related to breast cancer are also present with non-cancer problems, so it is important not to panic if you develop a problem but to ensure you get it checked out.

If you have breast cancer will you feel a lump?

Most breast cancer present as a lump in the breast. Often women are surprised by the unexpected appearance of a lump and are unsure whether to get it investigated. No matter how sudden or how the lump feels, it is very important to see your doctor. Cancer lumps often feel hard and craggy and grow steadily in the breast. Eventually the cancer will spread to the lymph glands causing hard lumps to be felt under the arm too.

Approximately ten per cent of breast cancers present without a lump, and in fact when you do feel a lump in your breast, around 80-85% of those are benign. Most lumps felt in the breast are not cancers but might be cysts or masses known as fibroadenomas.

Cancer can show up without a lump, and if you experience some of these other symptoms you should also get checked out:

  1. Change in the size and shape of the breast
  2. Thickening of the skin of the nipple or ulceration
  3. Eczema of the nipple, itching or scaly patches
  4. Nipple turning inwards
  5. Thickening or dimpling of the skin of the breast
  6. Lumps noticed under the arm

Is breast cancer is painful?

Unlike most cancers, breast cancer does not present with pain. That doesn’t mean that if you have a painful lump it can’t be cancer, but it is unusual for pain to be the first thing a women with breast cancer notices. The most common way that women find a breast cancer is when they feel a lump in the breast or notice a discharge from the nipple. In the future, we want breast cancer to be found on mammogram, before there is even a lump, because we know that the earlier a cancer is detected, the better it can be treated.

Is a nipple discharge normal?

It is true that some nipple discharges are very normal- take breast feeding for instance! It is also quite common to get a discharge after breast feeding for a while. Not all nipple discharges are normal however, and they can mean different things. Breast specialists worry particularly with one sided nipple discharges that come from just one place on the nipple what every colour they are, and we also don’t like nipple discharges that have blood in them. The best plan is to get every nipple discharge checked out by a specialist who can help you understand what the problem is, and help you solve it too. Remember not to squeeze your nipples- they can respond by producing or increasing a discharge. If you have been squeezing, the first step to preventing a discharge is by stopping.

What changes in the nipple are related to breast cancer?

There are two particular changes on the nipple which are concerning for breast cancer. The first is an itchy scaly eczematous rash which can develop on the areolar (the coloured part of skin around the nipple) or on the nipple itself. This kind of rash can cause the skin to peel or become red and raw. It is termed ‘Paget’s disease’ and is a spread of cancerous or pre-cancerous cells along the ducts to the nipple where they cause rash or an ulcer.

The second symptom that can develop is an inversion and in-drawing of the nipple. Many women have inverted nipples which are completely normal, but if a nipple suddenly becomes inverted, particularly on one side only, it is cause for concern and should be investigated.

 

Whilst all cancer is treatable and potentially curable it is better to pick up cancer as early as possible. Remember to go for screening mammography and sonar after the age of forty every year, and get your GP or a breast specialist to examine you once a year too. Being breast aware also means learning to love your breasts, and getting to know your body. You may be the best person to pick up when something is wrong with your body if you learn what is normal for you and what is not.

Any woman (and even men) can get breast cancer which is why it is so important to know about the disease and know about all potential treatments. It is often not clear why some people get cancer and others do not, and the more we learn about the disease, the better we get at curing it.

What is cancer?

It is natural in life that we are all born, we grow and we all eventually die. The cells that make up our bodies are just the same. They have a life cycle which involves multiplying, growing and eventually dying in a process called ‘apoptosis’. In cancer, some of the cells of the body will misbehave and do not carry out the normal cycle. They will continue to grow and multiply but they will not die. Eventually they will spend all of their time multiplying and none of their time working as a normal cell does so that they grow into a tumour. This tumour invades the normal cells and makes new blood cells to feed its growth. It is out of control.

Eventually the tumour decides to break up and uses the bloodstream and lymphatic cleaning system of the body to travel to distant parts of the body, such as the brain and the bones, the liver and the lungs. There these small cancer cells will settle and begin to multiply in their new position, destroying the normal functional tissue in that area. These are called ‘metastases’ and the increase in these tumours will eventually lead to death.

Is breast cancer common?

Breast cancer is the most common cancer to affect women worldwide. There is no adult woman, population or culture that is free from the risk of getting breast cancer. The rates of cancer vary throughout the world, from one in 8 women in the United States to much less in Japan and the Far East. There are not accurate statistics for the prevalence of breast cancer in South Africa, but we think they may be similar to those in the United States because we have a similar diet and lifestyle.

Breast cancer is also the most common cause of cancer death for women in the world today although there has been a dramatic decrease in cancer deaths over the past forty years due to increased awareness and increased screening of women.

Who gets breast cancer?

