BreastHealth 201905

Disclaimer
“What women should know: A book about breast

health” is not a substitute for personal medical
attention. Any application of the information
provided by the authors is at the reader’s
discretion and sole risk.
Always consult your medical practitioner before

embarking on any diagnostic, therapeutic or
complimentary health programme.
The publisher shall not be held responsible for

any loss occasioned by any cause whatsoever.
Contents
Preface i
About the author ii
Introduction ii
Benign breast problems

What is this lump I feel in my breast? 1 Thrush 12
Solid masses 3 Non-lactational breast abscess 12
Cystic masses 7
When is it normal to have painful 13
I have an infection in my breast... 9 breasts?
Help! When is a breast pain not a breast pain? 15
Lactational breast abscess 11 What is breast pain then? 17
Breast cancer
Who gets breast cancer? 33 Clinical breast examination 48
What is cancer? 35 Mammogram 48
Is breast cancer common? 35
Who gets breast cancer? 35 When should I start checking for 49
How treatable is breast cancer? 36 cancer?
Do chances of survival drop if caught later 36 You are at average risk of breast cancer if: 51
and if so, by how much? Screening guidelines for average risk 51
patients
What is my risk of developing 37 You are at above-average risk of breast 52
breast cancer? cancer if:
Risk factors that cannot be controlled 39 Screening guidelines for above-average 52
Risk factors that can be avoided 40 risk patients
Cancer runs in my family... Does that 41 What are the symptoms of breast 53
mean I will get it? cancer?
Faulty genes in my family? 43 If you have breast cancer, will you feel 55
What should I do if I have a family history 44 a lump?
of cancer? Is breast cancer painful? 55
Family counselling and genetic counsel- 44 Is a nipple discharge normal? 55
ling services What changes in the nipple are related to 56
breast cancer?
How can I check for breast cancer? 45
Ultrasound 47 How is breast cancer diagnosed? 57
Magnetic resonance imaging (MRI) 47 What will happen when I am seen by a 59
Breast self-examination 48 doctor?
Changing your life

Can I avoid getting breast cancer? 99 What is a healthy lifestyle? 105
Why is a healthy diet and lifestyle 101 What is good for you? 108
important? What is bad for you? 108
Why are regular mammograms impor- 102
tant? What about supplements for breast 109
Myths: what causes breast cancer? 103 health?
Evening primrose oil (EPO) 111
Picture credits 117
How can I treat this pain? 19 I was born with it... 27
Would surgery help? 20 Nipple inversion 29
Accessory breasts 29
Does it fit? Getting some support... 21 Amazia 30
Your bra doesn’t fit properly if: 24 Breast enlargement in the baby 30
Your bra will fit properly if: 26 Prepubertal breast development 30
What is a triple assessment? 60 What are the side-effects of breast 79

How soon will I be told if it is cancer? 61 cancer treatment?
Breast cancer staging 61 Side effects of breast cancer surgery 81
Side effects of radiation treatment 82
Can breast cancer be treated? 63 Side effects of chemotherapy 83
What treatments are available? Side effects of hormonal treatments 84
Chemotherapy 66
Receptor-dependant treatment 67 What about breast reconstruction 85
Radiation treatment 68 surgery?
Surgery 69 When do we do reconstruction? 88
How do we do reconstruction? 88
Can I afford to be treated? How 71
will I support my family? Can a man get breast cancer? 89
I haven’t got medical aid. Now what 73 Who gets it? 91
do I do? What type of breast cancer do men get? 91
Navigation of medical aids 73 How do we investigate it? 91
Cancer policies 73 Treatment 91
Disability cover 73
Estate planning (making a will) 74 Where can I get help and support 93
Saving now for the future 74 about breast cancer?
Take your time 95
Will I cope if I get cancer? 75 Get a second opinion if you want one 96
What about my family? 77 Read around the subject wisely 96
Get support 96
Folic acid 111 Are there other cancers I can be 113

Vitamin B6 111 screened for?
Green Tea or Green Tea extract 111 I am a young woman (19-39) 115
Indole-3-Carbinol 111 I am in my middle age (40-49) 115
Grape Seed extract 112 I am a mature woman (50-65) 116
Rooibos Tea 112 I am older and wiser (above 65 years) 116
i Things women should know - A book about breast health
Preface
Platinum Life is very excited to introduce our improved “What women should know:
A book about Breast Health”.
Prof Carol-Ann Benn is a specialist surgeon with a wealth of knowledge and experience
in the field of breast health. Her passion is ensuring access to healthcare that is multi-
disciplinary and holistic.
This book, written for all women, aims to give the reader relevant information about
topics from breast health to both cancerous and non-cancerous breast conditions.
Breast cancer affects the lives of all, from the patient to the family. Breast cancer is
neither ageist, racist or sexist and can affect anyone. The incidence has increased and
it has become one of the most prevalent cancers amongst female South Africans today.
Throughout the project’s development, Prof Benn has emphasised the importance of
education. Too often people postpone doctor’s visits for a variety of reasons.
Early detection is directly linked to a better chance of survival, and so it is of the

utmost importance to know your own body, do regular breast self-examinations and
go for scheduled screenings. Moreover, making more informed decisions about diet,
medication and exercise will improve one’s overall health and life expectancy.
There is a vital need in our society for health education. This booklet aims to bring
women and their families up-to-date on all aspects of breast health, and in doing so,
help fulfil this need.
We hope that you will find this booklet informative and that it will help you understand
the importance of maintaining healthy breasts!
Kind regards,
Liesl Matthews
Director
Introduction & About the author ii
Introduction
I am thrilled to be involved in this book and to have the opportunity to share knowledge
and interest in breast health. It is important that every woman understand her body and
“know her breasts”. From young to old, all women will experience a breast symptom.
Knowing your breasts, their size and shape, is critical to ensuring early detection of all
breast health concerns.
Everyone is scared of becoming ill, so when they do, it is natural for a person to want
to fully understand their specific disease or health concern. Women in South Africa
are strong and independent and, once they have the knowledge and understanding of
breast health and breast problems - from simple pain and infections to more complex
diseases like breast cancer - they then have the power to take an active part in the healing
process rather than remaining passive victims. It is your body, so by using the information
enclosed you and your loved ones can partake in decisions affecting health and future
well-being.
The more women know about and understand the potential risks and concerns of breast
health and treatment options for breast problems, the better the health outcomes and
survival rates are. What women should know first and foremost is that it is your body
and you are the most important person in taking responsibility for your health. Never
rush into “emergency breast surgery”; take a friend with you to consultations, ask for
explanations from your treating medical teams and go for second opinions. Be aware
that breast cancer can affect any woman regardless of age or race and that most women
who get breast cancer have no recognizable risk factors. This is why the information in
this booklet is so important. In addition, it is vitally important for women, once educated
about their breasts, to then be willing to educate one another, create awareness of
such diseases within their communities and support each other when they experience
problems or become ill. It is through initiatives such as this book that we hope this will
happen.
Enjoy reading this book and learning more about breast health. Take the information you
learn in this book and share it with others - your work colleagues, your family and friends,
and, ultimately all the women of South Africa.
About the author

Prof Carol-Ann Benn is aspecialist surgeons with an interest in breast health.
They work at both the Helen Joseph Breast Unit and the Netcare Breast Care
Centre in Johannesburg and also lecture at the Department of Surgery at the
University of Witwatersrand. Their primary aim is to work towards educating
healthcare professionals as well as the public about breast health.
benign (bēnīn´),
adj. Of no danger to health, especially relating to a tumorous
growth; not malignant.
The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company.
1 Things women should know - A book about breast health
Most breast lumps are not breast cancer and non-cancerous lumps
do not develop into breast cancer. The safest approach to all breast
lumps is to always have them examined by a medical professional
because no matter how often you examine women’s breasts
as a doctor or check your own breasts as a patient, it cannot be
assumed that a lump in the breast is of no concern. We do not have
eyes on our fingers which is why a clinical examination must be
followed with a simple, non-threatening, non-painful investigation
called an ultrasound or breast sonar (done by a radiologist, with a
mammogram for women if over the age of 35 years) The ultrasound
(sonar) can determine what the lump is.
In the past we used to categorise breast masses according to the

age groups in which they occurred. A far safer approach is to look
at how breast masses appear on an ultrasound (breast sonar). We
want to emphasise that this is the safest and most effective way to
determine whether a lump in the breast is cancerous or not. If a
doctor or patient is really concerned a triple assessment comprising
of a clinical examination, sonar and/or a mammogram as well as a
core needle biopsy will confirm what the lump is.
"The safest approach to all breast lumps is to
have them examined by a medical professional."
Solid Masses
Fibroadenoma If the fibroadenoma becomes
painful, if it gets bigger than 3
A fibroadenoma is a highly cm (i.e. a giant fibroadenoma)
mobile, round, smooth, firm or if you are worried about it,
lump usually found in the it can be removed with surgery
breast of younger women e.g. via an incision around the nip-
teenagers and women in their ple or base of the breast. Re-
early twenties. It is sometimes member that surgery leaves
called the ‘breast mouse’ be- both scars on the skin and
cause it is mobile and appears in the breast tissue and can
to ‘run’ from the examining make breast investigations
performed later in life more Fig. 1.1: Illustration of typical
hand. These lumps do occur fibro adenoma.
in older women though not difficult to interpret.
commonly. Fibroadenomas
come from the lobules (milk If you already have a fibroad-
tissue) and are sensitive to fe- enoma and are pregnant, you
male hormones like the other can expect the size of the fi-
breast tissue from which they broadenoma to vary slightly
develop. during pregnancy and lacta-
tion, but this will not interfere
Most fibroadenomas are felt with breastfeeding or milk
when they reach a diameter of production. Calcified fibroad-
around 1-2 cm, and can grow enomas are sometimes found Fig. 1.2: Advanced case of
to more than 5 cm. Women in elderly women as a hard, fibro adenoma.
who have one fibroadenoma mobile lump that can be easily

often go on to find more of seen on a mammogram.
them when they start look-
ing in both breasts, however
this is not a major concern.
A fibroadenoma cannot be-
come cancer, neither do they
increase your risk of getting
cancer. Once a doctor has con-
firmed your lump is a fibroad-
enoma using ultrasound and Fig. 1.3: Sonar of fibro
adenoma.
a core needle biopsy, it can
be left alone. Some may even
disappear spontaneously. Re-
member that a clinical exam
should be initially followed by
an ultrasound.
Benign Breast Problems: Solid Masses 4
Phyllodes Tumours There are no identified risk fac-

tors for having a phyllodes tu-
Phyllodes tumours (PTs) take mour, nor does there seem to
their name from the Greek word be strong genetic predisposition.
‘phyllon’ which means ‘leaf’ be- Unlike breast cancer which arises
cause of their leaf-shaped growth from the glandular elements of
pattern. Their other plant-like the breast, these are tumours
behaviours is their ability to leave that arise from connective tis-
roots and reoccur. Unlike fibroad- sue within the breast tissue.
enomas, phyllodes tumours Malignant phyllodes tumours
don’t form a neat shell around don’t spread like breast cancers
the outside of the tumour, but to lymph glands and usually just
instead grow into normal breast recur locally, but the more ag-
tissue. This means that when gressive tumours can spread to
they are removed with surgery, the lungs and liver. Some can be
a rim of normal breast tissue has so large (up to 30 cm in size) that
to be removed as well to ensure complete removal of the breast
everything has been removed. If and part of the chest wall may be
this is not done, little bits of the required.
tumour may remain in the breast Fig. 1.4: Sonar of a Phyllodes
and, like the roots of a weed, they Because doctors don’t encounter tumour.
will cause the lump to grow back, phyllodes tumours frequently,
often more aggressively than they are often misdiagnosed as
before. benign fibroadenomas. Breast
masses should never be brushed
Phyllodes tumours do have a off as ‘harmless fibroadenomas’
risk of recurrence even if they and that is why most diagnoses
are benign (non-cancerous), but today should only be undertaken
they also have a risk of spreading by a specialist radiologist with the
or recurring if malignant (cancer- use of an ultrasound and guided
ous). The type of tumour and core needle biopsy.
its risk of recurring or spreading
(metastasising) can only be deter- Any features on an ultrasound
mined once it has been removed that are not typical should result
and examined microscopically. in a core needle biopsy, which in- Fig. 1.5: An advanced Phyl-
Once the grade of a phyllodes volves a small biopsy done under lodes tumour.
tumour is established, you may local anaesthetic. All masses, ir-
need to undergo a second surgi- respective of diagnosis, should be
cal procedure to ensure you have followed up 3 or 6 months later
a clear margin of disease-free tis- by an ultrasound. Furthermore,
sue of 1-2 cm, followed by recon- any masses that grow, or are
struction. Reconstructive options larger than 3 cm, should always
depend on factors such as breast be surgically removed/cut out.
size and patient choice, varying
from breast reduction to other
more extensive options.
Solid Masses
Fat Necrosis
Severe injury to the breast (e.g. from a
motor vehicle accident or being punched
in the breast) can cause fat necrosis. It
can also occur after some breast reduc-
tion operations. The problem with fat ne-
crosis is that it feels like a hard, irregular
lump, which mimics breast cancer. The Fig. 1.6: Sonar of fat necrosis.
only way to tell the difference is through
a mammogram and core needle biopsy.
There is no treatment required for this
problem and surgery is not advisable.
Once the investigations have confirmed
that the lump is fat necrosis, all that is
needed is reassurance and monitoring it
to see that it doesn’t get bigger or change
its shape.
Fig. 1.7: A severe case of fat necrosis.

