IMAGINE hearing someone say that treating women with breast cancer is a pleasure, because the outcome can often be good for those concerned. Those are the words of Prof Justus Apffelstaedt, head of the Breast Clinic at Tygerberg Hospital and associate professor of surgery and head of the Surgical Oncology Service at the University of Stellenbosch.

He recently returned from the 6th European Breast Cancer Conference where he presented a paper on the “Status of Breast Care in South Africa”. It was held in Berlin and was attended by the “who’s who” in world breast cancer. The 5300 delegates included doctors, surgeons, clinicians, scientists and patients. They discussed not only scientific advances in treatment but, equally importantly, they talked about the ethical, social, political and practical issues associated with breast cancer patients. They looked at the whole woman, not just one part of her.

“Today you could say with breast cancer patients living for much longer than they did in the past that we have breast cancer survival solved. What we’re increasingly concentrating on now is quality of life. That’s the new buzz phrase,” says Apffelstaedt.

It’s one that will sing in the ears of hundreds of thousands of women who’ve suffered from a disease that not only carries a potential death sentence but also has serious social and psychological consequences depending upon the treatment a woman receives.

Previously, the emphasis was less on how a breast looked after the operation: “We were intent on saving lives — and the combination of surgery and radiotherapy often left the conserved breast cosmetically unacceptable. Now that the survival rate is so much better we’re becoming more sensitive to the aesthetic needs of the breast cancer survivor.”

Oncoplastic surgical techniques make it possible for a woman to wake up post-operatively with a beautiful breast from the start.

Typically a woman diagnosed with breast cancer is initially in shock and unable to fully comprehend all the information. Yet by the time she feels a lump, the cancer has been there for four to five years and there’s no need to rush into theatre. “When we tell someone she’s got breast cancer we send her home for a few days because she’s shattered and needs to absorb the diagnosis,” says Apffelstaedt.

When she returns she is advised to take her partner and they meet a team of surgical, medical and radiation oncologists as well as a plastic surgeon. Options are discussed, the patient returns home, talks to family and only then are final plans made.

If surgery is required it often becomes an oncoplastic procedure, a concept that encompasses plastic surgery techniques to reshape the remaining breast after a tumour excision or to reconstruct the breast after a mastectomy. It includes correction of imbalance relative to the natural unaffected breast.

It is a welcome concept for women with breast cancer who not only have to deal with the diagnosis and life- changing implications of the cancer, but also the effect of possibly disfiguring surgery to their breast.

Once the operation is over and the results of the tissue pathology are back, the patient meets the team members again who then advise a way forward particular to her needs.

The important issue is that a woman should not be sent from one specialist to another, asking different doctors about options. Women need the support of a team approach. Apffelstaedt says that “patients should not accept primary breast cancer treatment outside a multidisciplinary team. Today breast reconstruction can safely be done in the same session as the mastectomy.”

The idea that patients had to wait for between one to five years for reconstruction is outdated.

Chemotherapy was one of the many topics discussed at the conference. Delegates were surprised by the findings of a large trial using Taxane chemotherapy, a form of treatment that’s four to six times more expensive than traditional antracycline based chemotherapy. Taxane chemotherapy did not show a significant increase in survival rates, “which means that most women can continue to have the more cost effective antracycline based chemotherapy”, says Apffelstaedt. Additionally, there are more side effects with the Taxane chemotherapy.

While theoretically a woman has a choice of therapy, in reality that decision is usually made by the oncologist. However, today with the internet making individual research  so much easier, there’s no harm in being informed.

Apffelstaedt points out that, “we have reached our limits using conventional chemotherapy, we’ll not see more significant improvements because its run is over. Now the emphasis will be on biologicals.” These are a new class of drugs that target metabolic pathways. A specific characteristic of a tumour is identified and the biological drug acts only on that characteristic. The approach is a bulls-eye one rather than a scatter gun. This is both effective and lessens potential side effects.

A good example is Herceptin which halves the recurrence rate in certain types of breast cancer. “We’ve not seen anything like this in cancer treatment for the past 30 years.” But biologicals are extremely expensive. Herceptin is available in SA but the cost of a standard regimen is about R300000.

“You can’t expect a medical aid to bankrupt itself on one form of treatment to the cost of other scheme members,” says Apffelstaedt. He suggests women opt for the best medical aid they can afford, as it’s unrealistic to expect top treatment with fourth rate subscriptions.

About 60% of women experience problems like depression after they have been diagnosed with breast cancer. Conference delegates discussed the effect of psychiatric intervention on the quality of a breast cancer patient’s life. It emerged that while therapy improves the quality of life of cancer patients it doesn’t extend their lives.

“It was previously thought that if women have psychiatric treatment they will live longer but contrary to general expectation that’s not the case,” says Apffelstaedt.

Another major topic of discussion was infertility in younger breast cancer patients. “Many of the treatments have an impact on a woman’s fertility and, depending on the treatment, 95% to 100% of patients can be infertile after it,” says Apffelstaedt. He adds that it’s a poorly researched subject but figures quoted at the conference showed that only one third of pregnancies resulted in childbirth after cancer therapy. The reason for this was not yet clear.

With the trend for women to put off having babies until they are older, when they tend to have fertility problems anyway, this has become an area of research. Methods of freezing foetuses or ova (eggs) were being studied but the failure rate was high.

“Specialised centres are looking at removing part of an ovary prior to cancer treatment and then replacing it once that is complete but results from this approach still need further confirmation,” says Apffelstaedt.

In a new development, Newswise reports on a US study in which scientists say they have uncovered a chemical reaction in genes controlling breast cancer that provides a molecular clock that could one day help to more accurately determine a woman’s risk for developing breast cancer and provide a new approach for treatment.

In the research, published in the latest issue of Cancer Epidemiology Biomarkers & Prevention, scientists from the University of Texas, Southwestern Medical Centre show that the chemical process, called methylation, is strongly correlated with breast-cancer risk and with precancerous changes in breast cells.

The researchers determined that methylation acts as a type of biological clock, indicating how many times a cell has divided. This information could aid researchers in determining an individual’s cancer risk.

“The more a cell has divided, the greater the risk for cancer,” Dr David Euhus, professor of surgical oncology says in the Newswise report. “Monitoring methylation levels could give researchers a way of seeing how often cells have divided and where a woman stands on that clock. Once the clock reaches a certain hour, breast cancer is more likely to ensue.

“Interestingly, having children, which is known to reduce breast-cancer risk if it occurs early in life, was associated with a reduction in methylation for some genes,” Euhus says. And while the clock is not always marching forward, there are ways to turn it back. “Methylation can be stopped or slowed down,” he says. “We found that having a baby set the clock back and so did getting close to menopause. Things that are known to reduce breast-cancer risk may also turn the clock backward.”

A test for methylation of tumour-suppressor genes is not yet commercially available and Euhus says additional research is necessary to fully understand the mechanism. Medications that interfere with methylation might provide a new approach for reducing breast-cancer risk, he says. However, measuring tumour-suppressor gene methylation might not work well to predict breast-cancer risk in all women.

For women with a strong family history of breast cancer, the concept won’t work because those breast cancers are associated with DNA repair issues and not methylation.

The good news overall is that a disease which terrifies so many has some of the world’s best brains at work on how to treat it from a holistic as well as a surgical and medical perspective. With Newswise