Anyone with breast tissue can suffer from breast cancer, it even affects men. Women of every age are at risk, even including young women in their 20s or 30s. Breast cancer has been seen in girls of nine years old. Your risk of getting breast cancer increases with your age, so as you get older you become more and more likely to get breast cancer. A woman less than 40 has approximately 1 in 230 risk of getting breast cancer rising to 1 in 29 after the age of 65.

It doesn’t matter what race or culture you are, all groups suffer from breast cancer. Women of all walks of life are at risk, whether rich or poor, healthy or unhealthy, insured or uninsured. Most women (more the three quarters) do not even have risk factors that put them at high risk of breast cancer. It depends on whether your cells decide to stop behaving and start multiplying irregularly and progressively.

Many women who get breast cancer ask “Why me? What did I do to cause this?” It is very normal to ask this type of question, but the answer is: Nothing. There is no single cause of breast cancer and no single event that will bring it on. There is nothing any women does or doesn’t do which causes breast cancer. It is an unfortunate event of life which we work to lessen through early diagnosis and treatment.

How treatable is breast cancer if caught early?

All cancer is treatable and there are good options for management and cure irrespective of the size when it is found. When breast cancer is detected early, before it invades tissues outside the breast, the survival rate is as high as 95%.

Breast cancer that has not invaded into the breast tissue but is still in the ducts (known as carcinoma in-situ) has a 99% cure rate. Often surgery alone is appropriate treatment. If a small cancer invades into the breast tissue but does not spread to the glands it also has a very good prognosis. The treatment of cancer is tailored more and more to the ‘personality’ of the cancer: how it behaves and what it responds to, not the size alone.

Do chances of survival drop (by how much?) if caught later?

When cancer is confined to the breast it is easier to treat and be sure of a cure. Patients do not die of cancer when it is confined to the breast. It is the spread of cancer of the brain, bones, liver and lungs which will eventually cause problems. The aim of breast cancer awareness and screening is to catch cancer early before it can escape the breast, breakthrough the lymph glands under the arm (the security guards of the breast) and spread from there to the rest of the body like a wave of terrorists that can hide away and reappear in the future.

Many of the more aggressive types of treatment for breast cancer such as chemotherapy are based around catching and killing these spreading cells. Even if the cancer has spread to bones, up to 75% of patients will be alive in five years after diagnosis.

All women are at risk from breast cancer, which affects one in eight women in the world today. Many risk factors are things that you have no or little control over, such as your family history or your race.

It is important to remember that three-quarters of women who get breast cancer were not at increased risk, and we don’t fully understand why different women get cancer yet. Even if you have all these risk factors, it only highlights the need to be careful and check your breasts regularly. It does not mean you are going to get breast cancer.

So what are the risk factors for breast cancer and how can you deal with them? You can separate risk factors into three groups:

Risk factors you can’t avoid:

Ethnicity: White women have more of a risk of getting cancer than black or Asian women. There is very little you can do to change a risk factor like this.

Age: The risk of getting breast cancer increases with age. At thirty your risk of breast cancer is 1 in 2000, that increases to 1in 50 at age fifty and by eighty years it is 1 in 10. That is why it is recommended to start checking for breast cancer above the age of 40 with a yearly breast exam by your doctor and a yearly mammogram.

Family history: There are breast cancers that run in families and in different minorities. Some families carry a gene that specifically increases the risk of breast and ovarian cancer (BRCA1 and 2) and we know that these are commonly seen in Ashkenazi Jews and Afrikaans women. In other families clusters of cancers like bowel and prostate through the generations point to an increased risk of breast cancers too.

Risk factors you can’t help:

Pregnancy: Nulliparity (not having children) or having children when you are over thirty is a significant risk factor for breast cancer. We know that a lot of breast cancers are driven by the hormones, and the hormones changes that occur during pregnancy have a lasting effect on your chances of getting breast cancer. Having one child at a young age does help protect against cancer, but after the age of 30 the risk is the same whether you have children or not.

Breastfeeding: After birth, breast-feeding of a considerable length of time has a protective effect on your breasts, but it is a marginal effect which is present if you breast-feed for one year or more. Having said that, the effect on your child is much much more with increased immunity, good bonding and long-term effects on weight control and intelligence also suggested. Breast feeding is one of the greatest gifts you can give to your child.

Early age starting your periods and late menopause:  the length of time your body is under the effects of female hormones during your lifetime also affects your risk of breast cancer. If you have started your periods before 12 years, or had a late menopause after 55 years, you have an increased risk.

 

Risk factors you can change:

Obesity: Having an increased body mass index (BMI) greater than 30 after the menopause puts a woman at increased risk of getting breast cancer. At any point in life it also put you at increased risk of a number of other conditions such as diabetes, high blood pressure and joint problems. It is never too late to change your diet, increase your daily exercise amount and make it a target to lose a few kilos.

