Digital mammography is the way to go, say breast-health specialists. Here, computer scientist Marina Jirotka examines the Digital Mammography National Database at Oxford University. Picture: JONATHAN PLAYER, The New York Times

IT REMAINS one of women’s darkest fears, clouded in myth and misinformation, but breast cancer can be beaten, and the latest mammography technology is playing a key role.

Survival rates are excellent, especially when the disease is caught early enough, says Prof Justus Apffelstaedt. He is associate professor of surgery at the University of Stellenbosch and head of a Cape Town multidisciplinary breast health clinic that is one of the first services to offer full-field digital mammography in SA.

October is Breast Cancer Awareness Month. Apffelstaedt is keen to sift out the facts from all the fiction that exists about breast cancer. Mammography is a prime example. It is key to fighting the disease, yet many people believe one form of mammogram is as good as another.

Not true, says Apffelstaedt. Full-field digital mammography is state of the art and “the way to go” for good reason, he says. It is proven to be much better than conventional mammography in picking up cancer in dense breasts (the word is used not about size, but to describe the property of certain breast tissue).

It is clearly possible for mammography to miss a cancerous lump in the breast, but the fact is that in specialised centres, 95% of lumps will be detected early enough by mammography and ultrasound, he says.

More importantly, when it comes to survival rates, tumours can be detected when they are small enough (less than 1cm in diameter) rather than the 3cm to 4cm size of lumps usually picked up by women who examine their own breasts.

The smaller the tumour, the larger the survival possibilities.

And irrespective of breast density, all women benefit from this technology.

For starters, he says the radiation dosage they will receive is much less - 40% of conventional mammography.

There is also less compression required, which means less discomfort during the procedure.

And there are distinct psychological advantages: the patient does not have to be left alone in the room as the radiographer goes off to develop the film, which can take up to five minutes.

That can seem like a lifetime for a woman waiting to see if anything sinister shows up in the captured image.

The radiographer or doctor reading the image can do post-acquisition manipulation, which dramatically cuts down on the need to reshoot the image.

It is also a “green technology”, he says, as there are no chemicals required in development of the film. The equipment is expensive (it costs about 10 times more than conventional mammography devices), and will thus only be found in high-volume centres.

One fiction that has popped up in recent years is that the incidence of breast cancer is increasing among younger women.

Apffelstaedt says that myth is probably due to young celebrity women (the most recent being Australian song bird Kylie Minogue) who increase media coverage of their cases.

However, it is a dangerous fiction to believe that breast cancer is mostly a middle-aged or elderly white woman’s disease and that black women have a lower risk of breast cancer.

Apffelstaedt says that is “probably not true”, and is far more likely to simply reflect black women’s reduced access to breast health care.

For black women, the peak incidence may be a decade or so earlier than white women, somewhere between 35 and 50. But Apffelstaedt says there are no good statistics to prove that as the breast-cancer registry “isn’t working too well”.

If there is any group that has been blessed with a low incidence of the disease it has been Asian women. However, Apffelstaedt says “in the eastern world the incidence of breast cancer is rising rapidly as they westernise”.

That gives a lie to the fiction that there is no link between breast cancer and diet.

It is difficult to quantify scientifically and say a particular food will reduce your risk of breast cancer, he says. However, the link between obesity, sedentary living and breast cancer rates is there for all to see. It is connected to unhealthy lifestyle habits one of which includes unhealthy eating. But physical activity is also important, and not just as a possible preventative measure.

Women who are physically active have a 30% reduced risk, and if they are physically active after being diagnosed, their recurrence is 30% lower.

One bad lifestyle habit that is not linked to breast cancer is smoking, says Apffelstaedt. Alcohol consumption, on the other hand, is. So is urbanised living. Yet the reality is that breast cancer does not discriminate, and when it comes to risk groups, anyone who has breasts can get it, he says, though of course men have a much lower incidence of it, thanks to their hormonal makeup.

When it comes to treatment options, one fiction is that chemotherapy contributes significantly to reducing mortality. That comes down to semantics: “You have to be careful how you use the word significant in this instance,” he says.

The contribution of chemotherapy to reduced mortality is significant in a statistical sense, but not in layman’s terms. Women should not expect to be magically cured by chemotherapy. It does increase survival odds, but only marginally. A multidisciplinary approach that combines a number of treatment options that include surgery, radiation, chemotherapy, hormonal and biologic agents is most effective.

That leads to Apffelstaedt’s advice to women that may sound controversial to some ears: “If you are diagnosed with the disease, go to a specialist centre, one that deals with breast health only.”

Some people say it doesn’t make a difference where you are treated if you have breast cancer. Apffelstaedt begs to differ. Of 125 studies, 123 have shown a direct link between the outcome and volume of cases a centre has seen. The risk of death in five years can be up to 60% higher in environments where only few breast cancers are treated compared with environments where more than 150 breast cancers are treated a year.

“This effect is larger than any chemotherapy, hormonal therapy and radiation,” he says. “It makes sense when you think about it. After all, if you buy an expensive car, you have it serviced by the agents, because you know they have the tools and the specialist know-how to look after your car best. The same applies to your body. ”

Also, specialist centres, which see more than 150 cases of breast cancer a year will achieve the best results as the most accurate diagnosis will be made and the most appropriate treatment options chosen, he says.

And women do not have to fear losing their breasts. It is not true that removing the entire breast is better than breast conservation. Breast conservation is not a new approach to treating cancer, says Apffelstaedt; it’s more than 20 years old.

Unfortunately, some specialists say there are still some doctors out there who are a little too “scalpel happy”, and remove the breast as first resort.

The fact is, says Apffelstaedt, that breast cancer metastasises (spreads) to places outside the breast. The tumour in the breast will not kill you — the spread of the cancer to areas such as the brain, lungs, will. As breast cancer often does that early in the course of the disease, a mastectomy will not guarantee better survival than breast conserving therapy.

In a well run, multidisciplinary breast health centre, out of 100 women with breast cancer, 60 will have breast conservation, 35 will have a mastectomy (surgical removal of the entire breast) with immediate reconstruction, and only five will leave the theatre without either their breast or a reconstructed breast. That points to the benefit of a specialised centre with a multidisciplinary team, Apffelstaedt says. “When the diagnosis is made, the patient is seen by a team consisting of an oncologist (cancer specialist), radiation oncologist, oncologic surgeon and plastic surgeon, who together decide on treatment.

That also points to one of the reasons Apffelstaedt is so messianic about mammography - full-field digital and by properly qualified staff: it can effectively change breast cancer from a “subacute lethal disease to little more than a speed bump in your life”.

He does not underestimate the distress women will feel at a diagnosis, and of course they will need intensive therapy, but detecting cancer early allows them to “keep their breast and their life”. His advice to women could come straight out of the Bob Marley song: “Get up, stand up and fight for your rights.”

SOME questions to ask when looking for a mammography centre:

- Is the radiographer additionally certified in mammography, and how many mammograms are done daily or annually? This is a case of more is better. An annual figure of about 2500 is a good minimum.

- Will my mammogram be read by at least two readers who both have been trained overseas in mammography interpretation?

- Are complete outcome records kept?

- If you are happy with the facility, go regularly so your mammograms can be compared year on year.

- If you change centres, ask for your previous mammogram films and take them to the new centre for comparison.

- Bring as much data with you as you can about previous mammograms and breast health history. Include dates and places of previous mammograms and other breast imaging, biopsies or treatments you may have received.