Benign Breast Problems: Solid Masses 6
Breast Hamartomas Fibroadenosis

(and cyclical breast pain)
Also known as fibroadenolipoma. This
is not a common breast lump and can Breasts alter cyclically with the differ-
therefore go unnoticed or unrecog- ent stages of the menstrual cycle. In the
nised by most doctors. Hamartomas of week prior to menstruation the breast
the breast are normally painless breast normally increases in size and sometimes
lumps which are softer and larger than becomes nodular and painful therefore
fibroadenomas. These lumps have been mimicking a breast mass.
likened to a ‘breast within the breast’
because they contain all the same types This is normally called ‘fibroadenosis’
of tissue found in a breast. This may ac- This term may be confusing and mislead-
count for some diagnostic confusion ing at times as it represents what is go-
especially if a Fine Needle Aspiration ing on inside the breast at a tissue level,
(or an FNA) is performed, because the but the process is normal. Breasts are
cells that make up the breast tissue are uniquely different to palpation - some
difficult to differentiate from abnormal are smooth, and some are nodular, and
cells. It is usually possible to confirm di- the term should not be used as if this is
agnosis with a core biopsy rather than abnormal or a disease of the breast.
an FNA. On a mammogram, these lumps
have a distinct picture showing a visible All breasts have a certain amount of fi-
lump separated from the normal breast brosis (connective tissue) and adenosis
tissue by a thin white margin. They are (gland or milk tissue) and disease should
often missed on ultrasound as they have not be attributed to a woman with these
the same density. If a clinical examina- types of breast symptoms. If concerned,
tion and core needle biopsy do not fully a breast ultrasound can aid the clinician
explain the lump, surgical removal is rec- in determining whether this is a mass or
ommended. just nodularity.
Fig. 1.8: Sonar of hamartoma.

Cystic Masses
Breast Cysts
Breast cysts are masses that might feel
like lumps but are actually just fluid-filled
sacs within the breast. No one knows
exactly why they form. It can be due to
the hormonal or structural changes in
the breast that happens naturally as
people age. Cysts occur in about 5% of
pre-menopausal women in the years
after childbirth and breastfeeding (35
to 50 years). Cysts might be single or
multiple, and often they are only picked
up on a mammogram or sonar. There
are 3 types of cyst; simple cysts (clear);
complicated cysts (with murky fluid) and
complex cysts (which have a growth on
Fig. 1.9: 51-year-old female patient’s sonar of breast cyst.
the wall). Cysts is do not cause cancer nor
become cancerous. They are easily diag-
nosed using sonar (ultrasound) and can
be aspirated with a fine needle (FNA).
The fluid drawn from this type of cyst is
usually yellow (simple cysts) or green-
ish (complicated) in colour. Simple cysts
require no treatment; complicated cysts
can become infected and may require
antibiotics and needle drainage.
Blood (red or black) in this fluid or com-

plex cysts (residual lump remaining after
the aspiration), requires further treat-
ment. If there is blood or a residual lump,
further evaluation is mandatory. This
takes the form of sending the aspirate for
cytology (it is a good principle to send all
aspirates for cytology) and then to biopsy
Fig. 1.10: Same 51-year-old female patient. MRI of the residual mass, if present, under ra-
breast cyst.
diological guidance. Surgery for complex
cysts may be necessary.
Benign Breast Problems: Cystic Masses 8
Galactocele
This is simply a cyst, found only in breastfeeding women, that contains retained milk but
has no signs of bacterial infection. It can be treated by needle aspiration of the cyst and
suppression of milk. Surgical excision can also be performed if necessary, though this is not
a very common practice.
Fig. 1.11: Infected galactocele gland. Fig. 1.12: Severe case of infected galactocele gland.
Breast infections most commonly affect women

between the ages of 18 to 50 years and can be
divided into infections related to breastfeeding
and those that are not (non-lactational abscesses).
It is important to treat any infection of the breast
early and correctly so as to ensure that it does not
develop into more serious problems. As with all
diseases of the breast, it is also important to make
sure a cancer is not missed.
"Breast infections are common."

Breast Infections
Lactational Breast Abscess cedure in order to drain the infected fluid
out of the breast.
This is a localised infection in the skin
and tissue of the breast that is caused
by bacteria which can enter the breast
through a crack or fissure in the nipple.
It commonly occurs in the second to fifth
week of breastfeeding when a mother
is still getting used to the breastfeeding
procedure. Milk retention and stasis can
make the problem worse. The breast
may become hard and swollen in its en-
tirety or only in one area, and it is pain-
ful to breastfeed or even to touch the
breast. When the breast is swollen like
this, it is called mastitis. This can be ad-
equately treated with antibiotics. During
this phase, frequent expression of milk
will help prevent stasis and progressive
infection. Cabbage leaves kept cold in the
fridge and then applied to the breast may
also provide relief from the discomfort.
Milk must be expressed from the in-

fected breast and, if the mother wants
Fig. 1.13: Prolactin and Oxytocin regulation during
to continue to breastfeed, the baby can lactation.
continue to feed from the other breast. If
the mother wants to stop breastfeeding,
lactation can be suppressed with fluid re-
striction and medication.
As the infection develops, if left untreat-

ed, it can form a collection of infected
fluid which can then cause even more
pain and sometimes a bulge in the breast
(known as an abscess). The current
recommended treatment is high-dose
antibiotics (Co-amoxiclav is the drug
of choice and is safe in breastfeeding Fig. 1.14: Severe case of a lactational abcess.
mothers) as well as repeated ultrasound-
guided aspiration. In this day and age, it
is uncommon to resort to a surgical pro-
Benign Breast Problems: Breast Infections 12
Thrush manage treatment of these scesses this infected fluid

infections, particularly in collection will not resolve
Thrush can also affect the patients who have HIV. on antibiotics alone but
lactating breast, causing can be managed with the
burning, shooting pains Breast cancer can also pre- use of high dose antibiotics
during breastfeeding and sent looking like an abscess (Co-amoxiclav is the drug
sore patches on the nipples or mastitis. This is called of choice if no penicillin al-
(as well as a paler areola). inflammatory breast cancer lergy is present) as well as
The difficulty with thrush is and accounts for 2-5% of repeated. Superficial skin
that it can be passed from breast cancers. No infection infections (boils, sebaceous
the baby’s mouth to the should be ignored, and all cysts and recurrent skin
mother’s breast (usually infections should be looked abscesses) can also occur
the cause of the infection in at by a breast specialist who in the skin over the breast,
the first place) and, as the will be able to optimally di- but these are not related
mother continues to feed agnose and treat unusual to the breast tissue and are
the baby, it can be passed causes. not breast cancer. Unusual
back to the baby again. It types of breast infections
is very important that the Non-lactational that require treatment in
mother and her baby are Breast Abscess specialist centres are granu-
treated at the same time, lomatous mastitis (which is
for long enough to ensure Breast abscesses can also an inflammatory condition
the infection is completely occur in women who are that presents with abscess-
gone. Thrush can be treat- not breastfeeding. They es in different parts of the
ed with fluconazole (Diflu- may occur around the nip- breast repeatedly. Diabetic
can) tablets and an antifun- ple as a result of chronic mastopathy is when diabet-
gal cream for the nipples. inflammation and active in- ic (usually insulin depend-
fection around the central ent diabetics) get repeated
Ultrasound-guided aspira- ducts of the breast beneath hard, inflamed breast mass-
tion. This is followed in the nipple. This is a result es. The above conditions
certain complicated cases of duct ectasia, a widen- respond to a medicine that
by surgical drainage with ing and thickening of the is used for asthmatics called
biopsy of the abscess wall, ducts due to inflammation montelukast.
but should not be per- (and very often also due to
formed outside of a special- smoking).
ist breast centre.
Less frequently an abscess As the infection develops
can be caused by an under- from mastitis, a collection
lying infection such as TB or of infected fluid forms in
the presence of HIV/AIDS. It the tissue along with sur-
is important to be treated rounding swelling. The skin
in a specialist unit that can may become thin or flaky.
Fig. 1.15: Severe case of a non-
adequately diagnose and Just like in lactational ab- lactational abcess.
Pain in the breast is a frequent complaint. All women will experience

breast pain at some stage in their lives, but some women are unfortunate
enough to suffer from constant or repeated episodes of breast pain.
When breast pain becomes so excessive that it begins to interfere with
the patient’s lifestyle, for example making it difficult to wear seatbelts or
having difficulty with sexual intercourse, it is known as mastalgia.
For most women breast pain is something that is experienced just prior
to the menstrual period or may be felt as an occasional twinge, but it
does not feature heavily in our lives. Importantly, breast cancer presents
with pain in less than 10% of cases and this will usually be a constant
pain associated with a lump. Even if there is no mass, but a constant,
localised pain, a mammogram or sonar should be obtained. Only 2% of
these cases will be due to cancer.
Trying to treat or cope with breast pain is often very frustrating. Most
textbooks describe breast pain as cyclic or non-cyclic depending on
whether it is related to the menstrual cycle or not. Two thirds of breast
pain are cyclical and caused by the changes in hormones in our breasts.
The rest is non-cyclical, of which one half is related to the bones and
joints beneath the breast. Unfortunately, it is difficult for women to
differentiate between these symptoms. All patients presenting with
breast pain should have a thorough history and clinical examination
with an ultrasound, and a mammogram if over 40.
It is easiest to approach pain according to the symptoms and

type of pain. Sometimes women may have more than one type of
pain. Sometimes it is only by treating the pain that its cause can be
determined.
"Breast cancer presents with pain in less
than 10% of cases."
When is a breast pain not a breast pain?
When it doesn’t come from the breast.
Nearly one fifth of all breast pain actually has nothing to do with the breast at all,
for example:
cardiac problems (heart related), especially with left-sided, pressing breast pain.
respiratory problems (lung problems such as pneumonia or pleurisy), often breast pain
that is worse whilst breathing.
gastro-intestinal problems (reflux heartburn), which might cause pain that wakes you
at night or when you are lying flat.
rib inflammation (costochondritis/ inflammation of the costal cartilage), which feels
like pinpoint pain on either side of the breast.
shingles (herpes zoster infection), causing an incredibly painful rash from the back to
the front.
Benign Breast Problems: When is breast pain not breast pain? 16
Fig. 1.16: Shingles on the back of a patient.
Fig. 1.17: In this close-up of the Shingles rash you can see that the rash develops into
blisters, similar to those of chickenpox.
What is breast pain then?

True breast pain can be divided into 5 types:
1 2 3
Isolated medial and
Burning shooting pains lateral pain on pressure
(chest wall pain)
These types of pains, par-
ticularly around the nip- This is known as costo-
Lateral pulling pain ple and associated with chondritis or Tietze syn-
an itchy feeling, can be drome, and accounts for
This is a pain that extends due to duct ectasia. This 10% of breast pain. Men
from the armpit towards is a dilatation or widening and women both suffer
the nipples along the sides of the small milk ducts. from this complaint but,
of the breasts. It is nor- These breast ducts are because the breasts are
mally more common in lined with very fine hairs above these joints, most
big-breasted women. and inflammation in the women perceive the pain
ducts is similar to asthma as breast pain. The pain
The breasts hang from or emphysema in the is localised to the breast
the pectoral muscle in a lungs. It causes debris to and feels like particular
fine, fibrous coating. Im- be trapped in these fine tenderness over the cos-
agine the muscle as a coat hairs, increasing the risk tochondral junction (the
hanger and the breast as of infection. The causes of ribs under the inner part
a heavy jacket hanging on duct ectasia are smoking of the breasts). The actual
the coat hanger. The coat and pollution. Patients can cause is not known but
will drag on the hanger experience burning dis- may be due to a viral infec-
and, in the same way, the comfort in the breast and tion or may be related to
breasts pull on the attach- occasional shooting pains. or exacerbated by exces-
ments below. This pain is Some complain of hot pok- sive muscle strain (sport).
usually worse at the end ing pains in the breast. Treatment is to abstain
of the day and is related to from doing the implicated
poor fitting bras which will Topical antibiotics dabbed sport for a few weeks and
not support the breast ad- on the nipples may help take NSAIDS (non-steroidal
equately from below. for this type of pain. anti-inflammatory drugs).
Benign Breast Problems: What is breast pain then? 18
prolactin levels. Women

who are patients in inten-
sive care units also have
4 5
raised prolactin levels.
Prolactin is a fascinating
hormone which is difficult
to “switch off” once acti-
vated. Transient increases
in prolactin may not be
reflected in blood levels
tested but may result in
Full, heavy uncomfort- a full, heavy discomfort
able breasts in the breast. Women
who have breastfed say
(Feels like one needs to the pain is similar to the
feed a baby.) This type of discomfort experienced
breast pain is hormonal when the breast is full of
and is most commonly milk. It is important to
caused by a change in the check thyroid function,
female hormone levels in as an underactive thyroid
the breast. It can be cycli- causes similar breast dis-
cal and related to the men- comfort, and consider any
strual cycle, or non-cyclical medication (such as some
and may be related to a anti-depressants) which
hormone called prolactin can affect prolactin levels Mondor’s disease
(a stress hormone). Most as well.
commonly the change in Mondor’s disease is a
the breast tissue around Conventional pain medi- rare and unusual cause
the time of your period cation does not work very of breast pain associated
increases the amount of well for this type of breast with a cord-like structure
blood in your breast as pain. Successful manage- running over the breast.
well as the amount of wa- ment of this breast pain It is pain in the lower or
ter retained by the breast. depends on understanding lateral aspect of the breast
This can make the breasts the cause and trying even- from a thrombophlebitis
feel heavy and full, causing ing primrose oil and vita- (inflammation of a vein)
pain down the side of the min B6 combinations as crossing within the breast
breast, and throughout. the first line of treatment. tissue. Anti-inflammatory
drugs (NSAIDS) and as-
When the pain is not re- Fibroadenosis is not breast pirin may give relief. This
lated to the menstrual pain. It is a lumpiness seen unusual condition can be
cycle, it may be caused by in the breast confirmed by associated with an under-
stress (either physical like a needle biopsy. However, lying breast cancer, so it is
chronic disease, emotional a large number of women important to ensure ap-
or mental) which results in with lumpy breasts do propriate breast investiga-
transient changes in the have frequent breast pain. tions before treatment.
What is breast pain then?
How can I treat this pain?

