The human body is made of trillions of cells. Normal cells grow and divide as the body requires them. As the cells grow older or become damaged they die. This process in our body is constant and is well controlled and orderly. Cancer is caused when normal human cells in a specific part of our body undergo damage, mutate and behave in a bizarre and disorderly manner. The cancerous cells start to grow and they divide in an uncontrolled fashion eventually forming a mass or a tumour. In the breast this may occur in the cells of the milk ducts or in the cells of the nipple and areola. These cells or part of this tumour may then separate and spread to distant parts of the body where they form new tumorous growths – this ability is what makes the tumour cells malignant.

There are a number of reasons why these cells become damaged in the first place and medicine considers these different reasons in two categories i.e. factors outside our body or extrinsic factors and factors in our body or intrinsic factors. Examples of extrinsic factors include exposure to nicotine, alcohol, radiation, hormone medications etc. Examples of intrinsic factors include a new or inherited genetic mutation, prolonged exposure to our own hormones and age. Usually there are a number of different triggers present causing cellular damage and resultant mutation and eventual cancerous tumour formation.

Breast cancer does not present the same way in every patient and you may not notice any changes, however the disease may present in the following ways:

• A lump that you feel in your breast
• A change in the size or shape of the breast
• Skin changes of the affected breast including an ‘eczematous’ type rash, swelling of the skin, ‘orange-peel’ or a dimpling change to the skin
• A discharge from the nipple which may or may not be bloody
• Breast pain or mastalgia
• A lump in the armpit or axilla

Ideally we would want to know you had breast cancer before you had any symptoms of the disease and this is why early detection is so important. Early detection can be achieved by a mammogram or ultrasound. Increasingly small or early breast cancers which have no symptoms may be found on screening mammography.

There are a number of factors that increase your chance of being affected by breast cancer, these are termed Breast Cancer Risk Factors. Some of these are factors that are totally out of your control such as your age, gender and your family history while others are modifiable such as your exposure to Hormone Replacement Therapy, Smoking, Obesity and Alcohol consumption.

Gender
Breast cancer is the common cause of cancer in women in South Africa after cervical (mouth of the womb) cancer. Breast cancer while most commonly occuring in women can sometimes affect men. In the UK there are approximately 62000 new cases of Breast Cancer each year of which only about 370 are in male patients.

Age
Breast cancer increases with increasing age. 80% of women with Breast Cancer are over the age of 50. At 30 years old your chance of having breast cancer is 1 in 2000 but by age 80 years old this increases to 1 in 10. This is why it is recommended that screening begins at age 40 years old.

Family History
A family history of breast cancer does increase one’s risk. The increased risk is especially true if there are more than one family members who have had breast or ovarian cancer and if family members have been diagnosed with breast cancer at a young age or if there is a history of male family members with breast cancer.

Reproduction Factors
A woman’s body produces Oestrogen as part of the normal female hormone make-up. Oestrogen has an affect on the cells within the breast and increased exposure over your lifetime can increase your risk of Breast cancer by a small amount. An earlier start to your periods – early onset menarche being the technical term – and later onset menopause increase your exposure to Oestrogen. Unfortunately, women who have chosen to delay childbirth to over the age of thirty or have chosen not to have children altogether and those women who don’t breastfeed for whatever reason; also have an increased exposure to oestrogen and therefore a small increased risk.

Hormone Replacement Therapy (HRT)
Many women have unbearable symptoms around the time of Menopause and will have a discussion either with their Family doctor or their Gynaecologist regarding Hormone Replacement Therapy. It is important to remember that your decision to commence HRT should be informed one and take into account your individual risk profile for Breast Cancer. Studies in the USA and in the UK have shown that women who commence HRT do increase their risk of Breast Cancer by a small amount. In real terms this means that for every ten thousand women taking HRT, 38 women will get Breast Cancer versus only 30 women not on HRT. If you had a strong family history of Breast and Ovarian Cancer the benefits of HRT probably do not warrant the increased risk of Breast Cancer.

Smoking
Research shows that especially in women who have started smoking at a younger age and in premenopausal women there is an association with a higher incidence of Breast Cancer.

Alcohol
Alcohol can increase levels of Oestrogen. Alcohol also may increase breast cancer risk by damaging DNA in cells. Compared to women who don’t drink at all, women who have three or more alcoholic drinks per week have a 15% higher risk of breast cancer.