Alcohol: Women who classify themselves as heavy drinkers are also at increased risk for breast cancer. This means that they are consistently drinking more than four drinks (units) a day or seven drinks per week. Remember that heavy drinking is not the same as problem drinking and that a nice glass of wine in the evening is normally classed as two or even three units, and a bottle of beer is 1 ½ units. It becomes very easy to become a heavy drinker without realising.

Hormone Replacement Therapy: Studies in the USA and in the UK have shown that women are at increased risk of breast cancer if they are taking most types of HRT for more than five years. It is also true that the closer to the menopause you start taking HRT the higher the risk of breast cancer. In real terms if 30 in 10,000 menopausal women get breast cancer, 38 in 10,000 women taking HRT will get it. This has to be weighed against the potential benefits so it is important to speak to a sympathetic gynaecologist who may suggest other more natural methods of dealing with your menopause.

It is not just about changing your lifestyle to decrease your risk of cancer. It is also important to change your attitude and start to get wise about breast health.

had a diagnosis of atypical hyperplasia or any other type of benign breast disease, or lobular carcinoma-in-situ

There is no direct family history of breast cancer in first generation (sisters or parents) or suggestions of hereditary forms of cancer.

No history of mantle radiation for lymphoma (a type of upper body radiation given for lymph gland cancer)

You are at above average risk if:

There is a close family history of breast cancer

This means that your parents, grandparents or children have had breast cancer. It also may include your aunts, cousins and other relatives if there are many in the family who have breast cancer, all from the same side of the family.

You have had a diagnosis of atypia on a previous breast biopsy. This is a form of benign breast disease but can be associated with an increased risk of later cancer

You had mantle radiation before the age of 32

 

Screening guidelines

Screening guidelines are intended to increase the chance of picking up a cancer or worrying area of cells once they have developed in your breast. There is no test or method that prevents cancer developing in the breast but we can pick it up as early as possible to ensure the best outcome for you. These guidelines are taken from the American

Average risk patients

Examine your own breasts each month and get to know what is normal for you

After the age of 40 see your doctor or breast specialist every six months for a clinical breast examination

After the age of 40 get a mammogram and sonar at least every two years

After the age of 50 get a mammogram and sonar every year

 

Above average risk patients

Examine your own breasts each month and get to know what is normal for you so it is easier to spot something abnormal if it happens

See your doctor or breast specialist every three to six months for a clinical breast examination, starting when you are ten years younger than the youngest age a breast cancer was diagnosed in your family (but not earlier than 25 years or later than 40)

Go for an annual mammogram and sonar starting no later than ten years before the youngest member of your family was diagnosed with breast cancer

If you have atypia diagnosed, you should start annual mammograms irrespective of age, and see your doctor for a clinical breast examination every three months

You may want to consider an MRI scan, which helps with the differentiation of normal and abnormal breast tissue in some difficult to diagnose patients.

 

Simple measure can reap great rewards. Getting to know your breasts and getting into the habit of checking them regularly is important. Consider booking your next mammogram and sonar for the week after your birthday- that way you will be reminded every year that it is time for a check-up!

Your doctor will discuss the plan for your breast cancer treatment throughout your care. Often the plan may change as new information is obtained- such as the results of a sentinel lymph node biopsy or the receptor status of your cancer. Every plan is likely to include surgery and at least one other modality of treatment. There are many different but equally good ways of treating breast cancer. Your doctor will discuss with you the way she thinks is best, based on the discussions within the multidisciplinary team and new evidence or new treatments which are always being developed.

 

The most important person in the discussion is you, or your loved one with cancer, and all the decisions around treatment are ultimately made by you. Doctors can give you the evidence and advice based on years of training and experience, but the patient must decide what is best for her.

 

Here are a couple of tips when considering your management:

Take your time

By the time a breast cancer is picked up by a clinician or on a mammogram, it has been developing in the breast for 2-6 years. There is no such thing as emergency treatment for breast cancer, and whilst it is important to seek treatment immediately, there is time to discuss with your family and friends, with previous cancer survivors and with support groups, what you feel about your cancer and your treatment.

Get a second opinion if you want one

There are different ways in which a breast cancer may be treated with equally good results. In different parts of the world the four pillars of treatments may be used in a different order. You own health and previous history of illnesses may influence the kind of treatment you can be offered. No doctor will consider it an insult if you ask for a second opinion.