First determine what kind of pain it is and bear the following principles in mind:
If your breast pain does not settle, please see a
general practitioner or specialist with an interest in
breast health.
Ensure that you have been for age-appropriate inves-
tigations such as an ultrasound and/or mammogram
and any necessary blood tests.
If your breast pain is affecting your day-to-day life, try
recording your breast pain on a pain chart for four
months. This way, you can notice the variations in
pain intensity over the menstrual cycles for exam-
ple, which may help your treating doctor identify the
cause.
Poorly fitting bras or old bras, combined with large
breasts, may result in pain under the breasts and
down the side of the breast, particularly as the day
progresses and gravity takes its toll on the breast liga-
ments.
Medications that can be tried at home include vita-
min B6 (pyridoxine) and gamma linolenic acid (GLA,
evening primrose oil). GLA in particular tends to sta-
bilise breast epithelial activity via hormonal metabo-
lism. The required dose of evening primrose oil is 2-6
capsules daily and should be taken in combination
with vitamin B6. Treatment should be continued for
a minimum of 3 months. In some studies, over 70%
Alternative contraceptive medication may solve of patients had a good response.
the issue of breast pain - consult your doctor.
If you are on the contraceptive pill, or a suitable can-
didate for it, your doctor may suggest an alternative
contraceptive pill after checking the relevant tests.
Benign Breast Problems: What is breast pain then? 20
Previously, breast pain was treated with Would surgery help?

strong hormonal manipulative medica-
tion such as danazol or bromocriptine. Breast pain that does not respond to any
However, the side effects of these drugs treatment should never be treated with
(weight gain, growing facial hair) often surgery. After all, a doctor does not treat
outweigh the benefits. a headache by chopping off the patient’s
head! Even after surgery, 50% of women
Breast pain that does not respond to who have breast surgery for breast pain
supplements may be treated with low continue to have continuous pain post-
dose anti-oestrogen medicines such as surgery. The only type of breast pain that
tamoxifen or Fareston (although these is improved by surgery may be the lateral
do not have FDA approval in the USA pulling pain felt mostly by large-breasted
for this use). Tamoxifen taken orally at women where a breast reduction might
very low doses is incredibly useful in pre- be beneficial.
menopausal women. Alternatively, some
studies suggest crushing these SERMs Remember that breast pain with an as-
and mixing them in KY jelly, then applying sociated normal mammogram is almost
them topically to the breast tissue. never associated with breast cancer.
In post-menopausal women, a related
drug called raloxifene (Evista) works in
a similar way and may help decrease
breast pain. This medication may have
the added benefit of decreasing the risk
of breast cancer, as will tamoxifen.
It is estimated that 80% of women are wearing the wrong size bra.
Is this you?
Wearing the wrong size bra 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 too shy to look for the correct size 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 a large portion of the breast
hanging down on the skin below the breast causing an area of
warm moisture to form through the day. This results in an excellent
breeding ground for bacteria and fungi to grow - often seen as a
white or red discolouration under the breasts. This can eventually
lead to darker discolouration, (pigmentation). An inappropriately
tight bra can also cause problems, such as constriction of the
respiratory muscles (the muscles that help us breathe) causing not
only breathing problems but back and shoulder aches too.
"Approximately 80% of women wear the
wrong size bra... Are you one of them?"
Getting the right fit...

Benign Breast Problems: Does it fit? Getting some support... 24
your bra doesn't fit properly if:

The underband at the back is riding up:
If the underband pulls 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 your
band is too loose, the straps will dig into your shoulders and you will 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 parallel to each other but stretch outwards:
This normally means that your underband is too tight and is overstretch-
ing 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 be-
cause 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.
Getting the right fit...

Benign Breast Problems: Does it fit? Getting some support... 26
your bra will fit properly if:

...you follow this easy plan:
Get some help:
Most lingerie shops and department stores offer a bra-sizing service and
you should take them up on it. This is usually an obligation-free service.
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 items that are worn
most often in your wardrobe, yet it’s the one item women are most reluc-
tant to spend money on. Spoil yourself and your bosom!
If you want to have an idea of your size before you shop:
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 under-
neath your breasts. Take a deep breath in and pull the measuring tape
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 underband size. The underband size is commonly what is known
as 32;34;36;38.
Next, measure around your chest, over the fullest part of your breasts
(normally at the nipples) when you are wearing a bra. Record this meas-
urement (e.g. 38 inches) and subtract this measurement from your un-
derband size (38 – 36 = 2). This will correspond to the cup size you should
try first.
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. Once you’ve meas-
ured your bust, you should then shop around and try on sizes one above
and one below the size you have measured. As you adjust the underband
size up (e.g. 36 to 38) come down by one on the cup size (e.g. 36D down to
38C). Not all bra styles will suit all breast shape, so it may take some time to
find a bra that suits and fits you. When you do find the right bra, it should
be comfortable and not dig into your skin anywhere. It should support your
breasts well and give you a good shape. A good bra can give you as much
shape and lift as expensive plastic surgery!
Every woman is different in her personality, her looks,

her shape… and her breasts. Breast size and shapes are
all different including difference in size of each breast
Occasionally a person can be born with an abnormality of
the breast. Most of these do not require surgical correction.
"Every woman's breasts are unique."

Breast abnormalities from birth

Nipple Inversion Accessory Breasts
The nipple may fail to evert at puberty This is a common condition and, if you
giving rise to an inverted nipple. This is look carefully, you might even have it!
a common condition and not abnormal. (One in five women does).
It is most often bilateral. If there are no
symptoms, then no treatment is needed. Supernumerary, additional breasts or
Women can even breastfeed with in- nipples may develop along the milk line
verted nipples but may require a nipple or milk streak. This phenomenon is a re-
shield. If an inverted nipple does become minder of the embryology of the breast
a problem, or if you are unhappy with it, in more primitive animals. They follow in
management of congenital nipple inver- the path of a line going from under the
sion can be undertaken either by manual arm, over the nipple and down to the
techniques or via surgery. groin. In practice breast tissue or nip-
ples most commonly develop above the
However, if a woman suddenly develops waist.
an inverted nipple in adulthood, it needs
to be investigated as it may signify an un- During pregnancy and lactation this ex-
derlying problem such as a cancer. tra breast tissue may enlarge and even
produce milk if a nipple is present. The
tissue can also become painful around
the period because it is stimulated by the
same female hormones that control the
breast. If this type of tissue causes con-
cern, it can be removed surgically.
Unusual breast shapes

The breast may have a constricted base
resulting in the breast looking like a
cone. This is caused by a tuberous breast
anomaly. Failure of one breast to develop
can be associated with lack of the under-
lying pectoral muscle to develop as well,
called Poland Syndrome.
Fig. 1.18: Inverted nipple.
Any significant differences between both
breasts should result in seeking advice
from a specialist breast unit. Timing with
regards to surgery needs to be when the
breasts have finished growing.
Benign Breast Problems: I was born with it... Breast abnormalities from birth 30
Amazia (absent breast) Breast enlargement in the

baby
Occasionally something goes wrong with
the embryological development of the Breast abscesses can also occur in female
foetus in her mother’s womb, such as a sex hormones (oestrogen) when cross-
genetic abnormality or if the pregnant ing the placenta in increased quantities,
mother is exposed to some dangerous prior to birth. This results in a breast
factor such as a toxic drug or a virus, bud in the young infant which may even
which may later cause her daughter’s produce milk (called “witch’s milk”). It
breasts to fail to develop. This can be is essential that these small breast buds
managed by reconstructive surgery are not squeezed or biopsied, as this
when the girl is old enough. It is very im- can affect normal development of the
portant to ultrasound the normal breast breast. No treatment is required, and the
and to ensure that there are no masses problem usually disappears within a few
making one side seem bigger. No surgical months after the birth.
removal of the normal breast should be
carried out. These are not related to the breast tissue
and are not breast cancer.
Prepubertal breast
development
This is a type of premature breast de-
velopment which often occurs on one
side only and it is occasionally seen in
young toddlers. The breast will develop
without any problems in the future, so
no treatment is required except for firm
reassurance that all is fine. Open surgical
biopsies will interfere with breast devel-
opment. Investigations should be done
to check for other signs of secondary
sexual development occurring early and
Fig. 1.19: Amazia in an adult female. to find the reason why.
cancer (‘kæns ),
n.
1. (Medicine / Pathology) any type of malignant growth or tumour,
caused by abnormal and uncontrolled cell division: it may spread
through the lymphatic system or blood stream to other parts of
the body.
2. (Medicine / Pathology) the condition resulting from this.
The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company.
Any woman (and even men) can get breast cancer which
is why it is so important to know about the disease and all
potential treatments. It is often not clear why some people
get cancer and others do not, but the more we learn about the
disease, the better we can get at curing it.
"Everyone is at risk of getting breast cancer."

Who gets breast cancer?

What is cancer?
It is a fact of life that we are all born we grow and we all eventually
die. The cells that make up our bodies are just the same. Each cell
in our bodies also has its own life cycle which involves multiply-
ing, growing and eventually dying in a process called ‘apoptosis’.
In cancer, some of the cells of the body begin to misbehave and
do not carry out the normal cycle as they should. They continue to
grow and multiply, but they do not die. Eventually they continually
spend all of their time multiplying and none of their time working,
as a normal cell does, so that they eventually grow into a tumour.
This tumour then invades the normal cells and tissue making new
blood cells to feed its growth and enabling it to spread elsewhere.
Eventually the tumour decides to break up and uses the blood-

stream and lymphatic cleaning system of the body to travel to
more distant parts of the body, such as the brain, the bones, the
liver and the lungs. There, these small cancer cells (bits of the
broken-up tumour) will settle and begin to multiply in their new
position, destroying the normal functional tissue in that area too.
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 affecting women world-
wide. 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 eight women in the United
States to much less in Japan and the Far East. There are no ac-
curate statistics for the prevalence of breast cancer in South Africa,
but we think they may be similar to those in the United States as
we have a similar diet and lifestyle to Americans.
Among cancer related deaths for women worldwide, breast cancer

is the most common, although there has been a dramatic decrease
in cancer deaths over the past forty years due to increased aware-
ness screening and more available treatment options.
Who gets breast cancer?

Anyone with breast tissue can develop a breast cancer. Women of
every age are at risk, from the very young to very old, all races
and cultures, people from all walks of life, rich or poor, healthy or
unhealthy, insured or uninsured - even men can get breast cancer!
A woman younger than 40 has a risk of approximately 1 in 230
of getting breast cancer, with this figure rising to 1 in 29 after the
age of 65.
Mammogram of cancer of the breast.
Breast Cancer: Who gets breast cancer? 36
Most women (more than three quarters) do not have any of the
factors that put them at high risk for breast cancer. 25% have family
history of breast and other cancers on both the father and mother
side of the family. With the remaining 10% having recognized ge-
netic mutations. Breast cancer happens when your cells decide to
stop behaving normally and start multiplying irregularly and pro-
gressively.
Many women who get breast cancer ask “Why me? What did I do
to cause this?” An understandable question, but the answer is:
“Nothing.” There is no single cause of breast cancer and no sin-
gle event that will bring it on. There is nothing any women does
or doesn’t do to cause breast cancer. It is simply an unfortunate
event of life which we can manage through early diagnosis and
treatment.
How treatable is breast cancer, if caught early?

All breast cancer is treatable and there are good options for man-
agement and cure irrespective of the size of the tumour when
found. When breast cancer is detected early, before it invades tis-
sues outside of the breast, the cure rate can be as high as 95%.
Breast cancer that has not invaded the breast tissue but is still in
the ducts (known as carcinoma in-situ) has a 99% cure rate. Sur-
gery alone maybe appropriate enough treatment, or even medica-
tion alone If cancer invades the breast tissue, but does not spread
to the glands, and it also has a very good prognosis. The treatment
of cancer is tailored more and more to the ‘personality’ of the can-
cer i.e. how it behaves and what it responds to, not the size alone
nor age of the patient.
Do chances of survival drop if caught later and,

if so, by how much?
When cancer remains confined to the breast it is easier to treat,
and chances of recovery are greater. Patients do not die of cancer
when it is confined to the breast. It is the spread of cancer to the
brain, bones, liver and lungs which will eventually cause problems.
The aim of breast cancer awareness and screening is to catch
breast cancer early before it can escape the breast, break through
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, cancer cells 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
the bones, with various oncology treatments, up to 75% of pa-
tients could be living five years after diagnosis.
All women are at risk of contracting breast cancer. After all,

statistics show that breast cancer affects one in eight women in
the world today. Risk factors are things that one may have little
or no control over (non-modifiable), such as family history or
race; or modifiable (weight; alcohol consumption).
Also, it is important to remember that three-quarters of

women who get breast cancer need not necessarily be of
increased risk, so there are many factors around breast cancer
which we don’t yet fully understand. 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 we
deal with them?
"Breast cancer affects one out of eight
women in the world today."
Risk factors
Risk factors may be separated into two different groups:
Risk factors that cannot be controlled:

• Ethnicity: White women have more of a risk of getting cancer
than black or Asian women. There is nothing 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, increasing to 1 in 50
at age fifty and to 1 in 10 by the age of eighty years. This is the
thinking behind screening programs starting at either 40 or 50
years with a yearly breast exam and mammogram. We do see
cancers in young woman so if you feel a lump or have a concern;
it is critical to have a clinical assessment and ultrasound.
• Family history: There are breast cancers that run in families and
in different minorities. Some families carry a gene that specifi-
cally increases the risk of breast and ovarian cancer (BRCA1 and
2) and we know that these are commonly seen in Ashkenazi
Jews and white Afrikaner women. In addition, family history of
clusters of cancers, like bowel and prostate cancer, through the
generations may point to an increased risk of breast cancers too.
• Pregnancy: Women who do not have children (nulliparity) or
women who have children when they are over thirty have a sig-
nificantly higher risk of getting breast cancer. We know that a
lot of breast cancers are driven/fertilised by hormones, and the
hormonal changes that occur during pregnancy can have a last-
ing effect on a woman’s 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 a woman has
children or not.
• Breastfeeding: After birth, breastfeeding one’s baby for a con-
siderable length of time has a protective effect on a woman’s
breasts, but it has only a marginal effect if a woman breast-
feeds for one year or more. Breastfeeding may provide cancer-
preventing benefits, whilst benefiting the baby with increased
immunity, providing good bonding and long-term effects on
weight control and intelligence also being suggested as breast-
feeding pros.
• Early-onset puberty (before 12 years of age) and late meno-
pause (after the age of 55): The longer a woman’s body is under
the effects of female hormonal fluxes during her lifetime, the
higher her risk of contracting breast cancer.
Breast Cancer: What is my risk of developing breast cancer? 40
Risk factors that can be avoided:

• Obesity: Having a body mass index (BMI) over 30 after meno-
pause puts a woman at increased risk of getting breast cancer.
Increased weight also puts a person at greater risk of suffering
from a number of other conditions such as diabetes, high blood
pressure, cholesterol and joint problems. It is never too late to
change your diet, increase your daily exercise and make it a goal
to lose a few kilos and keep your BMI ideally under 25.
• 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 units of alcohol a day or
seven drinks per week. That nice glass of wine you have in the
evenings is normally classed as two to three units and a bottle
of beer is 1 ½ units. Remember that heavy drinking is not the
same as “problem” drinking and that it is very easy to become a
problem drinker without realising it.
• Hormone Replacement Therapy: Studies in the USA and in the
UK have shown that women are at increased risk of breast can-
cer if they have been taking most types of HRT for a prolonged
period of time (more than five years). It is also true that the
closer to menopause that a woman starts on HRT, the higher
the risk of breast cancer. The actual math shows, if 30 in 10,000
menopausal women get breast cancer, 38 in 10,000 women
taking HRT will get it. The risks have to be weighed against the
potential benefits of HRT so speak to a sympathetic gynaecolo-
gist who may be able to suggest varied methods of dealing with
menopause.
• Hormonal Contraceptive: Recent studies show that taking con-
traceptive pills in your 40s also increases breast cancer risk;
there is no data to show cancer risk if taking contraception in
your teens, twenties or thirties.
Cancer knowledge is about lifestyle change but more importantly

changing your attitude and this starts with education about breast
health and taking responsibility for your body.
The old adage that you can choose your friends but not your family
holds true when looking at your cancer risks.
Today people live longer than at any other time in history. For instance,
in the 19th century more babies died from diseases, men and children
died prematurely working in the mines, plagues carried off the frail,
women died in childbirth, and 40 was considered a ripe old age!
So, even though cancer did exist back then, and people still died from
it, the death toll from cancer did not seem that high because people
died of many other things long before they were ever at risk of getting
cancer. Today more people live until well into their 80s and 90s, with
1 in 4 people over 70 having some type of cancer. This is not due to an
increase in cancer, but rather due to more opportunities in our body’s
cells to become abnormal and the inability of our bodies to kill or
clean out these abnormal cells.
It is not uncommon for more than one member of a family to get

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 or sequence of
genes causing an increased chance of cancer (uncommon)
"It is not uncommon for more than one
member in a family to get cancer."
Faulty genes in my family?

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’s
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 cancers (up to 10%) 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 that has this gene has to develop the cancer.
Clues that the cancer that runs in your family may be due to an inherited faulty gene
include:
Number of relatives A young age when the Pattern of different

from your bloodline familial cancers occur cancers in the family
who have had cancer
The more blood relatives The younger a person is The type of cancer a person
who have had cancer (par- when they develop cancer has and who it affects in the
ticularly clusters of breast, (compared to the expected family is important. In some
ovarian and/or bowel/mela- “norm” in the general com- families all patients may de-
noma/thyroid cancer) the munity) the more likely it is velop the same type of can-
more likely the cancer is due to have been caused by in- cer, such as breast or bowel
to an inherited faulty gene. herited factors. 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 pre-

sent, 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 de-
velop the cancer, just that
you have an increased risk
and need to be more vigilant
with screening.
Breast Cancer: How do I know if my family carries a faulty gene? 44
What should I do if I have a family history of cancer?

Remember, you can’t change your family genetics, but knowing about all the cancers
in the family is important. Try to find out what types of cancer your relatives have had
and how old each person was when they developed the disease as well as who was not
affected by cancer. Family history of cancer can change over time as other people be-
come part of the family. Different cancers in the family are often due to a combination
of genetics and may not be a single faulty gene. This is a bit like a lock combination for
a family, such as “3;2;1” and may not be able to be detected by genetic tests that can’t
work out combination of genes. It is important to keep the doctor updated about any
new cancers diagnosed in the 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 will spend time explaining how to
be more vigilant with screening for cancer and how modifying diet and lifestyle factors
may decrease risk. 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 have been discussed.
After female gender and advancing age, a positive family history of cancer is the strong-
est risk factor in developing breast cancer. In most cases there is not a long and exten-
sive 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 at a
young age; cancer in both breasts, as well as clustering of different cancers of the breast
(primarily ovarian and male breast cancer). Only less than 8% of all breast cancers will
be due to these genes, which are known as BRCA1 and BRCA2. Others, which are 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 patients and families who have a strong family history, or a positive genetic
test is highly specialised and requires a team approach to management. Close com-
munication between breast specialists and genetic specialists and discussions about
screening, early detection and risk reducing surgery should be managed only in a spe-
cialist unit. Risk reducing surgery is not “aesthetic surgery” but rather reconstructive….
and is not as simple as “Barbie breasts for life”.
Studies have shown that it is possible to reduce the

number of women dying from breast cancer by 45%
using 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.
"The number of women who die from cancer can

be reduced by 45% by using simple measures."
How to check for breast cancer

What does screening involve?
Early detection is the key to a favourable cancer outcome. If a cancer is detected early,
the risk of spreading is lower and there is a better chance that it can be treated. The later
a cancer is detected, the more intensive treatments may be required to prevent further
spread and the higher the likelihood of dying from the cancer.
There are many measures you can take to detect cancer early and decrease your risk of dy-
ing, including breast self-examination, clinical breast examination by your doctor or breast
specialist, mammography, ultrasound (breast sonar), and magnetic resonance imaging
(MRI).
Ultrasound Magnetic Resonance

Ultrasound (breast sonar) is an imaging
Imaging (MRI)
method used to look at the tissue inside the MRI is another method of imaging the
breast. It uses high-frequency sound waves breast using a different form of modern
to echo back a picture of the structures in- technology. A magnetic field provides the
side the breast. It can be used to evaluate doctor with a three-dimensional image of
abnormalities found on clinical examination the breast. It also requires the injection
and mammography. Ultrasound is particu- of a dye into your blood, which will help
larly good when examining breast tissue the MRI distinguish normal tissue from
of younger women and assessing breast abnormal tissue. This is an expensive test
masses. and adds an extra dimension to assessing
disease and looking for extent of cancer. It
The accuracy of an ultrasound is highly de- is of particular value in young women and
pendent on the skill of the technician or in dense breasts.
doctor carrying out the test. This may mean
that tests need to be repeated if ultrasound MRI is useful in patients who have inher-
readings do not fit clinical findings. ited disorders such as BRCA genes or a
higher than normal risk of breast cancer
with ‘difficult to read’ breasts.
Breast Cancer: How to check for breast cancer 48
Breast Self-Examination Mammogram

During breast self-examination, a woman Mammography is an examination of the
takes time to examine her breasts and breast using a low dose of X-rays to de-
gets used to the way they look and feel. tect any abnormalities within the breast.
She checks her breasts for any differences You stand beside the mammography
which might include a change in the size X-ray machine and place your breast
or shape of the breast, irregularities on a pad, where it is pressed down by
in the skin, or changes in the nipple a Perspex plate which splays the breast
particularly when lifting one’s arms, and out so that the greatest amount of tissue
any lumps in the breast or in the armpit. can be examined. An X-ray image is taken
It is an easy way for women to familiarise of each breast from at least two views.
themselves with their breasts and it is Studies have shown that annual mam-
free. mograms significantly reduce the num-
ber of women over the age of 40 who
We recommend you carry out breast self- die from breast cancer by ensuring early
examination monthly, at the same time detection. The radiation exposure from
in your cycle (if still menstruating), or on mammography is less than experienced
the same day each month. in a shopping mall.
Clinical Breast Examination Older mammography uses photographic

film to record the pictures, but newer,
A clinical breast examination is an better technology allows digital mam-
examination performed by a healthcare mography, where the picture is recorded
professional. It includes a physical by a computer and can be better inter-
examination but should also include preted. This is particularly useful in wom-
a history where the doctor discusses en with dense breast tissue and younger
clinical concerns. Little evidence exists women before menopause (still having
that clinical breast examinations periods).
plus mammography is better than
mammography alone, but contact with
your doctor or breast specialist provides
an opportunity for you to discuss your
health or breast related concerns
allowing for a more focused examination
also providing you with a channel if you
notice any symptoms.
Screening guidelines used to be similar for all women, irrespective

of their risk factors. We now know that some women are more
at risk than others, and that cancers can occur in young woman
therefore different patterns of screening are advised for patients
depending on their risk profile and clinical concerns.
"Different patterns of screening are

suggested for each individual."
What is my risk?
You are at average risk of breast cancer if:
You have no breast cancer symptoms.
Never had breast cancer, or another form of cancer.
You have never had a diagnosis of risk lesions in the breast (atypical hyperplasia;
lobular carcinoma in-situ).
There is no family history of breast cancer in the first generation (siblings or
parents) or no history of other forms of cancer.
There is no history of mantle radiation for lymphoma (a type of upper body
radiation given for lymph gland cancer).
Screening guidelines
Screening guidelines are intended to help
increase the chances of detecting cancer or
unusual cells once they have developed in a
person’s breast. There is no test or method that
prevents cancer developing in the breasts, but
it can be diagnosed early to ensure the best
outcome for you.
Screening guidelines for average risk patients:

Examine your 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 have an annual mammogram and sonar at least every two
years.
After the age of 50 have an annual mammogram and sonar.
Breast Cancer: When should I start checking my breasts? 52
You are at above-average risk of breast cancer if:

You have a 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 cases of breast cancer from the
same side of the family.
You have had a diagnosis of atypia or other risk lesions on breast biopsy. This is
a form of benign breast disease but can be associated with an increased risk of
cancer at a later stage.
You have had mantle radiation before the age of 32.
You have high alcohol consumption, are overweight or have been on hormone
therapy for many years.
Simple measures can reap great rewards.

Getting to know your breasts and getting
into the habit of checking them regularly is
very 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!
Screening guidelines for above-average risk patients:

Examine your breasts each month and get to know what is normal for you.
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 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 been diagnosed with atypia, 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.
There is no single symptom which proves that you definitely have

breast cancer. Most of the symptoms related to breast cancer are
also present with non-cancer related conditions. It is therefore
important not to panic if you develop a symptom that you have
not experienced before, but rather be sure to get it checked out.
"There is no single symptom which indicates

that you definitely do have breast cancer."
What are the symptoms?

If you have breast cancer, will you feel a lump?
Most breast cancers present as a lump in the breast. Women are often surprised by the
unexpected appearance of a lump and are unsure whether to have it examined or not. No
matter how suddenly a lump appears or how the lump feels, it is very important to see
a doctor. The concept that cancerous lumps often feel hard and craggy and grow slowly
is not always true and besides you don’t have eyes on your fingers, therefore all lumps
should be assessed by ultrasound. Leaving a lump to check to see if it goes away is not
sensible as eventually all cancer will spread to the lymph glands resulting in one feeling
hard lumps under the arm too (axillary lymph nodes /glands). Remember most lumps (80-
85%) are not breast cancer (benign). They may be cysts or fibroadenomas. Approximately
10% of breast cancers present without a lump, but all lumps and concerns worth being
examined by a doctor.
When does cancer present as a “non-lump”?

Cancer can occur without a lump. If you experience any of these symptoms you should
schedule an appointment with your doctor
• Change in the size or shape of the breast (breast can feel doughy thickening or dimpling
of the skin of the breast).
• Thickening or ulceration of the skin of the nipple, breast changing to a red colour, ec-
zema of the nipple, itching or scaly patches, nipple turning inwards.
• Lumps noticed under the arm.
Is breast cancer painful?

Unlike most cancers, breast cancer does not usually present with pain. That doesn’t mean
that if you have a painful lump it can’t be cancer, but rather that it is unusual for pain to
be the first symptom of breast cancer. The most common way that women discover breast
cancer is when they feel a lump in the breast, notice a discharge from the nipple, or a
change in the breast shape. The more breast cancers that are detected by a mammogram
(before there is even a lump) the earlier a cancer is detected, the easier it
is to treat.
Is a nipple discharge normal?

It is true that some nipple discharges are normal (physiological) - take breastfeeding for
instance! It is quite common to have a discharge for a while after breastfeeding; the im-
portance is not to squeeze the nipples and continue the stimulus for milk production once
stopping breastfeeding. The nipple is a glorified plug and should not be squeezed. Other
nipple discharges, whilst not normal, are caused by different things and are not all sinister.
Breast Cancer: What are the symptoms of breast cancer? 56
Breast specialists worry most about spontaneous nipple discharges that occur without
squeezing; or from one nipple or from just one place on the nipple (no matter the colour).
Nipple discharges that have blood in them are also particularly worrying. The best plan
is that every nipple discharge should be checked out by a specialist who can help you
understand the problem and provide a solution. Remember not to squeeze your nipples
- they can respond by producing or increasing a discharge. If you have been squeezing,
the first step is to stop, and the application of a topical antibiotic can help.
What changes in the nipple are related to breast cancer?

