Breast cancer accounts for a quarter (24.11%) of all cancers in South African women. In 2022 alone, there were over 11 000 new cases. And, it is the leading cause of cancer deaths in women worldwide. It’s also increasingly detected in women under 40. This trend mirrors global patterns: younger women are being diagnosed with more aggressive forms of the disease, underscoring the need for early detection and awareness. While lots of attention is given to self-screening, the importance of mammograms and knowing the symptoms, what happens after a breast cancer diagnosis is more mysterious. That’s because the next steps differ according to the diagnosis and recommended treatment options. Dr Maré Du Plessis, a specialist surgeon at Mediclinic Milnerton, lent his expertise.
Meet the experts: Dr Maré Du Plessis is a specialist surgeon at Mediclinic Milnerton. He works as part of a team with oncologists to care for breast cancer patients.
Now That We Have Sophisticated Mammography, Is Self-Examination Still Important?
With mammograms, experts are now able to detect very small lesions early on. “But sometimes a patient will feel a lump and that abnormality does not show up on the mammogram. We always encourage patients to do self-examination as well,” explains Dr Du Plessis. Bottom line: yes, self-examination and screening mammography in combination are crucial and advised.
You Feel A Lump In Your Breast – Now What?
“You need to see a doctor who can perform an examination, and then order imaging investigations of the lump to be done,” says Dr Du Plessis. Based on those findings, the doctor will most likely recommend a biopsy to extract a sample of the tissue inside the breast, to determine whether it is cancerous. If there is a cancer diagnosis, the next step is to establish what stage the cancer has progressed. Finally, the oncologist will speak with you before deciding on treatment. This is determined by the clinical findings and further radiological investigations.
“In the case of more advanced cancer, chemotherapy treatment is typically indicated ahead of surgery, to shrink the tumour,” explains Dr Du Plessis. “With stage one and two breast cancer, surgery is usually the first step.”
READ MORE: What To Know About Breast Cancer As A Young Woman
What’s A Biopsy?
The biopsy is a medical procedure that removes cells, tissue, or fluid from the body – in breast cancer, tissue – to examine and test if cancer is present. And no, it doesn’t have to involve surgery, says Dr Du Plessis. “The biopsy is almost always done by the radiology team, under ultrasound guidance, or by doing what is called stereotactic biopsy,” he explains. “They use the mammogram machine to locate the lump with a needle and thereafter a needle biopsy is performed.”
When Does Surgery Happen For Breast Cancer?
“Treatment of breast cancer is multifaceted,” says Dr Du Plessis. “Surgery is generally the main course of action, but there are other forms of treatment.” These include chemotherapy, radiotherapy and in some cases hormonal therapy. Sometimes, Dr Du Plessis receives a referral after a mammogram has picked up the lump, or the patient has felt the lump, so a diagnosis hasn’t been made yet. “Other times,” he explains, “a general practitioner already sent the patient for a biopsy and the cancer diagnosis has already been made. I will always work as a team with an oncologist, as surgery is just one of the many components of breast cancer treatment.”
Ultimately, the treatment depends on the stage of the cancer, which is dependent on the size of the lump and whether there’s any evidence of spread to the lymph nodes in the armpit or into the axilla (where the arm connects to the shoulder). And, your oncologist will also want to know if any cancer is present elsewhere in the body.
Dr Du Plessis Explains How Some Cases Are Assessed:
“If it is stage one or two cancer, usually there is surgery only. But sometimes, there is the possibility of radiotherapy, or potentially hormonal therapy as well after stage one and two breast cancer surgery. In certain cases of earlier stages of breast cancer, chemotherapy may still be indicated. This would be based on further tests performed on the biopsy sample taken.
With stage three breast cancer, almost always, we first do what we call neoadjuvant chemotherapy. That means the tumour is too big for surgery. In order to achieve clear margins and ensure success of the curative surgery, we wait until chemotherapy has shrunk the tumour, which can take about six months. In most cases with stage three breast cancer, the patient will also have radiotherapy after the surgery has been done.”
READ MORE: 11 Symptoms Of Breast Cancer In Women That Aren’t Lumps
When Is Hormonal Therapy Done – And What About Chemotherapy?
“Some breast cancers are sensitive to oestrogen and progesterone,” explains Dr Du Plessis. “The circulating oestrogen progesterone in the patient’s bloodstream make the tumour grow.” When the pathologist picks this up, hormonal therapy is given in the form of an oestrogen and progesterone blocker (hormonal therapy). This helps with reducing the rate of recurrence of breast cancer.
Chemotherapy can be indicated before or after breast cancer surgery, like in the cases mentioned above. Neoadjuvant chemotherapy is a treatment that happens before the main treatment, in this case, surgery. “It’s designed to shrink the size of the tumour and to address confirmed involvement of the lymph nodes in the axilla (the armpit),” says Dr Du Plessis. “Adjuvant chemotherapy means we give chemotherapy after the surgery. This generally happens where the cancer was thought to be early breast cancer, but testing of the tissue post-surgery indicates a higher stage. Or, when a breast cancer type is more prone to recurring.”
Does A Mastectomy Always Mean Both Breasts Are Removed?
“We don’t just offer a patient a bilateral or double mastectomy just because they have breast cancer. The risk of complications with bilateral mastectomy outweighs the benefit – if it’s not medically necessary,” says Dr Du Plessis.
But! If you have the BRCA 1or BRCA 2 genetic mutation (which means there is an 85 to 90% chance of developing breast cancer again in future), it’s advisable to undergo a double (bilateral) mastectomy. And, for all young breast cancer patients, patients under 40, or those with a family history of breast cancer, Dr Du Plessis says they test for the BRCA 1 and 2 genes.
Options Available
“There are generally three options for breast cancer patients, and these options are decided on by consultation,” says Dr Du Plessis. “Either you have a lumpectomy (a wide local excision) or a mastectomy, or a bilateral/double mastectomy.” With a mastectomy, the whole breast is removed. When a lumpectomy is indicated for a smaller tumour, the patient might still decide to have a mastectomy.
These decisions are based on the size and stage of the tumour, as well as the size of the tumour in relation to the size of the breast. “A lumpectomy on a small breast, for instance, may not have a cosmetically acceptable result. We may advise a mastectomy in this scenario,” says Dr Du Plessis.
And neither is a superior treatment either, says Dr Du Plessis. “Mastectomy is not superior to a lumpectomy with regard to oncological outcomes or chance of cure,” he says. “If the tumour is small and can be properly removed by a lumpectomy, that is generally what we would recommend.”
With a lumpectomy, Dr Du Plessis says the patient receives radiotherapy afterwards. This is to minimise the chance of any microscopic cancer left behind. “So, a patient must be willing to do radiotherapy after surgery if they choose to undergo a lumpectomy,” he says.
What Is The Cure Rate In Breast Cancer?
After completing all the available modalities of breast cancer treatment, the five-year survival rate of stage one and stage two breast cancer is between 90 to 100 percent. For stage three disease, the five-year survival rate is close to 70 percent.
READ MORE: What The Stages of Breast Cancer Mean, Including Each One’s Estimated Survival Rate