Read around the subject wisely

The internet is wonderful at opening doors to a world of knowledge and it is important that you research as much as you want into your treatment. Many large cancer organisations around the world have excellent and trustworthy information for patients. Some of these are:

  1. Netcare Breast Care Centre of Excellence(SA): www.breasthealth.co.za
  2. CANSA (SA): www.cansa.org.za
  3. Breast Health Foundation (SA): www.mybreast.org.za
  4. National Cancer Institute (USA): www.cancer.gov
  5. Susan G Komen for the Cure (USA): www.komen.org
  6. Breakthrough Breast Cancer (UK): www.breakthrough.org.uk
  7. Macmillan Cancer Care (UK): www.macmillan.co.uk
  8. American Cancer Society (USA): www.cancer.org

There is also a lot of advice and treatments offered on the internet that are not based on good scientific evidence, and many well-meaning people who have sought other methods of treating cancer. When you read all sources of information, it is important to read critically and not to trust everything you read or hear of. Discuss any concerns or reading you have done with your doctor as they can often help you discern the true and trustworthy from the fraudulent.

Get support

You do not have to survive cancer alone. In every part of the country there are networks of breast cancer survivors who are ready to support you from diagnosis onward. Some of these organisations are:

  1. Bosum Buddies: www.bosombuddies.cfsites.org
  2. Reach for Recovery: www.reach4recovery.org.za
  3. Look Good… Feel Better…: www.lgfb.co.za
  4. People Living With Cancer: www.plwc.org.za

Many of these organisations hold meetings, for support and for gaining information about their disease. They also get involved in fundraising for breast cancer charities. Most organisations are committed to helping you fight your cancer and walking with you every step of the way. You never stop being a breast cancer survivor, and in time you will be able to support others too.

How will I cope?

Most patients experience psychological problems following the diagnosis of breast cancer and the most difficult period is between diagnosis and surgery or treatment. Breast cancer patients will experience the following emotions:

  • Anger
  • Depression
  • Anxiety
  • A sense of helplessness
  • A sense of powerlessness
  • Vulnerability
  • A sense of unfairness

Breast cancer patients will also experience certain fears around their treatment such a fear of being sick, fear of being in pain, fear of the side effects of treatment and fear of disfigurement. It is important for all these fears to be discussed because many side effects of treatment and surgery can be alleviated. Knowing more about the treatment and realistic expectations of the course of management and the future will help. Anxiety about disfigurement after mastectomy can be allayed by remembering that reconstructive surgery is an option in most breast cancer cases.

What about my family?

Breast cancer affects not only the patient but also the patient’s family and friends. Open communication between family members is important. Family may need time to understand and support their loved one undergoing such a difficult time. They may also have feelings of helplessness, shock and confusion. They may find it difficult to cope with these emotions and determine how best to support their loved ones.

Children and Teenagers

Children whose close relative (mother, sister or grandmother) has cancer are often aware of a change in their lives and those surrounding them. Even young children can sense that something is wrong and this may frighten them. There may be a change in the daily routine or absence of a loved one, and this can cause fear which manifests as anger or tantrums. They may consider that they are responsible and require reassurance that this is not the case. Open and honest communication is best, addressing all fears and discussing their feelings. They may have lots of questions which should be encouraged and answered in a way they will understand.

Telling children and young people the truth about illnesses and cancer, at a level they can understand and cope with, will reduce the stress, guilt or fear they may feel. Spend additional time with them and ensure that they have opportunity to spend quality time with the cancer survivor. Older children and teenagers may be expected to take on additional responsibilities in the family and it is important to remember they are still children who need loving support.

Partners

One of the hardness life events is coping with illness in your intimate partner. There may be feelings of fear, confusion or helplessness and an overwhelming concern which prevents communication. The key to navigating this difficult time is to maintain open and honest communication between partners with time protected to spend alone and discuss feelings. Loving words and physical touch will remind your partner of your care. Another source of stress may be a change of role and responsibilities within the family, and concerns over financial well-being.

When a breast cancer patient requires spending a long period of time in hospital, there can also be difficulty maintaining good contact and communication, and the supporting partner may have a feeling of isolation or uselessness in their contribution to the treatment of their loved one. Often unrealistic expectations may need to be addressed, and it is important try and maintain life in the same way as it was before the diagnosis.

Intimacy issues between the patient and her partner should be addressed. It can be problematic because each partner must attempt to cope with their feelings. It may be difficult to express love physically in the same way as before, due to physical changes or emotional preoccupations. Finding new ways to express love and gain satisfaction is part of new methods of communication.

Some sexual problems may stem from the treatments for cancer themselves and others may be a result of emotional changes. Communication between partners and involvement of healthcare providers can often help identify problems which can be solved. Understanding unrealistic expectations or unhelpful feelings of anxiety or guilt will help the situation immeasurably, and there are many healthcare workers who wish to give help and advice.

 

The more someone knows about breast cancer and the treatment options available the better equipped they will be to deal with it. It is important for a partner, family, friends and health care practitioners to speak openly rather than pretending there are no problems or concerns. Sometimes it may be helpful to speak to breast cancer survivors, a psychologist or a social worker.