There are two particular changes to the nipple which most likely indicate breast cancer.
The first is an itchy, scaly, eczematous rash develops on the nipple itself. A scaly itchy rash
on the areola (the coloured part of skin around the nipple) is more likely to be eczema.
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 a rash or an ulcer on the actual nipple. The second symptom is an inver-
sion or in-drawing of the nipple. Many women have inverted nipples (which is completely
normal) but if a nipple suddenly becomes inverted, particularly on one side only, it is a
cause for concern and should be investigated.
Whilst all cancer is treatable and potentially curable, it is better to detect cancer as early
as possible. Remember to go for screening (mammogram and sonar) once a year after
the age of forty/fifty depending what your local screening guidelines are. Also, get your
GP or a breast specialist to examine you once a year. Being breast aware also means
learning to love your breasts and getting to know them.
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.
Fig. 2.1: A clinical photograph of a woman with Paget’s Fig. 2.2: Inverted nipple due to breast cancer.
disease. You can clearly see the scaly, crusty skin of the
destroyed nipple and the irregular areola outline.
When you feel a lump or are concerned that you

may have developed a breast symptom, the first way
to put your mind at ease is to know that more than
70% of all patients with breast symptoms do not have
cancer. The only way to be sure of what the problem
is, is to be seen by a specialist to ensure correct
imaging and diagnosis.
"More than 70% of all patients with

breast symptoms do not have cancer."
How is breast cancer diagnosed?
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 also to chat about your general health and medical history. It is
important to identify risk factors and potential health issues for the future and not to just
focus on one aspect of your health. The best way to know exactly what type of lump it is,
or the cause of your symptom(s) is to have your general practitioner or breast specialist
carry out a triple assessment. This means that every lump or symptom is investigated and
managed in the same rational manner.
Breast Cancer: How is breast cancer diagnosed? 60
What is triple assessment?

Clinical examination
This involves not just an examination but a careful history of symptoms and risk
factors. Your doctor will look at you to see if there are any visible breast changes such
as skin thickening, nipple changes or dimples in the breast. After that your doctor
will feel the breasts in the same way as you would do in a self-examination. They will
feel into the axilla/armpit and all over the breast looking for lumps or pains. It is also
important to look at the nipple carefully, checking for any discharge or abnormalities.
Your doctor will do a full clinical examination to check for any other changes or
abnormalities, including taking your blood pressure.
If a lump or other abnormality is identified at this time, your doctor will discuss the
implications with you. No doctor has X-ray fingers, so any clinical examination will
always be 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 overlooked. Normally this includes a mammogram
with at least two views (occasionally more views) and an ultrasound of the breast
and axilla/armpit. In women under 35 the breast tissue is too dense to rely on
mammograms alone so an ultrasound is done as well. An MRI scan is also useful as it
offers a different way of assessing the breast tissue.
Pathological diagnosis
If there is a lump or concerning area, the radiologist may wish to do a core needle
biopsy. A core needle biopsy is best done by the radiologist because they can do
the biopsy under X-ray (mammogram) or sonar guidance (i.e. under vision). The old
technique of Fine Needle Aspiration (FNA) should not normally be used because it can
be inaccurate and does not give enough information to the doctor. Surgical biopsies
in theatre should almost never be done; not only are they not the best method of
diagnosing cancer but they affect both the ability to treat cancer and impact survival
negatively.
The sample taken (by radiological core biopsy) will then be sent to a pathologist who
will cut the core biopsy into small slices and stain them in a special way to allow easy
identification of any abnormalities or cancers.
How is breast cancer diagnosed?

How soon will I be told if it is cancer?
Anyone from your general specialist to specialist breast surgeon or radiologist may
be concerned about a lump, mass or concerning area on the mammogram, but no
conclusive diagnosis can be made without a tissue sample being taken by biopsy. This
test takes at least 48 hours. The most important thing to remember is that breast
cancer is not a death sentence, neither is it an emergency. By the time a cancer is
palpable (at 1 cm) it may have been present in your breast for at least five years.
There is never a requirement for an emergency mastectomy, and the best treatment
for breast cancer always starts with a discussion in a multi-disciplinary unit as not all
treatment should start with surgery and one may need to begin with chemotherapy
rather than considering immediate surgery. So, even if a cancer diagnosis is made you
still have time to consider your options and seek advice or another opinion. In fact,
not rushing into treatment is the most important advice.
Breast cancer staging

Patients often ask what stage their cancer is once it has been diagnosed and how
advanced it is. Although this might seem very important, the character (personality)
of the cancer and the way it behaves and reacts to treatment is far more important.
For instance, an early stage but aggressive cancer may progress more rapidly if not
treated than a large but “laid-back” tumour.
Staging is based on clinical and laboratory findings. Staging systems are used to clas-
sify breast cancer to make it easier for the doctor to treat the disease in a logical
manner, also ensuring all doctors dealing with breast cancers have a common, stand-
ardised base on which to plan their treatment strategies. The most commonly used
staging system is the TNM staging system which allows doctors at particular centres
to compare diagnosis stages and treatment with other centres all over the world.
Thus, “what stage” breast cancer is diagnosed as in South Africa can be compared
with those documented in the United Kingdom and United States of America.
With regard to the commonly used TNM staging system, the “T” refers to tumour
size, the “N” refers to nodal status and the “M” is used to determine metastatic dis-
ease which is what it is called when the 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 can detect metas-
tases through a variety of methods once the tumour metastases are of a size that can
Breast Cancer: How is breast cancer diagnosed? 62
be visible on radiological investigations.
Part of the staging is to perform certain tests to determine whether the cancer has
spread (M):
X-rays of the chest check for lung spread

X-rays of the bones and bone scans check for bone spread
Brain scans check for brain metastases (MRI)
Abdominal ultrasound (sonar and CAT scans) check for liver spread
Blood tumour markers (these should be used as a serial assessment, not as in-
dividual values) only when cancer spread has been documented or suspected.
There are four stages of cancer:
Stage zero, one and two cancers are early stages;

Stage three cancers are locally advanced (large breast cancers greater than 5 cm)
Stage four cancers have spread to elsewhere (M+).
Let’s remember biology of cancer rules; so, stage four HER2-positive breast cancer
can have good long-term outcomes with the correct treatment. Most breast can-
cer patients can be treated for many years with oncology drugs.
Fig. 2.3: Breast cancer stages.
It is your right to learn as much as you want about the cancer. Ask about new treat-
ments and remember that your time with your doctor is just that: YOUR TIME, so
take as much time as you need during your consultation. It is your body and your life,
so become involved with your health. Remember that there are many new drugs
and trials available and options that can be explored for all breast cancers.
If you or a loved one are diagnosed with breast cancer, a lot of time will
be spent with doctors discussing various treatment options available
to you.
Breast cancer management relies on a firm foundation of the multi-

disciplined team. What that means is that every doctor involved in
cancer treatment should be speaking to every other doctor and that
this should be done in a multi-disciplinary meeting and documented
with the feedback discussed with patient. The intention is that, from
the start of a patient’s treatment, there is an individual plan, tailored
to the exact stage and type of breast cancer. The team of people
involved in care includes the breast surgeon, the reconstructive
(plastic) surgeon, the radiologist who carries out mammograms and
biopsies, the oncology and radiation specialists (oncologists), as well as
a psychologist and survivorship specialist. The most important person
is the patient navigator; usually a nurse whose role is to ensure that
the patient and family has support and guidance along all aspects of
treatment.
Breast cancer management involves treatment of the whole body,

not just the breast as 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 types of
therapy, often managed by different members of the multi-disciplinary
team. Team work to ensure the correct order of treatment is critical to
ensure excellent patient outcomes.
"Each patient should have a unique treatment

plan, tailored to their individual needs."
Treatment principles
Therapies can be divided into those that affect the breast, to get rid of the cancer
present in the breast, or in the nearby lymph glands, and those therapies that seek
out and destroy breast cancer cells that may be present elsewhere in the body.
The therapies are:
Whole body treatments to find any cancer that might have spread to other parts
of the body:
Oncology
Chemotherapy
Receptor-dependent treatments (hormonal)
Target treatments
Immunotherapy (usually drugs that manipulate the immune system)
Radiation
Local treatments to the breast:

Radiation
Surgery
Each type of treatment can be considered independently, but remember that in

almost all cancer management the patient will have at least one local and one
whole body treatment. This does not mean that they may require all the different
treatment methods. It is dependent on the type of breast cancer, patient choices
and options made available by the specialists in the MDM.
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.
Breast Cancer: Treatment principles 66
Oncology
Oncology is the use of medicines to attack and kill cancer cells in your body. The simplest
analogy is antibiotics to treat cancer. The concept of chemotherapy is to use cytotoxic (cell
killer) treatment to kill cancer cells. These medicines may be given by means of a drip or
in tablet form.
We know that cancer cells multiply more quickly than most of the body’s normal cells.
The cancer cells work very hard and are in the duplicating phase of the cell cycle almost
constantly. Chemotherapy finds cancer cells by identifying all the rapidly dividing cells in
the body and then attacks them by preventing them from duplicating further.
The treatment works well, but also affects normal cells in the body that 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 and diarrhoea.
The larger a breast cancer grows, and with certain breast cancer types, the greater the
chance of it spreading to the rest of the body. Oncology drugs can find and attack cancer
cells outside of the breast. This is why cutting out a cancer alone is not good enough and a
form of oncology medicine is given to all patients with these types of cancer.
There are genetic methods of determining whether a patient will benefit from chemo-
therapy, and these use samples of the breast cancer tissue to analyse how aggressive it
is. These tests are expensive but may be beneficial in ensuring that the correct patients
get chemotherapy.
Understanding breast cancer

Reclassifying breast cancers
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 tumours will be as different as the sizes, shapes
and personalities of the people they belong to. We used to classify breast cancers into
broad groups of those that are hormone sensitive and those that are not. We now clas-
sify breast cancers into 4 families. Each family has a different way of living, behaving and
generally spreading (leaving home). The first 2 families both have receptors for oestrogen
(ER) and progesterone (PR) but are differentiated by understanding the division rate of
the cells. This is called the KI and it is determined when the pathologist looks down the
microscope and sees how many cells are dividing.
Luminal A breast cancers: are strongly ER and PR positive and have a cell division rate of
under 15%.
Luminal B breast cancers: have variable ER and PR positivity and a KI of over 15%.
Doctors can use hormone and receptor blockers to prevent anything encouraging cancer
growth or prevent any other potential cancer cells to develop. There is still so much we
don’t know about receptors, and a lot we are learning, but there are some receptors we
know how to block. What we do know is that most luminal A cancers do not need chemo-
therapy at all and just require some form of cancer cell ER and PR blockade for a length
of time.
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 receptors. The most common medicines are Tamoxifen
and blockers called aromatase inhibitors.
Luminal B breast cancers are a large group of cancers that can have KI (division rates vary-
ing from 15% to 100%......and some may not require the addition of cytotoxic treatments
(chemotherapies). This is where genetic profiling of cancer cells is so important in this
group of patients.
The third biological type of breast cancer is a HER2-enriched and can be subdivided into:
HER2-positive, endocrine negative

HER2-positive, endocrine receptor positive (triple positive)
Her2 receptor over-expression

This is the newest abnormality to be found in breast cancer, and has changed the treat-
ment of Her2 positive cancers which were often aggressive and may be ER/PR negative.
Breast Cancer: What treatments are available? 68
biology personalise treatments

All cells have Her2 receptors which encourage growth of normal cells. Some breast cancer
cells have too many Her2 receptors which means 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. New treatments are continuously being
tried out with current cancer patients and patients are welcome to participate in trials of
a new treatment.
Radiation treatment
Radiation is another method of killing rapidly dividing cells such as those seen in breast
cancer. It works in a local area, not throughout the body like chemotherapy. Radiation
treatment is given by directing a beam of radiation, made up of thousands of X-rays, onto
the breast which attack any cells which may be cancerous. It helps to reduce the risk of
a cancer coming back after surgery, especially if the cancer is large or close to the rim of
normal tissue to be 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. Radia-
tion ‘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:
• When a cancer is very big (greater than

5 cm);
• When a cancer has involved glands un-
der the arm (lymph nodes), or the glands
have burden of cancer cells;
• When any breast tissue is left behind af-
ter an operation (radiation is always re-
quired in breast conserving treatment);
• When the multidisciplinary team is con-
cerned that the margins of normal tissue
around the cancer were too small (not a
big enough ‘fire break’). If there is true
cancer at the margin however, the can-
cer should be removed with surgery, not
radiation.
What treatments are available?

Surgery
In breast cancer management, surgery will take place at some point along the treatment
path. Surgery can take place more than once, rarely for diagnosis, and mainly for treat-
ment 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 that may have to be undergone are:
Sentinel Lymph Node Biopsy Mastectomy

Often the first part of cancer treatment, car- The oldest and most well-known method of
ried out to see if the cancer has spread from surgically treating breast cancer is a mastec-
the breast to the glands under the arm (lymph tomy. This is a procedure where the whole
nodes). On the day of the operation the pa- breast is removed from the body, and the
tient is injected with a radioactive chemical / patient is left with a flat chest and one scar.
or siena (magnetized Fe particle and or blue Very often, immediate reconstructive sur-
dye which is not harmful, where the doctor gery can be carried out so that the patient
uses a special probe and blue dye to find the has only one operation and is left with a sim-
first gland the cancer would have spread to ilar breast mound to before the operation. A
the ‘sentinel’ (which means the guard). The mastectomy today is choice and most often
surgeon will make a small cut in the armpit done as a skin and nipple sparing procedure.
under a general anaesthetic and take this
gland out. Sometimes a woman may decide to have
both breasts removed, called a bilateral
If the cancer has spread, it is called ‘locally- mastectomy. This is only done after intense
advanced’ and increases the chance of it discussion of all the options, and a realistic
having spread outside the breast to the rest assessment of the risk of further cancer in
of the body. Cancer that has spread to the the other breast as well as psychological rea-
rest of the body is best treated with oncology sons for the procedure.
medication.
Fig. 2.4: Sentinel lymph node biopsy. Fig. 2.5: Bilateral mastectomy scars, 21 days post
operation.
Breast Cancer: What treatments are available? 70
Wide Local Excision or Breast Conserving not be required.