Exercise
Engaging in regular exercise is good for you for many reasons, and one of them is to lower your risk. Many studies conducted over the past 20 years have shown consistently that an increase in physical activity is linked to a lower breast cancer risk. How exercising lowers breast cancer risk is not fully understood. It’s thought that physical activity regulates hormones including Oestrogen and insulin, which can fuel breast cancer growth. Regular exercise also helps women stay at a healthy weight, which also helps regulate hormones and helps keep the immune system healthier.

Obesity
Does being overweight increase your risk of breast cancer? The question has been looked at by many studies and the only clear evidence is that being overweight after you have been through menopause definitely does increase your risk of Breast Cancer. Before menopause the evidence is not clear, however if we take into account that Oestrogen can be produced by the fatty tissue in our bodies then being overweight would increase exposure to Oestrogen. It is wise to be aware of the general health benefits of maintaining a healthy weight.

This article about risk factors outlines some of the risk factors associated with Breast Cancer and is most certainly not exhaustive as there are many other factors that are at play but these are some of the important factors.

You may want to write down a list of questions you have prior to your consultation as very often you may forget what your major concerns are during the consultation.

You can, if you so wish bring your partner or a family member or a friend to your consultation. Please bare in mind that you will be asked a number of personal questions related to your medical history, risk factors and your gynaecological history. Please make notes regarding your current medication including contraception and/or hormone replacement therapy or bring all your chronic medication with you to your consultation.

Try to obtain a complete family history regarding members of your family tree who have been affected by Breast cancer and any other cancer – this includes your maternal and paternal side of the family. Draw a family tree starting with yourself and moving on to your siblings, then move one level up to your parents and each of their siblings (also include any of your first cousins affected by cancer), finally do the same for your grandparents on each side and their siblings.

Be honest about your habits including smoking and alcohol consumption.

The healthcare provider will take a full history from you focused on your past medical conditions, your gynaecological history, your family history of breast cancer and when you noticed the lump.

The provider will perform a physical examination which would include a general examination and a breast examination.

A breast examination requires that you undress your upper body which will include removing your top and your bra. You should be provided with an examination gown to wear and make you feel comfortable. The provider will have to look at your breasts with your arms at your side and then raised above your head while you are seated on the examination table and then examine each breast and feel within the axilla or armpit for any lumps. The provider will take note of differences in size or shape and if there are any abnormalities of the skin of the breast and the nipple. You will then be asked to lay down on your back and the process will be repeated first with your arms at your side and then with your arms raised above your head.

Once the examination is completed the doctor should provide you with a summary of what he/she has found and if there are any concerns. You should be given an outline of your management plan and be provided with an opportunity to ask any questions. A good doctor should also teach you how to perform a Breast Self Examination and become Breast Aware and explain to you how often and when to do this and explain to you what symptoms would be of urgent concern.

Medical imaging of the Breasts uses many different forms of specialised imaging which include mammography, ultrasound, CT or CAT scans and MRI’s. Screening is most commonly done by using mammography and ultrasound where it is needed.

A mammogram is an x-ray image of the breast obtained by a specialised x-ray machine. The image obtained by the machine is captured digitally and is reviewed by a trained radiologist. The radiographer taking the images will usually take up to two images of each breast.

Increasingly ultrasound imaging is also used, especially in younger women or women with smaller and denser breasts as this provides more information about the breasts.

A mammogram is an important step in taking care of yourself and your breasts. You may be scheduled to go for a screening mammogram or your doctor may be requesting a diagnostic mammogram or ultrasound to further investigate a specific problem. Whether you are new to the experience or have had many mammograms, knowing what to expect may help the process go more smoothly.

Firstly, try to go to the same facility or practice every time so that your mammograms can easily be compared from year to year. If you’re going to a facility for the first time, bring a list of the places and dates of mammograms, biopsies, or other breast treatments you’ve had before.

Secondly, schedule your mammogram when your breasts are not tender or swollen to help reduce discomfort and get good pictures. Try to avoid the week just before your period. Please inform the facility or your requesting doctor if you are breastfeeding or if there is a chance that you could be pregnant.

On the day of the exam, don’t wear deodorant or antiperspirant. Some of these contain substances that can show up on the x-ray as white spots. If you’re not going home afterward, you might want to take your deodorant with you to put on after your exam. You might find it easier to wear a skirt or pants, so that you’ll only need to remove your top and bra for the mammogram.

