Breast cancer: where do we go from here?

Over the last six weeks there have been important developments in this healthcare field.

As leaders in breast health in South Africa, we have been involved in all of these activities, including the biennial meeting of Breast Surgery International held in Canada and the Breast Health Global Initiative held in Hungary. Here the implementation of guidelines, including guidelines for cost effective breast health management in developing countries were discussed.

Some facts about breast cancer in South Africa:

An estimated 6,000 women are diagnosed with breast cancer in South Africa each year - about 80% of this number depend on the government to provide healthcare.

All women are at risk of developing breast cancer. Urbanisation and a westernised life-style have contributed to increased numbers of breast cancer – in 1997, 140 new cases were registered at Tygerberg Hospital, this year we expect about 350.

For the majority of these women treatment means the loss of a breast and later, the loss of life.

From a health administration perspective, the final years of these women's lives will be costly - therapy with expensive drugs, radiation and hospital stays.

Are we doing enough with the limited resources at our disposal?

The increasing shortage of healthcare workers in South Africa is a reality. In the Western Cape, the combination of breast health management expertise and the availability of radiation, chemotherapy and advanced surgery are restricted to two academic hospitals in Cape Town.

Earlier diagnosis of breast cancer can change the disease from lethal to curable for most women, yet early diagnosis is not happening, pointing to a failure of educational campaigns.

The most realistic way of detecting cancers early in South Africa is clinical examination.

In 2000, at the development for a Breast Cancer Screening Policy for the National Department of Health, we argued mammograms were out of reach in our communities, as the infrastructure and expertise was not available; nothing much has changed in this respect.

It is not that women are unaware of lumps in their breasts - they simply do not enter the health infrastructure for a painless breast mass. Clinical examination, which is cheap and enforces the importance of self-monitoring, would detect many masses at incidental contact. Therefore community care centres should be required to conduct annual breast examinations when they come into contact with women over 35 years.

We have offered to support the community health centres in teaching clinical examination skills and speed up referrals for women with problems.

Diagnosis for women with breast masses should be pathology driven - a prerequisite to be seen at our breast clinic. Although the Department of Pathology at Tygerberg Hospital has been training community centre staff in the technique of fine needle aspiration - a simple way of establishing a diagnosis of malignancy - much still needs to be done.

All too often colleagues still have to take women to theatre to establish a diagnosis by open biopsy.

This is a huge waste of scarce resources on top of the trauma caused to women.

Mammograms should be restricted to academic centres to generate the minimum quantity of examinations necessary to maintain and grow expertise in line with Breast Health Global Initiative guidelines. Money earmarked for mammography at secondary hospitals would be wiser spent on improving pathology services. Furthermore, it is difficult to understand why in the Western Cape, where the only course leading to certification in mammography is offered, tertiary hospitals have to make do with outdated equipment, and the Gauteng and Natal tertiary hospitals, with a much lower disease burden, are equipped with the latest technology.

Surgical therapy for breast cancer is increasingly taking place at secondary hospitals, without the advanced technical options available at tertiary level.

Research has shown this may result in more than half of women receiving inadequate therapy.

Breast cancer management must be restricted to hospitals with more than 100 cases per year. In our province, only Tygerberg and Groote Schuur Hospitals achieve such numbers.

Medical oncology needs to be brought up to date - the Western Cape is stuck with chemotherapy that is outdated by about 10 years and therefore stuck at a "basic" level according to the Breast Health Global Initiative guidelines. In provinces with much less of a breast cancer burden, modern agents such as taxanes are more freely available.

Our motivation for these agents has not even received recognition, indicating an administrative problem at drug provision level in our province rather than engagement for the benefit of our women. We are aware that these drugs are expensive; on the other hand, women's lives depend on them.

So where do we go from here?

A summary of suggestions:

- Pathology services must be improved for primary and secondary health care centres.
- Imaging for breast cancer must be restricted to tertiary centres.
- Breast cancer management must be restricted to high volume environments, i.e. more than 100 cases per year, where multidisciplinary clinics optimize outcomes.
- Medical oncology must be brought up to date with access to taxanes and biologicals.