Surgery
Reconstruction
Also known as a ‘lumpectomy’ operation,
this can take place if the surgeon believes it is All patients who have breast surgery should
possible to remove the cancer safely without have the opportunity to have reconstruction.
removing the whole breast. This procedure Reconstruction is most often done at the
might be elected because the cancer is small, same time as the cancer surgery. All woman
or because the breasts are large enough to al- should have a discussion around breast re-
low a big area to be removed. Cancer is never construction before cancer surgery. As soon
taken out alone, it is always taken out with a as 5% of the breast is removed, a defect is left
margin, which acts as a fire break between
the cancer and the normal breast tissue. This Breast reconstruction is not plastic surgery.
precaution reduces the risk that the cancer Once an area of the breast is removed if
may come back in the same place. careful attention is not paid to moving tissue
from the surrounding areas back to fill the
There are some important safety measures defect; a permanent dent or deformity is left,
that must be taken when performing breast and this is difficult to correct post-radiation
conserving treatment (BCT). The first require- therapy.
ment is that the surgeon must be sure that
all the cancer can be removed safely. The The reconstruction may be part of breast
second is that the patient must be willing and conserving surgery or after a mastectomy, ei-
able to have radiation treatment, because ther at the same operation or at a later date.
BCT is not safe if you do not have radiation. Plastic surgeons can use tissue from other
Lastly, it is important that BCT is carried out parts of the body to reconstruct the breast
with the help of a surgeon skilled in recon- and they may also use prostheses, made of
structive techniques. Normally this is a plas- materials such as silicon, to give the shape of
tic surgeon or a surgeon with comprehensive a breast under the skin and muscle, if there
training in breast reconstruction. has been a mastectomy. All women have the
right to be considered for reconstructive sur-
Axillary lymph node dissection (ALND) gery, even if the operation was performed a
long time ago.
If the cancer has spread to the glands, a mini-
mum of 7 glands (or glands still involved with
cancer) under the arm will need to be re-
moved. There will be 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 of-
ten 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 an ALND may Fig. 2.6: Breast reconstruction/ implant
A diagnosis of cancer can be one of the most stressful experiences

of a person’s life. In addition to the worries about survival and
treatment, many patients find that they have concerns regarding
the cost of medical treatment. In South Africa, 80% of patients
are managed within the government health service and 20% have
medical insurance which means that they can be treated in private
hospitals. Many people find that they have let their 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 criteria to check in the case
of being diagnosed with breast cancer.
The most important thing to remember is that you cannot afford

NOT to be treated for breast cancer.
"You cannot afford NOT to be

treated for breast cancer."
Can I afford to be treated?

I haven’t got medical aid. Check your policy too as many
Now what do I do? companies encourage good health by
funding screening mammography and
There are many excellent public hospitals Pap smears even to patients without day-
and superb academic cancer specialists to-day benefits.
who work in government hospitals. As
with all types of illnesses, knowledge is Cancer policies
power. Knowing what management to
expect will help you navigate the medical Even if you have medical aid, some of
system. Books like this one and the inter- the initial concerns about cancer are
net can help you get more information not about survival or treatment; they
to assist in your journey. There are many are about affordability. As a result, many
organisations whose aim it is to help pa- insurance companies offer policies
tients who do not have the resources for which allow patients to unlock financial
travelling to a hospital or for managing resources to bridge the gap between
treatments. See the “Help and Support” what is covered and what is required.
page for further details.
Disability cover
Navigation of medical aids
Disability cover protects your ability to
All medical aids, even hospital plans, earn a living. It allows you to retrieve
have to provide some cancer cover. This money from your policy when you are
will include in-patient care but may also unable to work for certain periods of
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. Always check
when you consider signing up for, or are
changing, medical aids to see 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.
Breast Cancer: Can I afford to be treated? 74
time, whether due to temporary or shows how much you love the people
permanent disability. The policy may around you. It is a good idea to also stipu-
be related to your ability to work or late who should make decisions for you if
your ability to carry out your specific you are too ill to decide for yourself.
occupation.
Saving now for the future
Estate planning (making a will)
Saving money is not easy, but if you are
No one likes to think of a time when they worried about how you can afford to
will not be here, but, as they say, ‘Death, cope in the event that you get ill, now is
taxes and childbirth: there is never a con- the time to start. Once you ensure that
venient time for any of them!’ you have coverage in place for manag-
ing your expenses (such as medical aid
Your estate is everything that you own, and disability, cancer or life insurance)
from a house and car to your jewellery have a look at your monthly budget and
and cell phone. If you do not plan for who look for ways in which you could save a
will receive these valuable items after small amount in an emergency fund each
you die, the government will decide this month. This can act as a financial buffer
for you and may leave your family and when you have a significant outlay, even
dear ones without the resources they if it might not be a medical expense, but
need when they need them most. it will be useful if you do have an unex-
pected medical diagnosis.
Drawing up a will is a simple exercise and
Budgeting also allows you to work to-
wards paying off debts. The greatest fear
in most patients is not how to afford fu-
ture treatment, but rather how to keep
up with past debts during a period where
you may be unable to work.
If you do get into debt or cannot afford

treatment, discuss the problem with
your doctors. They may know of charities
that can provide financial assistance or
they may find a longer, but easier, solu-
tion to payments.
Most patients experience psychological problems following a

diagnosis of breast cancer. The most difficult period is between
diagnosis and surgery or treatment. Breast cancer patients will most
likely experience some or most of the following emotions (all of which
are quite normal):
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 as a fear of being sick, a fear of being in pain, a fear
of side-effects of treatments and there is 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 future will help. Anxiety about disfigurement after mastectomy
can be allayed by remembering that reconstructive surgery is an
option in most breast cancer cases.
"It is normal to feel a sense of unfairness

following a diagnosis of breast cancer."
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 under-
stand 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 one.
Children and Teenagers truth about illnesses and cancer at a

level they can understand and cope with,
Children whose close relatives (mother, will reduce the stress, guilt or fear they
sister or grandmother) have cancer are may feel. Spend additional time with
often aware of a change in their lives and them and ensure that they have the op-
the lives of those surrounding them. Even portunity to spend quality time with the
young children can sense that something cancer survivor. Older children and teen-
is wrong, and this may frighten them. agers may be expected to take on addi-
There may be a change in the daily rou- tional responsibilities in the family and it
tine or absence of a loved one and this is important to remember they are still
can cause fear which manifests as anger children who need loving support.
or tantrums. Children may think that they
are responsible and will require reassur- Partners
ance that this is not the case. Open and
honest communication is best, address- One of the hardest life events is coping
ing all fears and discussing their feelings. with illness in your partner. There may be
They may have lots of questions which feelings of fear, confusion or helplessness
should be encouraged and answered in a and an overwhelming concern which
way they will understand. prevents effective communication. The
key to navigating this difficult time is to
Telling children and young people the maintain open and honest communica-
tion between partners with time taken to
Breast Cancer: How will I cope? 78
be alone and to openly discuss feelings. ner must attempt to cope with their feel-
Loving words and physical touch will re- ings. It may be difficult to express love
mind your partner of your care. Another physically in the same way as before, due
source of stress may be a change of roles to physical changes, pain or emotional
and responsibilities within the family preoccupations. Finding new ways to
as well as concerns over financial well- express love and gain satisfaction is part
being. of exploring new methods of communi-
cation.
When a breast cancer patient requires
long periods of time in hospital, there Some sexual problems may stem from
can be difficulty maintaining good con- the treatments for cancer themselves
tact and communication. The supporting and others may be a result of emotion-
partner may have a feeling of isolation al changes. Here too, communication
or uselessness in their contribution to between partners and involvement of
the treatment of their loved one. Often healthcare providers can often help iden-
unrealistic expectations may need to be tify problems and find solutions to them.
addressed and it is important to maintain Understanding unrealistic expectations
life in the same way as it was before the or unhelpful feelings of anxiety or guilt
diagnosis. will help the situation immeasurably.
Intimacy issues between the patient and There are many healthcare workers who
her partner should be addressed. This wish to give help and advice.
can be problematic because each part-
The more someone knows about breast cancer and the treatment options available to
them, 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 and honestly rather than pretending
there are no problems or concerns. Sometimes it may be helpful to speak to other breast
cancer survivors, a psychologist or a social worker.
Because cancer is part of your body, it is difficult to find and kill cancer
cells without harming at least some of the normal cells in your body.
Most cancer treatments have 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. The field of survivorship
deals specifically with managing the “new you” post initial cancer
treatment.
"Cancer is part of your body - it is

difficult to kill cancer cells without
harming the normal cells."
Side effects of cancer treatment

Side effects of Breast Cancer Surgery
Pain in the region of your operation sensation of your previous nipple.
Any operation can cause pain in the
region surrounding the operation site. Feeling of imbalance
This pain should be short-lived and you When a woman undergoes a mastec-
should speak to your specialist doctor tomy, it can take some time for her to
or nurse to help you with painkillers for adjust to the new feeling of weight dis-
a limited time. Pain can sometimes be a tribution in her chest, particularly if she
sign of infection, so it is important to seek is large-breasted. There may be feelings
advice if the pain is getting worse rather of imbalance, which can cause compen-
than better. sation in the muscles of the back and
shoulders leading to pain. This can often
After a mastectomy, women can be avoided with the consideration of im-
sometimes experience ‘phantom breast mediate reconstruction of the breast or
pains’ which means they experience breast reduction on the other side. An
feelings of pain or tenderness that external prosthesis in the bra can also
appear to come from the breast that require some getting used to.
is no longer there. This is because the
nerves to that breast have been cut Lymphedema
as part of the mastectomy operation. When a woman undergoes an operation
It can take some time for the body to and removal of some of the glands under
learn that the breast is no longer there the arm, it can cause swelling in the arm
and to adjust to the sensation of no from retained body fluid. This is called
longer having a breast. This may still lymphedema. The risk of lymphedema
happen even when the breast has been is increased when cancer treatment
immediately reconstructed. also includes radiation to the armpit.
Approximately one in ten women who
Loss of sensation have gland surgery will get lymphedema,
In order to remove a breast, the nerves and this can range from mild swelling
in the skin and tissue below must be cut. to a debilitating condition. A specialist
This will lead to a feeling of numbness physiotherapist can help with exercises
in the area the nerve supplied, normally to improve the drainage of the arm,
over the skin of the chest area, and often and there are many implements and
in the inner aspect of the upper arm. It is garments to wear which can also aid the
normal to lose some sensation in these condition. Patients with lymphedema
regions and it can take a number of years can prevent the situation from getting
for sensation to return. worse by avoiding lifting heavy weights,
exercising the arm and alerting their
It is also important to remember if doctor to any signs of infection in the
you have reconstruction of the nipple, arm.
that the new nipple will not have the
Breast Cancer: What are the side effects of breat cancer treatment? 82
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 when 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, but this only made
the problem far more common and more
severe.
Fig. 2.7: Lymphedema in patient following breast cancer
surgery
Side effects of Radiation Treatment

Skin changes breast can become larger due to swelling
During radiation treatment the skin on within the breast during treatment, and
and around the breast can become very in the long-term the breast can become
sensitive and tender. It can be itchy or red smaller or firmer.
too. This is because of the radiation and
will settle down after the treatment ends. Fatigue
Sometimes the skin colour can change or Many women find radiation can leave
fine veins (‘telangiectasia’) may develop them feeling tired and fatigued after
over the skin around a mastectomy scar. treatment, particularly later on in cancer
These are small changes which may be management. The fact that the regime
permanent. It is important to discuss any requires daily hospital visits can also
skin lotions or creams a patient might leave a patient suffering from exhaustion.
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
Side effects of cancer treatment

Side effects of 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 too. The cells that are most frequently damaged are those that divide and
multiply 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 treatment is finished. The selection of

and diarrhoea wigs and scarves available for women
These occur as the cells of the gut are who have lost their hair is extensive,
damaged or killed by the chemotherapy and many charities will support women
agents and take time to replenish. Most in looking their best, even during
of these side-effects can be managed chemotherapy. Cold caps to decrease
well by your doctor and most of them hair loss can also be used.
go away during the recovery part of the
chemotherapy cycle. Numbness and tingling of the
hands and feet
Hair loss The sensation of numbness can be
Many patients fear losing their hair uncomfortable or frustrating for a
and are surprised to find that many patient. It is a side-effect of some of the
chemotherapy agents do not cause this chemotherapy agents given in breast
side-effect. Even if the hair is lost, it will cancer. Oncology doctors work hard to
most commonly grow back after the prevent this becoming a problem in the
long term. (Vitamin B is effective)
Fig. 2.8: Patient receiving chemotherapy.

