I was considering material for this editorial on breast cancer in South Africa, while strolling around the streets of New York, after a whistle stop visit to some of the premiere breast cancer units in the USA. I wandered past the advertisement of The Lion King (proudly African) and thought about the circle of breast cancer management seen in the last half century, and how this has affected South African women diagnosed with the disease.
Fifty years ago, women’s movements and clinicians started promoting certain aspects of breast health that steadily gained momentum throughout the world. Now, it would seem that we have come full circle.
The first circle is that of breast cancer screening:
An emotive topic that has circled from no screening at all, to studies showing poor value and lack of success in self breast examination and clinical breast examination, to world wide acceptance of screening mammography from the age of 40 years and older. The 2012 New England Journal of Medicine states: November review created a stir and many heated debates resulting in a move back to self breast examination due to a perceived lack of success in screening mammography in actually altering breast cancer mortality.
Maybe, in a country like ours that cannot afford effective screening, we can lead the way with a reasonably balanced approach, awareness and teaching around breast examination, (particularly as 60% of cancers are diagnosed at sizes over 3cm), increasing the use of ultrasound guided core biopsy diagnosis, and the selective use of digital mammography and MRI.
South Africa still scores zero for the lack of acceptance of radiological guided core biopsies for breast cancer, and the significant overuse of surgical biopsy diagnoses as well as clinician-directed pressure into urgent and “emergency” mastectomy followed by adjuvant treatment.
The second circle is the move from the ablative mastectomies of the 1960’s to breast conserving surgery and radiation therapy: The Fischer/Veronessi trials show equal survival outcomes with breast conserving surgery versus mastectomy and paved the way for the breast conservation era. Initial problems around large excisions, resulting in poor aesthetics, drove the migration to pushing the aesthetics boundaries with the use of a variety of oncoplastic techniques like breast reduction reconstructions, local parenchymal flaps, larger autologous flaps, to the acceptance of closer margins to larger tumour size excision ratios. Now back to the current trend, according to the SEER data on mastectomies (including “prophylactic” risk reduction mastectomy) including prosthetic reconstruction and nipple saving techniques (Barbie breasts at all costs).
A full circle with many new questions as to why women are now electing to remove breasts, both affected and essentially normal breasts.
Is the answer as simple as our ability to reconstruct equal “Barbie breasts” or is it more complex? Do repeated mammograms and call backs and core biopsies, or over diagnosing of potential pathology on MRI scans, and clinician-driven suggestions play a role in the type of breast cancer surgery offered?
Does South Africa know that many good multi-disciplinary units stand divided once again with the line firmly drawn between those clinicians who insist on breast conservation and those that don’t?
Possibly, the rainbow nation colours should shine, and as there are many different colours, so there are many different options. We should realise that as long as safe cancer rules apply, women should have some say as to how their bodies are treated for breast cancer, to the understanding of the biology of cancer, from the Halstedian concepts of breast cancer. Researchers then focused on understanding the systemic nature and treatment of the disease as well as the genetic profiling of cancers.
We have circled from the early 1970’s understanding of the value of Tamoxifen (a not so simple SERM and other endocrine therapy) to the use of systemic chemotherapy therapy for almost all invasive tumours over 10mm in size. We now offer genetic profiling of cancers, resulting in less chemotherapy and more individualised treatment plans.
Possibly, the most modern circle is the understanding of the concept that any break in a chain results in a sub-optimal outcome.
Today, breast cancer management throughout the world, and in many centers in South Africa, has led the way with the concept of multi-disciplinary care, with many specialists participating in a combined approach to ensure better patient care. Doctors who specialise in radiology, pathology, oncology, surgery, and allied specialists (psychology, nursing) communicate and take time to ensure best patient care. The circle or wheel being the patient that can move on from a devastating diagnosis and drive the process to a united approach that ensures holistic patient care. Perhaps, we can host our next meeting at Pride Rock here in Africa…