By: Lunga Memela (Communication Engagement Lead)
A bouquet of scientific research, vaccine development debate, issues of equity, accessibility and overall public health enquiry has commanded global attention across industries as the novel coronavirus pandemic (COVID-19) took centre-stage over the past couple of months. But, lest we forget, equal effort still needs to be invested into other illnesses, such as preventing the upsurge of non-communicable diseases.
As #BreastCancerAwarenessMonth rapidly draws to a close, raising awareness about breast cancer prevention and the importance of its early detection amongst young and old males and females will remain critical and must be sustained.
To maintain momentum, Health Systems Trust (HST) interviewed some key role players who shared their insights and experiences, especially in view of the local South African context which remains in dire need of health systems strengthening through proactive research, community outreach, innovative thinking and health promotion.
We spoke to the President of the Association of Surgeons South Africa, Dr Ines Buccimazza who is also a Senior Specialist in the Department of Surgery at the University of KwaZulu-Natal's Nelson R Mandela School of Medicine and heads Inkosi Albert Luthuli Central Hospital's Breast and Endocrine Clinical Unit. She said breast cancer is the most common malignancy in women world-wide, including in South Africa – the global incidence is 24.2% and in South Africa 23.6%; the lifetime risk of an average South African woman (up to the age of 74 years) of developing breast cancer is 1:26.
"Whereas breast cancer is the most common cause of death in women globally (15%), it is the second leading cause of death in South African women (16%), after cervical cancer: annually 19.1% of South African women die as a result of cervical cancer. Thus, breast cancer is associated with a significant healthcare burden and it is imperative that the necessary resources are available to manage the large numbers that present to our healthcare facilities," she explained.
Buccimazza said there have been tremendous advances in the treatment of breast cancer, particularly in optimising treatment. "This 'de-escalation' of treatment does not mean that less therapy is given; on the contrary, the treatment is more tailored to the disease and thus can be administered with less morbidity. The caveat is that de-escalation is more applicable to early stage disease. Therefore, creating awareness helps to detect the disease at an early stage, when the treatments are not only more effective, but associated with less morbidity due to less invasive surgical, regional and systemic therapies."
"One way of detecting disease early is to be aware of its presence, [being] educated on how it presents and the methods of early detection. The latter falls is the preserve of screening programmes."
Her sentiments were echoed by Dr Laura Stopforth who heads the clinical unit of Greys Hospital's Oncology Department and doubles as acting Academic Head of Department for Radiotherapy and Oncology at UKZN. She added that, "Any stigma related to breast cancer is detrimental and unnecessary. De-stigmatising breast cancer also helps to combat stigma associated with other cancers."
Male breast cancer exists
This brought us to the topic of male breast cancer which, while considered rare (accounting for only 1% of all breast cancers), it must be noted that men also have breast tissue, and male breast cancer usually always presents at an advanced stage in our setting. "Unlike female breast cancer, where early stage breast cancer is seen in around 40% of patients locally, the diagnosis of early breast cancer in males is very unusual. This is largely due to the fact that very little breast tissue is present in males; undiagnosed cancers continue to proliferate in the minimal breast tissue and eventually ulcerate through the skin," Buccimazza explained. "These differences aside, the diagnosis, management and prognosis of male breast cancer, stage for stage, is similar to that of their female counterparts."
Breast cancer prevalence in young women
"Although uncommon, breast cancer does occur in young women (<40 years). It presents and is diagnosed in a similar manner as in older women, but the treatment plan has to consider fertility and long-term health matters," Buccimazza advised.
"Certainly, in families where there is a suggestion of a hereditary predisposition for breast cancer (multiple [3 or more] first degree members; two successive generations; affected member(s) under the age of 50 years), the awareness in family members of all ages and genders should be heightened and clinical assessment mandatory to exclude a genetic mutation that may be transmitted across generations."
On doctor-patient relationships
Early detection is key because it enables early intervention which weighs less on medical professionals too. "The management of breast cancer is multimodal, sequential treatment that spans many months and, in some cases, (those with endocrine-responsive tumours) many years. As surgeons, our involvement commences with diagnosing the cancer and continues over the initial phases of treatment. A relationship of trust is forged with the patient and family during this time. Being empathetic while remaining emotionally detached in order to retain objectivity, is difficult."
The South African context
Another challenge highlighted was that most South African patients are socio-economically disadvantaged and every visit to the hospital incurs an expense many cannot afford. "It saddens me that the healthcare system in the state sector is not designed to fast-track all the investigations upfront and that there are no social support systems to aid patients financially. Many patients simply default their treatment and never return. We unfortunately do not have the resources to track all these patients nor the means to aid them financially."
Breast examination by trained nurses are available at clinics, community health centres and hospitals, as well as training on how to perform a breast self-examination, Stopforth highlighted. "Whilst not as sensitive in detecting breast cancer as mammograms, they are easily accessible and a reasonable second-best option."
It was even more encouraging when Hlengiwe Madonsela shared her lived experience as a breast cancer survivor. Born in Marrianhill, Durban and now one of HST's very own Psychosocial Advisors, growing up, Madonsela could have never imaged that one day she would get diagnosed with breast cancer in addition to other chronic illnesses. It was in May 2019 when the doctor confirmed the news after Madonsela had done a self-check and discovered a lump in her breast. The healing process, which led her to undergoing chemotherapy and a mastectomy, has not been easy. She stressed that early detection is key, and that having a good support system at home and at work really goes a long way.
"The clinics do teach women's health – nurses hold health talks, there are posters on the walls etcetera, so it's important that we continue raising awareness to avoid ignorance and promote prevention," Madonsela said.
Fortunately, there is breast cancer custodianship across provinces in South Africa with initiatives such as the Pink Drive and the Cancer Association of South Africa (CANSA) who do arrange mobile cancer screening and they can be contacted to determine when and where their next screening event is being held.
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