Breast Cancer: What are the side effects of breat cancer treatment? 84
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 from making the hormone or preventing it
from getting to the cancer. This can simulate menopause in most women who take these
treatments. The side-effects are therefore effects of the menopause.
Hot flushes, night sweats and (‘thrombosis’) in the veins of the legs and
vaginal dryness arms. It is important to tell your doctors
A hot flush is a sudden rush of blood to the if this has ever happened to you before,
face and neck that can last for anything if you are taking hormone medications,
between a few seconds and an hour. It as it may affect the medication you are
is difficult to treat with medication, but given.
relaxation and loose clothing can often
help to cope with these events. The Bone and joint pains
same hormone deprivation that causes Most of the hormone medications
this can also cause your vagina to be dry given to patients can affect the joints
which may cause increased infections in and bones in some way. They can cause
the bladder and painful intercourse. arthritic pains in the joints or muscular
aches that can be difficult to tolerate.
Increased risk of clotting Some of the medications can also cause
Some hormonal medications can thinning of the bones which should be
increase your risk of developing clots monitored by your doctor.
The psychological impact of losing a breast or disfiguring

breast surgery 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
or wide local excision of breast cancer. 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 that a delay of a day or two to
determine what your surgical options are is better than
a lifetime with one breast or no breasts at all. A 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.
"There is always time to get

advice or a second opinion."
Breast reconstruction surgery

Breast Cancer: What about breast reconstruction surgery? 88
When do we do reconstruction?
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
and avoids multiple operations. Having this procedure depends on the
patient’s age, the size 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 (moving breast tissue around
or in from areas close to the breast (autolgous flap) or having a silicone
or saline implant. Despite bad publicity silicone implants have had in
the past, they don’t cause certain immune system disorders. There is a
small incidence of a type of lymphoma with certain textured implants
and this should be discussed with your reconstructive surgeon. 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 can 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.
The occurrence of male breast cancer varies

throughout the world. In North America
there seems to be an increasing incidence
especially amongst black males, with about
a thousand cases being diagnosed per year.
Breast cancer is 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 occur in men.
"Male breast cancer is more common
amongst men older than sixty."
Breast cancer in men

Who gets it?
The vast majority of male breast cancers
The risk factors for male breast cancer are present as a painless breast lump. They
interesting; it is definitely not associated may have a nipple discharge or nipple
with benign male breast lumps or breast changes, but very few are painful.
enlargement (gynaecomastia). There About 5% of these cancers will present
appears to be an inherited component with spread to other organs (metastatic
because the lifetime risk of a male disease). Any unilateral breast mass that
getting breast cancer if his mother and is firm, fixed or ulcerated in a man should
his sister had breast cancer is about 2.5%. raise suspicion.
Male breast cancer is more common How do we investigate it?

in families who have the BRACA2
gene mutation and in males who All potential cancers are investigated
have Klinefelter syndrome (which is the same way, whether it is in men or
the chromosomal abnormality XXY). women. The investigations that should
It seems to be increasing in men who be done are a mammogram and sonar.
work on electrical lines and factors such Sensitivity in mammograms is the same
as radiation, X-rays and electromagnetic in men as it is in women. A core needle
waves have also been implicated. biopsy will provide the pathological
diagnosis.
What type of breast cancer
do men get? Treatment
Male breast cancer is almost always a The treatment for male breast
ductal carcinoma (the most common cancer is the same as for women. It
type). Lobular carcinoma is rarely seen usually involves surgery, oncology
in men and when it is, it is usually in (chemotherapy and hormone therapy)
association with Klinefelter syndrome. and radiation therapy working as a multi-
Any variation of ductal carcinoma can disciplinary team. Men are normally
be seen in male breast cancers including managed with a mastectomy (can be
Paget’s disease (cancerous eczema of done with reconstruction immediately
the nipple). 80% to 90% of male breast and a sentinel or lymph node dissection),
cancers are responsive to hormones. followed by chemotherapy and radiation
treatments if necessary. Tumours that
Male breast cancer is no different to are greater than 2 cm have twice the risk
female breast cancer. All people have of returning than those where the lesions
some breast tissue, but men have less. are less than 1 cm, so it is important to
When cancer does develop, it tends to be make sure the margins are wide, and the
more advanced from early on, with the cancer is well-treated. Hormone therapy
chest wall and skin also being involved. can improve the survival rate if the
cancer is sensitive to hormones.
Breast Cancer: Can a man get breast cancer? 92
Although the prognosis is believed to

be worse in male breast cancer than
in female breast cancer, it is actually
identical stage for stage. 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.
Fig. 2.9: A severe case of male breast cancer.

Your doctor will discuss the plan for your breast cancer
treatment with you throughout the term of 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 they think 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
ultimately, the patient must decide what is best for them.
"There are many different but equally

good ways of treating breast cancer."
Help and support
Take your time

By the time breast cancer is detected by a clinician or on a mammogram it will have been
developing in the breast for approximately 2-6 years. There is no such thing as emergency
treatment for breast cancer. While it is important to seek treatment immediately there is
always time to discuss with your family and friends, with previous cancer survivors and
with support groups concerning your feelings about your cancer and how you would like to
proceed with your treatment.
Breast Cancer: Where can I get help and support about breast cancer? 96
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.
Your health and previous history of illnesses may influence the kind of treatment you are
offered. No doctor will consider it an insult if you ask for a second opinion.
Read around the subject wisely

The internet is wonderful for opening doors to a world of knowledge and it is important
that you research as much as you want into your treatment. Most large cancer organisations
around the world have excellent and trustworthy information for patients, these include:
Netcare Breast Care Centre of Excellence (SA): www.breasthealth.co.za
CANSA (SA): www.cansa.org.za
Breast Health Foundation (SA): www.mybreast.org.za
National Cancer Institute (USA): www.cancer.gov
Susan G Komen for the Cure (USA): www.komen.org
Breakthrough Breast Cancer (UK): www.breakthrough.org.uk
Macmillan Cancer Care (UK): www.macmillan.co.uk
American Cancer Society (USA): www.cancer.org
Be warned that there is a lot of advice and treatment options offered on the internet that
is not based on scientific evidence. Many people have sought other methods of treating
cancer but without good results. When you are researching on the internet, it is important
to read critically and not to trust everything you read. Discuss any concerns or readings
you have done with your doctor as he or she will often be able to help you determine the
trustworthiness of the source.
Get support
You do not have to endure 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:
Bosom Buddies: www.bosombuddies.cfsites.org
Reach for Recovery: www.reach4recovery.org.za
Look Good… Feel Better…: www.lgfb.co.za
People Living With Cancer: www.plwc.org.za
Many of these organisations hold meetings for cancer sufferers to receive support and
gain information about the 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.
change (CHānj),
n. The act or instance of making or becoming different.
Dictionary.com
Unfortunately, the answer is that nothing can stop

you from getting breast cancer. All the scientists
and doctors in the world have not yet been able to
determine a way to prevent cancer developing.
But the good news is that we are clear about the

ways we can cure cancer, and that cancer caught
early is normally the easiest to cure.
"There is no way to prevent

cancer from developing."
Can I avoid getting breast cancer?
Why is a healthy diet and lifestyle important?

It is a good idea to lose weight because we know that an increased BMI can increase your risk
of breast cancer after menopause. Following a healthy diet is good for you and can reduce
your risk of other cancers (e.g. colon cancer). It is also good for your heart to eat healthily
and exercise regularly. There is no known way to prevent breast cancer and there is no diet
(despite the claims of some being marketed currently) to prevent or reduce breast cancer.
Changing your life: How can I avoid getting breast cancer? 102
Why are regular mammograms important?

Regular mammography provides a method of early diagnosis and allows doctors to
investigate worrying areas of the breast before they develop into cancer, but it does
not prevent a patient from getting cancer. We have not developed any method of
doing that yet. We only know how to reduce the risk of getting cancer.
Myths: what causes breast cancer?

We may not understand fully why cancer occurs and we may not know how to prevent it,
but we do know what doesn’t cause cancer. Here are some of the myths you may have
heard. The good news is that they are not true.
“The pill causes breast cancer...” concerned that chemicals in many beau-
Many trials have looked at the link be- ty products called parabens, were show-
tween oral contraceptives (“the Pill”) and ing up in the cells of breast cancers. The
breast cancer. The pill contains hormones method the scientists used to investigate
which mimic the hormones that the body this was flawed however, and the link
uses to control fertility (oestrogen and has been disproved. You must always
progesterone) and it has been shown think carefully when reading scare sto-
that these can increase the risk of getting ries about cancer and it is a good idea to
breast cancer. In the decade after the pill get advice from the big cancer organisa-
is stopped however, your risk re- turns to tions who examine these claims carefully.
normal. Only some studies show this risk The National Cancer Institute in the USA
and it seems that it may only affect some believes that there is insufficient data
people, particularly those who are on the to support the link. So, between para-
pill over the age of 40. It is important to bens and cancer for now it is safe to use
discuss this kind of risk before you start paraben-containing anti-perspirants,
the pill, particularly if your family or per- face creams, shampoos and other such
sonal risk of breast cancer is high. products.
“Continual use of anti-perspirants “Wearing a bra can give you can-

and deodorants cause breast cancer...”
cer...” There is no relationship between wearing
This worry comes from the idea that it a bra and getting cancer. It is sometimes
is good for the body to sweat to get rid believed that bras stop toxins flowing out
of potential ‘toxins. If these ‘toxins’ build of the breast, but this has never been
up they may cause cancer. Whilst many proven and does not make anatomical
people are concerned that there may be sense. It is true that obesity is a risk fac-
environmental reasons for people getting tor for cancer, so it may be that slender
cancer, it is unlikely that a failure to sweat women, who may not need to wear bras,
or toxin build-up is responsible. This get cancer less often but it is unrelated
claim has been examined in a study from to the bra.
a large cancer centre in America. It found
no association between anti-perspirants “Drinking water from plastic bot-
and cancer. tles can give you cancer...”
Plastic bottles are made from many
In another study, the investigators were
Changing your life: How can I avoid getting breast cancer? 104
chemicals and some of these, called di- “Using cell phones could be
oxins, have been found to cause cancer harmful to your breasts...”
in animal experiments. It is thought that
The largest study done on this subject,
exposing water to the bottles, especially
published in 2010 could not find a link,
if heated by the sun, can cause the chem-
but it was also unable to disprove a link.
icals such as BPA to flow out into the wa-
One of the problems is determining
ter and increase the risk of cancer. As yet
frequency of cell phone use from self-
there is no correlation between breast
ratings. One type of brain cancer was
cancer and these chemicals in humans.
increased among frequent cell phone
Most disposable bottles used for water
users but overall, they had a lower rate
do not contain BPA but to be on the safer
of cancer than never users.
side you can opt for bottles labelled BPA-
free, or labelled five, four, two or one in
the recycling emblem on the bottom.
“Healthy living” is the new catch phrase of our time. The media is filled
with stories and pictures of people exercising, eating health foods
and living the good life. Taking a look at the evidence, world medical
literature to date strongly suggests that living a healthy lifestyle is indeed
beneficial.
But what exactly is a “healthy lifestyle” and how do we ensure we live

a healthy life? While there is nothing wrong with healthy living, many
of the messages carried in the media are overstated. People are told
to mega dose on vitamins, to follow fad diets and to buy “wonder pills”
that claim to give them new vigour and vitality. Many even suggest they
can prevent cancer.
So, what is the truth?

"Medical literature strongly suggests that
living a healthy lifestyle is beneficial."
What is a healthy lifestyle?

There seems to be a close relationship between dietary fat intake and breast cancer
incidence in most populations. Although this does not prove that a diet high in saturated
fats will significantly increase the risk of breast cancer, it is very suggestive. Closely
associated is the observation that obesity has been shown to double the breast cancer
risk in women after menopause. So, if you are over-weight and over fifty years, your risk
of getting carcinoma of the breast is twice that of an optimal-weight fifty-year-old female.
No association between obesity and breast cancer has ever been demonstrated in pre-
menopausal females or women who are still having their periods. There are many other
advantages to eating a low-fat, high-fibre diet.
Eating a healthy diet We should eat about thirty grams of fibre

Try to replace saturated fat with good, per day. In South Africa, rural people tend
healthy fats in your diet. These so-called to eat more fibre and easily reach this
good fats are unsaturated, either poly- target, but urban people tend to eat half
unsaturated or mono-unsaturated. of this or less. One of the best ways to
boost fibre intake is to supplement your
These are found in vegetable oils such daily fibre intake with a high-quality fibre
as sunflower, safflower, corn and soya supplement. Other ways to boost your
bean oils as well as olive oil, avocados fibre intake include eating unrefined
and rapeseed oil (canola oil). The breads and cereals and plenty of fresh
important component of these oils is vegetables. A recently completed study
the omega-6 fatty acid, linoleic acid. involving more than 40 000 people over
The other good fat is fish oil fat. The a period of ten years in the USA found an
chemicals in fish oil are eicosapentaenoic inverse relationship between increased
acid and docosahexaenoic acid, which fibre intake and decreased heart attacks.
are beneficial to the body. Fish oils tend
to lower the triglyceride fats in the body Avoid heavy alcohol consumption
and contain omega-3 fatty acids and There is a strong correlation between
are found in high concentration in cold high alcohol consumption and breast
seawater fish such as mackerel and cancer. Women who drink more than two
salmon. units of alcohol per day (one large glass
of wine) may have a higher risk of getting
Eat plenty of fresh fruit and vegetables. breast cancer. Before alcohol is given up
These should form a large component of totally, it is important to remember that
any diet since, besides being a source of small daily doses of alcohol are actually
fibre (roughage), these foods contain the good for you. In small quantities it can
antioxidant vitamins (vitamins E, C and reduce the risk of heart disease. This
A) which are the free radical scavengers is because alcohol raises the levels of
in the body. They mop up the toxic free good cholesterol (HDL cholesterol) which
radicals that may play a part in cancer, decreases the chance of coronary artery
heart disease, aging and so on. disease.
Changing your life: What is a healthy lifestyle? 108
What does exercise do for you? cancer has ever been demonstrated, so
Exercise increases good cholesterol smoking does not cause breast cancer.
which is protective against heart disease.
It also helps blood pressure and helps Avoid prolonged stress
you to lose weight. Recent findings from It is difficult to avoid stress nowadays.
a large study in the USA found that breast Although it has repeatedly been
cancer patients who walk or exercise for demonstrated that stress can damage
three to five hours a week are 50% less your health, there is no relationship
likely to die from their cancer. between stress and breast cancer. The
hormones that are affected by stress
Give up smoking however can suppress the immune
Each cigarette you smoke harms your system with decreased wellness. Some
health and passive smoking harms good ways to bring down stress levels
those around you. Cigarette smoke are through exercise or by increasing
causes health problems due to blocked the ability to relax, by using relaxation
arteries, cancer (lung, bladder, oral) and techniques, listening to music, being
obstructive lung disease (emphysema, in nature. Alternative medicine such
chronic bronchitis, aggravates asthma). as aromatherapy, reflexology or
It should be noted however, that no acupuncture may also help.
correlation between smoking and breast
What is good for you?

