The Breast Care Unit at the Charlotte Maxeke Johannesburg Academic Hospital, run by a dedicated team of specialist nurses and experts in the field.

They provide access to quality breast care, regardless of geographical location and socioeconomic status.

The unit sees up to 350 women with newly diagnosed breast cancer every year and provides a service to seven district hospitals. Patients from other provinces and all over Africa are also accommodated. On an annual basis, this hospital treats more than 200,000 patients.

The sad reality is that due to a lack of education around the disease, patients often arrive at the hospital at a time when a fairly treatable disease, if detected early, has progressed beyond the point of treatment.

Charlotte Maxeke Johannesburg Academic Hospital also trains medical students, interns, medical officers, registrars and junior consultants in breast care making it a centre of excellence in this field. There is also a “Breast course 4 Nurses” programme to empower nurses in breast care.

Breast cancer develops when normal cells of the breast change behaviour and grow out of control. The abnormal cells divide to form a tumour and this mass of cells is often palpable as a lump in the breast.

The cells can also break off and spread to other places in the body, by the lymph to lymph nodes or by blood vessels to other organs.

Breast cancer is the most common cancer among women in South Africa. The most recent results from the National Cancer Registry showed that more than 8100 women were diagnosed in 2013. One out of 28 South African women will develop breast cancer during their lifetime and numbers are expected to rise in the future.

Although some population groups have a higher risk than others, it is really important to know that any woman can develop breast cancer.

It is also important to understand that breast cancer is much more common in women but men can get breast cancer too.

• A breast lump: this is the most common sign. The lumps are often not painful when they are small.
• Skin changes: this includes dimpling, redness or an ulcer (a break in the skin)
• Nipple changes: the nipple can be pulled in or change direction, there can also be abnormal discharge from the nipple.
• A lump in the armpit: there can be palpable lymph nodes.
• A change in breast size and shape.

Any patient with a suspected cancer needs what we call a “triple assessment”. This includes an examination by a doctor, breast imaging by mammogram and ultrasound and a needle biopsy which takes small samples of tissue for testing.

Your doctor will do some tests to check how large the cancer is and whether it has spread to lymph nodes or elsewhere in the body. Your choice of treatment plan will depend on staging to some degree. Early-stage small breast cancers are more likely to respond well to treatment.

Different types of breast cancer can have very different behaviour, which is called tumour biology. This is why treatment can be very different among breast cancer patients. Breast cancer describes many different diseases and that is what makes the understanding and the treatment both difficult and interesting.

There are various different treatments and the treatment plan depends on the type and biology of the cancer, the stage and also on patient choices.

Management of breast cancer has become very complex and specialised and is therefore best treated by a multidisciplinary team with experts from each field. They will discuss your situation to find the best way forward for you.

In general, most patients will need treatment to the breast area, which is called local treatment and they need treatment for the whole body, which is called “systemic treatment”. Surgery and radiation are local treatments, chemotherapy, hormone and targeted therapy are systemic treatments.

Most patients will have some or all of the following treatments:

• Surgery: Almost all women will need surgery to remove the cancer. This can be a mastectomy, the removal of the breast, or breast-conserving surgery in which only the lump with some healthy tissue around it is removed and women keep their breast. Women who have breast-conserving surgery usually must have radiation after surgery. In most cases, the surgeon will also operate to test or remove the lymph nodes in the armpit.
• Radiation therapy: This treatment is mostly used after surgery to destroy any remaining cancer cells in the breast or armpit area.
• Chemotherapy: This treatment uses medications to control cancer cells. Some women will need chemotherapy before surgery and some may need chemotherapy after surgery.
• Hormone therapy and targeted therapy: Some medications only work if the cancer has certain characteristics. Your doctor will check if these treatments would help you.

Treatment of breast cancer can take a long time. Often the initial intense treatment can take several months to a year.

Hormone therapy often only starts afterwards and can take up to ten years. You need to know that many people with breast cancer do very well after treatment.

People who get high-quality standardized treatment (treatment in a multidisciplinary team who follow guidelines) and who present at an earlier stage (with small cancers) are more likely to do well.

Treatment of breast cancer includes many choices and you are likely to meet a number of specialists from the multidisciplinary team during your treatment journey.

