A personalised approach to breast cancer treatment

According to Dr Marilize Truter, General Surgeon at Mediclinic Midstream, breast cancer carries a lifetime risk of 1 in 27 in South Africa, according to the 2020 National Cancer Registry. 

In terms of outcomes, Dr Truter explains that the five-year survival rate for women with cancer located only in the breast is 99%. This decreases to 86% if the cancer has spread to the regional lymph nodes and the 5-year survival rate for patients with breast cancer and spread to distant organs is 31%. Thus, early detection of breast cancer and presenting early for treatment, may result in more effective treatment, leading to a reduction in pain and suffering and a significant decrease in loss of life.

“Screening mammography is used in asymptomatic patients. The age you start with screening is determined by your risk to develop breast cancer. If your radiologist finds an abnormality or if you have exceptionally dense breast tissue, then he/she will recommend an additional breast ultrasound study,” explains Dr Liesel Devel, a radiologist based at Mediclinic Midstream. “Only patients at high risk of getting breast cancer (such as family history or prior cancer) will receive both mammogram and ultrasound studies.”

Several factors play a role in the management of a patient diagnosed with cancer. These include the type of breast cancer, the stage of the cancer (where it is and how big it is), the grade of the cancer (how fast it is growing) and other details about the cancer cells, such as the amount of DNA in them, the age and overall health of the patient.

It is also important to note that breast cancer treatment is not a one size fits all approach and should be individualised to each patient. Dr Nicolette Landman, Plastic and reconstructive surgeon, explains that the management of these patients cannot be done by a single specialist and a multidisciplinary team is key to better outcomes. At Mediclinic Midstream, each patient is discussed in a multidisciplinary meeting and a treatment plan formulated to provide the best possible clinical outcomes.

The question is which patients are regarded as high risk? According to Kelly Loggenberg, a Genetic Counsellor that forms part of this multi-disciplinary team, there are a few key factors when assessing family history. The age of diagnosis, the number of relatives diagnosed, and the type of cancer diagnosed will determine the level of risk. If a close relative has been diagnosed with cancer at a young age (under 50), or 2 or more relatives on the same side of the family are diagnosed with the same or related cancers (e.g. breast cancer, ovarian cancer, male breast cancer, young onset prostate cancer, pancreatic cancer) the risk may be considered increased. “In any of the above situations, you may want to consider a consultation with a genetic counsellor to assess the familial risk and ensure appropriate screening is in place,” she explains.

“A genetic counselling session would be advised for any individual who is concerned about their family history of cancer, as well as individuals who have been diagnosed with breast cancer, particularly if they meet any of the above criteria,” Loggenberg continues. “A genetic counsellor will take a detailed family history to enable an accurate risk assessment, determine if genetic testing is appropriate and discuss available options as well as make necessary screening recommendations based on the history of cancer in the family. If a genetic cause of cancer is confirmed, the result and implications thereof are discussed in detail, as well as considering options available to reduce risks going forward and implications for relatives.”

Radiation oncologist Dr Maritha Rossouw explains the treatment options available at Mediclinic Midstream: “Our team of specialists offers chemotherapy, radiotherapy, hormonal therapy, surgery as well as targeted therapy like Herceptin for patients with HER2 receptor positive breast cancer. The decision is made together as to the best individualised treatment for the patient.”

Dr Truter explains the process: “After being diagnosed with breast cancer when surgery is indicated, the patient can either have breast conserving surgery also called lumpectomy, which involves removing the part of the breast affected by cancer, or a mastectomy which involves removing all the breast tissue.” Depending on the clinical findings and imaging, it will then be decided if the patient is a candidate for a sentinel lymph node biopsy or an axillary dissection. When breast cancer spreads it spreads through one lymph node to more in the armpits. This first lymph node is called the sentinel lymph node. It needs to be assessed to determine the staging and prognosis, which will influence the further management.

In reference to the reconstruction, Dr Landman explains the options, “There are three main options for breast reconstruction surgery, where the patient’s own tissue is used to recreate the breast, a prosthetic reconstruction using an implant or a combination of the two, using the patient’s own tissue and an implant placement.”

The type of reconstruction a patient is best suited for remains very individual. Factors to consider include the type of mastectomy or cancer the patient had, whether the patient has had radiotherapy, the patient’s general condition as well as the size and shape of the remaining breast.

Knowing that there is an excellent team of specialists available to assist, early diagnosis remains vital to the best outcomes for patients. Dr Davel offers the following reassurance to patients that may have delayed a check-up due to fear during the pandemic, “At Mediclinic Midstream’s Radiology Department we take extra care to keep you safe. Appointments are prescheduled to save time and limit your potential exposure to the admin staff. Dedicated staff are assigned to the mammography unit to limit exposure and increase efficiency while minimising the time you spend in the unit. Our mammography units are diligently cleaned before and after every examination.”