Eating a low saturated fat, low salt, high-fibre diet.
Taking some supplement or vitamins if you feel you need them.
Exercising regularly (half an hour of aerobic exercise on alternate days is the minimum).
Quit smoking.
Restricting alcohol consumption to two units per day.
Avoiding stress.
What is bad for you?

Taking mega doses of vitamins (particularly vitamin A).
Taking mega doses of minerals (particularly iron, zinc, selenium).
Passive smoking (even if you do not smoke yourself, sitting in a room with other
smokers can be damaging to your health).
Listening to the glib promises of unbelievable vitality if you take this new “natural
remedy”. In other words, beware of the “gurus”.
Not going to your doctor when you notice something is wrong.
It is important to remember that many vitamins, supplements

and herbs contain active ingredients which can interact with
other medications you take. For instance, some supplements can
decrease the effectiveness of breast cancer chemotherapy and
radiation. It is extremely important to consider all supplements
as medications and inform your doctor of what you are taking.
"Consider all supplements as medications."
Supplements for breast health

Evening Primrose Oil (EPO) NOTE: Most multivitamins have levels
The therapeutic use of evening primrose of folic acid, vitamin B6 and vitamin B12
oil (EPO) was long considered as “alter- well above the levels found to be benefi-
native medicine” but today European cial in the Chinese study.
and American physicians commonly
prescribe it as the drug of choice to treat Vitamin B6
mastalgia, i.e. tender and lumpy breasts Vitamin B6 improves the symptoms of
with symptoms of pain and dull heavi- PMS (premenstrual syndrome) and fi-
ness. The effective ingredient of EPO is brocystic breast changes. Some women
gamma linolenic acid (GLA), which in the find that taking vitamin B6 supplements
body turns into prostaglandin (PGE1). It eases PMS symptoms. This is particularly
seems to correct the disturbed fatty acid true for women who suffer from severe
metabolism often prevalent in mastalgia breast pain and fibrocystic breasts, spe-
and PMS. Mastalgia often occurs in con- cifically around the time that PMS symp-
nection with premenstrual syndrome toms occur. The nutrient appears to help
(PMS) for which EPO also is an effective, by assisting the liver in its effort to wash
relatively cheap and safe therapy. The excess oestrogen from the body. In addi-
response to EPO therapy is usually slow, tion, B6 raises levels of the hormone pro-
often requiring over 6 months for full re- gesterone and assists in the manufacture
sults. AVOID DURING PREGNANCY. of serotonin, a neurotransmitter that
enhances mood.
Folic Acid
A team of American and Chinese re- Green Tea or Green Tea Extract
searchers has discovered that folic acid American researchers recently conclud-
(folate) may be effective in helping ed that a compound in green tea inhibits
prevent breast cancer in both pre- and the growth of cancer cells. The secret of
post-menopausal women. The research- green tea lies in the fact that it is rich in
ers found a clear correlation between catechin polyphenols, particularly epi-
dietary intake of folic acid and the risk gallocatechin gallate (EGCG). EGCG is a
of breast cancer. The protective effect powerful antioxidant which, besides in-
of folic acid was even more pronounced hibiting the growth of cancer cells, also
in women who also had a high dietary kills cancer cells without harming any of
intake of vitamin B6, vitamin B12 and the healthy tissue. Further studies have
methionine. Researchers believe that shown, however, that it is unlikely that
folic acid exerts its protective effect by the average intake of green tea will pro-
preventing errors in DNA replication and tect against cancer.
by helping to regenerate methionine, a
vital component in DNA synthesis. They Indole-3-Carbinol
also point out that both vitamin B12 and Cruciferous vegetables of the Bras-
vitamin B6 are vital cofactors required for sica genus, for example broccoli, Brus-
folic acid to “do its job”. sels sprouts, cabbage and cauliflower
contain indole-3-carbinol and research-
Changing your life: What about supplements for breast health? 112
ers suspect that this component is one genetic material of cells that could lead
of several found in vegetables that may to tumour formation. The development
protect against cancer. Diets high in fruits and progression of cancers of the lung,
and vegetables are associated with a de- breast, stomach, prostate, colon, skin
creased risk of cancer. In premenopausal and other body parts may be stalled as
women, a supplement containing I3C and a result.
7-hydroxymatairesinol significantly in-
creased the urinary 2:16-hydroxyestrone Rooibos Tea
ratio, a known biomarker for the reduc- Rooibos Tea has been thought to be a
tion of breast cancer risk. Because it may healthy alternative to other types of
induce cytochrome P450 enzymes (14), hot drinks. It contains 37 antioxidant
I3C may interact with several medica- compounds which destroy harmful free
tions. Root vegetables such as turnips radicals in the body, thus protecting the
also contain some indole-3-carbinol. cells against attack. There has never been
a scientific study of the potential cancer-
Grape Seed Extract fighting benefits of rooibos tea, however.
The antioxidants in grape seed extract
work hard at helping to control cellular
damage, routinely hunting down and
neutralising mutations within the
Increasing your general wellness means increasing your

knowledge of diseases and understanding your risks. Your risk
of becoming ill or suffering from different medical conditions
changes throughout your life. This is a guide to the ways you
can maintain good health and increase your vigilance against
possible diseases throughout the course of your life. It is
important to have a general practitioner who will get to know
you and understand your health conditions from as early a stage
as possible.
"Your risk of becoming ill changes

throughout your life."
Screening for other cancers

I am a young woman (19-39)
General health: Get a full check-up once a year, including a discussion about weight,
smoking and alcohol consumption. This also includes surveillance for depression, thy-
roid diseases and surveillance of moles.
Heart: Have your blood pressure checked every year, and cholesterol checked routinely.
Reproductive screening: Have a cervical (Pap) smear every year for cervical cancer
screening. Ensure you know your HIV status and practice safe sex.
The senses: Have a hearing test every ten years. Make sure you are seeing your dentist
regularly to avoid nasty surprises.
I am in my middle age (40-49)

• General health: Get a full check-up once a year, including a discussion about weight,
smoking and alcohol consumption. This also includes surveillance for depression, thy-
roid diseases and surveillance of moles.
• Heart: Have your blood pressure checked every year, and cholesterol checked routinely.
• Blood sugar: Ask your doctor to check your blood sugar level to check for diabetes
every one to three years.
• Reproductive screening: Continue with cervical (Pap) smears every year. Ensure you
know your HIV status and practice safe sex.
• The senses: Have a baseline eye test at 40 and continue every two years. Continue
with hearing tests every ten years and make sure you are seeing your dentist regularly.
Changing your life: Are there other cancers I can be screened for? 116
I am a mature woman (50-65)

smoking and alcohol consumption. This also includes surveillance for depression,
thyroid diseases and surveillance of moles.
• Blood sugar: Ask your doctor to check your blood sugar level for diabetes every one
to three years.
• Strong bones: Discuss having a bone mineral density test after you reach menopause.
• Reproductive screening: Continue with cervical (Pap) smears every year. Ensure you
know your HIV status and practice safe sex.
• Keeping a healthy gut: Guard against colonic polyps and cancer by having a flexible
sigmoidoscopy every five years or colonoscopy every ten years. Fecal occult blood tests
may also assist in ensuring any colon problems are picked up before they develop into
cancer.
• The senses: Continue to have an eye test every two years. Continue with hearing tests
every ten years and make sure you are seeing your dentist regularly.
I am older and wiser (above 65 years)

smoking and alcohol consumption. This also includes surveillance for depression,
thyroid diseases and surveillance of moles.
• Blood sugar: Ask your doctor to check your blood sugar level for diabetes every one
to three years.
• Strong bones: Have at least one bone mineral density test to ensure you are not at risk
of increased fractures from weak bones.
• Reproductive screening: If you have had three negative smears and are not at high risk,
you can choose whether to stop having cervical (Pap) smears. Ensure you know your
HIV status and practice safe sex.
• Keeping a healthy gut: Guard against colonic polyps and cancer by having a flexible
sigmoidoscopy every five years or colonoscopy every ten years. Fecal occult blood tests
may also assist in ensuring any colon problems are picked up before they develop into
cancer.
• The senses: Continue to have an eye test every two years. Continue with hearing tests
every ten years and make sure you are seeing your dentist regularly.
Picture Credits
Fig. 1.1: http://www.healthcentral.com/breast-cancer/h/cryoablation-of-breast-fibroadeno-
ma.html.
Fig. 1.2: http://dcregistry.com/users/breastcancer/fibroadenoma.jpg
Fig. 1.3: http://www.ultrasound-images.com/images/giant-fibroadenoma-1a_small.jpg
Fig. 1.4: http://biij.org/2006/2/e33/fig6.asp
Fig. 1.5: http://www.surgical-tutor.org.uk/default-home.htm?core/neoplasia/fibroadenoma.
htm~right
Fig. 1.6: http://radiographics.rsna.org/content/vol19/issue90001/images/large/g99se24g1b.
jpeg
Fig. 1.7: http://www.issoonline.com/content/2/1/26/figure/F1
Fig. 1.8: http://radiologyspirit.blogspot.com/
Fig. 1.9: http://www.imageonemri.ca/trellis/Case_Studies
Fig. 1.10: http://www.imageonemri.ca/trellis/Case_Studies
Fig. 1.11: http://www.pathologyoutlines.com/topic/breastgalactocele.html
Fig. 1.12: http://www.sciencephoto.com/media/251958/view
Fig. 1.13: http://www.glowm.com/index.html?p=glowm.cml/section_view&articleid=304
Fig. 1.14: http://www.vashishtsurgicalservices.co.uk/benign_disease/patient_info/benign_
breast_infection.htm
Fig. 1.15: http://www.vashishtsurgicalservices.co.uk/benign_disease/patient_info/benign_
breast_infection.htm
Fig. 1.16: http://www.howtocureshingles.com/blog/wp-content/uploads/2011/07/shingles-
images-5.jpg
Fig. 1.17: http://www.zostavax.com/shingles-photos.html
Fig. 1.18: http://www.prplastic.com/inverted_nipple_2.htm
Fig. 1.19: http://global-clinic.info/dis.php?cid=6&id=194
Fig. 2.1: http://www.fastbleep.com/medical-notes/surgery/24/66/420

Fig. 2.2: http://joespulpbits.com/2010/07/07/listen-to-your-body/
Fig. 2.3: http://breastcancerawareness.net/tumor-testing-breast-cancer-stages-622.html
Fig. 2.4: http://www.rcsed.ac.uk/RCSEDBackIssues/journal/svol2_5/205005.html
Fig. 2.5: http://rockisrocknbeads.blogspot.com/2012/10/mastectomy-photos-without-recon-
struction.html
Fig. 2.6: http://www.yalemedicalgroup.org/stw/images/155072.jpg
Fig. 2.7: http://quadrille2010.blogspot.com/2010_09_01_archive.html
Fig. 2.8: http://chemotherapyadvices.com/antimicrobial-chemotherapy/
Fig. 2.9: http://www.picturesdepot.com/medical/21109/male+breast+cancer.html
All supporting imagery purchased from Shutterstock.com.

What women should know: A book about breast health
Published by Platinum Life (Pty) Ltd
39 Ferguson Road
Illovo, Sandton
2196
Tel: 0860 542 542
For further information or advice about breast health, or to discuss a problem, contact:
Netcare Breast Care line: 0860 233 233
www.breasthealth.co.za
[email protected]

BreastHealth 201905

Uploaded by

Copyright:

Available Formats

BreastHealth 201905

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

BreastHealth 201905

Uploaded by

Copyright:

Available Formats

Disclaimer

“What women should know: A book about breast

Always consult your medical practitioner before

The publisher shall not be held responsible for

Benign breast problems

Changing your life

What is a triple assessment? 60 What are the side-effects of breast 79

Folic acid 111 Are there other cancers I can be 113

Early detection is directly linked to a better chance of survival, and so it is of the

About the author

In the past we used to categorise breast masses according to the

who have one fibroadenoma mobile lump that can be easily

Phyllodes Tumours There are no identified risk fac-

Fig. 1.7: A severe case of fat necrosis.

Breast Hamartomas Fibroadenosis

Fig. 1.8: Sonar of hamartoma.

Blood (red or black) in this fluid or com-

Breast infections most commonly affect women

"Breast infections are common."

Milk must be expressed from the in-

As the infection develops, if left untreat-

Thrush manage treatment of these scesses this infected fluid

Pain in the breast is a frequent complaint. All women will experience

It is easiest to approach pain according to the symptoms and

When is a breast pain not a breast pain?

When it doesn’t come from the breast.

Fig. 1.16: Shingles on the back of a patient.

What is breast pain then?

prolactin levels. Women

What is breast pain then?

How can I treat this pain?

Previously, breast pain was treated with Would surgery help?

Getting the right fit...

your bra doesn't fit properly if:

Getting the right fit...

your bra will fit properly if:

0 = AA cup 1 = A cup 2 = B cup 3 = C cup

Every woman is different in her personality, her looks,

"Every woman's breasts are unique."

Breast abnormalities from birth

Unusual breast shapes

Amazia (absent breast) Breast enlargement in the

"Everyone is at risk of getting breast cancer."

Who gets breast cancer?

Eventually the tumour decides to break up and uses the blood-

Is breast cancer common?

Among cancer related deaths for women worldwide, breast cancer

Who gets breast cancer?

How treatable is breast cancer, if caught early?

Do chances of survival drop if caught later and,

All women are at risk of contracting breast cancer. After all,

Also, it is important to remember that three-quarters of

It does not mean you are going to get breast cancer.

Risk factors that cannot be controlled:

Risk factors that can be avoided:

Cancer knowledge is about lifestyle change but more importantly

It is not uncommon for more than one member of a family to get

Faulty genes in my family?

Number of relatives A young age when the Pattern of different