It is really important that you are part of decisions. It is always of great help to bring a family member or close friend along. You should always let your team know how you feel about treatment and you need to make sure you understand your options. In general, you should ask the following about any of the treatments offered:

• What are the benefits (upsides) to the treatment?
• Will it make me feel better or live longer?
• What are the risks (downsides) to the treatment?
• Are there any alternatives to the treatment?
• What will happen if I do not have the treatment?

You will need to come for regular checkups. You will also need some regular tests like a mammogram. The doctor will check you at each visit but you should also watch out for some new changes which could be signs of the cancer coming back.

Some examples are new lumps in the scar or breast area, pain in bones, chest or stomach, breathing problems or headaches and if you have any new symptoms you should inform your doctor.

Although most breast lumps are not cancer, you should always have the lump checked. Your doctor will examine you and you will need a breast ultrasound. Often a mammogram will also be done especially if you are over the age of 35 years. If there is any concern a biopsy will then be performed.

• Exercise regularly.
• Maintain a healthy weight.
• Limit alcohol intake.
• Avoid or limit the duration of hormone-replacement therapy.
• Planning to have a baby before the age of 30 and breastfeeding for at least six months can also reduce risk

Early diagnosis and screening

Many patients come with advanced cancers to our unit. There are all sorts of barriers that make their journey more difficult. Some are caused by the healthcare system and some by socioeconomic problems, lack of understanding of the disease and significant out-of-pocket transport costs.

Treatment of breast cancer is most successful when treating women who present early with small cancers.

Early diagnosis can be achieved by increasing awareness of the public as well as health care providers so that women recognize the signs of early cancer and healthcare professionals also recognize cancers and refer for treatment early. We are supporters of the Breast Course 4 Nurses program which trains nurses in breast care. We also hope that this initiative will offer information and make South Africans more aware about breast cancer.

There are different ways to screen for breast cancer. The aim of screening is to find a breast cancer before the woman has noticed a problem. Many high-income countries offer population-based screening programs which use mammograms to look for early cancers. We do not have population-based screening programs to date in South Africa. Plans are on the way to increase awareness and to use clinical breast examination as an initial screening method.

Clinical breast examination: This is a breast examination performed by a trained healthcare worker and helps to achieve an earlier diagnosis and treatment. All women over the age of 40 should have a clinical breast examination at least once a year. These can be done by trained nurses at clinics and doctors. Ask your clinic to examine your breasts when you visit.

Breast self-examination: All women need to know their breasts and should examine their breasts on a monthly basis.

Breasts change over the menstrual cycle, with pregnancy and with age. The best time to examine your breasts is after the period or at any time during the month if you are no longer having periods.

Technique is important:

1. Start by standing in front of a mirror. Are there any new changes? Put both your hands at your side and check your skin and nipples, the breast shape and dents.
2. Lift your hands above your head to check the lower part of the breasts. If your breasts are large you may need to lift them so you can see the skin under the breast.
3. Now lie down and lift your one arm above the head. This will flatten the breast and makes it easier to feel. With the other hand start feeling the breast in the area close to the armpit. You can move around the breast in circles to cover all areas. Then also feel under the armpit. You will need to bring down the arm to be able to relax the area and feel for lumps. You then switch hands and do the same on the other side. Always use the flat three middle fingers to feel. Don’t squeeze the breast between fingers as all breasts will feel lumpy like that.
4. If you have found any new changes always go and have it checked out.

In 90% of cases, the cause of a woman developing breast cancer is unknown. Most risk factors cannot be changed but some can be modified. Some of the known risk factors include:

• Gender: women are 100 times more likely to develop breast cancer than men.
• Age: the older a woman, the more likely she is to get breast cancer.
• Ethnicity: White women have the highest risk of developing a breast cancer.
• Family history: A history of breast cancer in a first-degree relative (e.g., mother, sister, or daughter) is only reported by 20% of women with breast cancer. Only about 5% of women have a gene abnormality (like a BRCA mutation). They can have a 40-70% risk of developing a breast cancer.
• Previous radiotherapy to the chest wall: patients who have had radiation for a lymphoma have an increased chance of breast cancer.
• Personal history of breast cancer: if a woman has had one breast cancer, she is at a higher risk than normal of developing another breast cancer.
• Having a personal history of having had a breast biopsy for other problems over the age of 40. -Hormone-replacement therapy.
• Lifestyle factors such as alcohol intake and physical inactivity.