• You’ll have to undress above the waist to get a mammogram. The facility will give you a wrap to wear.
• A technologist will position your breasts for the mammogram.
• To get a high-quality picture, your breast must be flattened. The technologist places your breast on the machine’s plate. The plastic upper plate is lowered to compress your breast for a few seconds while the technologist takes a picture.
• The whole procedure takes about 20 minutes. The actual breast compression only lasts a few seconds.
• You might feel some discomfort when your breasts are compressed, and for some women it can be painful. Tell the technologist if it hurts.
• Two views of each breast are taken for a screening mammogram. But for some women, such as those with breast implants or large breasts, more pictures may be needed.
• In almost all patients an ultrasound may be performed as well to get a better or different view of specific areas in the breast that may be of concern.

A biopsy may be done when there is an area of concern on your mammogram or ultrasound or if there is an obvious lump in your breast. The biopsy result will help to plan the further management of the breast problem once the final diagnosis.

The biopsy may be a needle biopsy which is performed under local anaesthetic or you may require a larger biopsy which may need to be performed in theatre. A needle biopsy is the most common biopsy and may be done by the surgeon you have consulted with if the lump or area of concern is easy to feel or maybe done by the radiologist using an ultrasound machine to identify the specific area, if it cannot be easily felt.

In both cases the doctor performing the biopsy will clean the skin overlying the area with a disinfectant solution so as to prevent infection and then will administer a local anaesthetic to the skin. He will then use a specific biopsy needle to obtain tissue from the area which needs further investigation. The procedure does have a certain amount of discomfort but is necessary to help in your management. The tissue obtained is sent to a laboratory for the Pathologist to examine under a microscope. The pathologist will make every effort to see if any of the cells in the tissue are cancerous.

The first step after you are diagnosed is to establish the stage of Breast Cancer. The staging includes the type of cancer, the size of the breast lump (remember some cancers may only be found on imaging and there may not be a lump), the condition of the skin and nipple of the affected breast, if there are any lumps in the armpit or axilla and finally if there is any evidence of distant spread of the cancer.

The treating surgeon or oncologist will request further investigations to get all of this information. He/she will use the information already gained from the imaging and the biopsies and may request further tests to establish if there is any spread of the cancer. You may be required to have further blood tests, a chest xray and an ultrasound of your liver. If you have any other symptoms or if any of these further tests show any suspicious areas your doctor may request a Bone Scan or a PET CT scan.

If the results show that there is no obvious distant spread then the treating surgeon and oncologist will take into account your age, your chronic medical conditions and the extent of the cancer to formulate a management plan which is tailored specifically to you.

Surgery and oncology have come leaps and bounds and as the treating team we have a number of ‘weapons’ in our arsenal to manage and hopefully defeat Breast Cancer. The treatment modalities include surgery, reconstruction, chemotherapy, radiotherapy and hormone therapy. The management plan may include all of these components or a select few depending on your individual requirements and the stage.

In simple terms breast cancer stages can be divided into the following categories:

• Very early stage cancer – the cancer cells have not yet become invasive
• Early stage cancer – the cancerous cells or cancerous tumour involving an area of the breast smaller than 5 centimeters
• Locally advanced cancer – the cancerous cells or cancerous tumour involves an area bigger than 5cm, the skin of the breast is affected by cancer, there are many large glands affected by cancer in the armpit or axilla
• Metastatic or Stage 4 cancer – the cancerous cells have spread and formed tumours distant from the breast, most commonly affecting bones, lung, liver or brain

A Sentinel Node is the first lymphatic gland in the underarm (axilla or armpit) to which fluid from the breast drains. In patients with Breast Cancer we identify this ‘sentinel’ node because it is where cancerous cells from a breast cancer tumour will spread. If there are cancer cells found in the Sentinel node then surgery to remove all the glands in the underarm will be completed. If there are no cancer cells then the patient will not need the surgery to remove all the glands.

The Sentinel Lymph Node Biopsy is done when there are no obvious signs of cancer spread to the underarm already – there are no signs of abnormal glands on the mammogram or ultrasound and no glands that can be felt in the underarm.

The Sentinel Lymph Node Biopsy can be done as a stand alone procedure especially in patients who need Neoadjuvant Chemotherapy (Click here to read ‘What is Neoadjuvant Chemotherapy?) or if further information is required to help make decisions to fine-tune your definitive surgical management. In most cases the Sentinel Lymph Node Biopsy is done at the same time of the surgery to remove the cancerous tumour whether this is a Wide Local Excision or a Mastectomy.

In order to perform a Sentinel Lymph Node Biopsy a number of steps will be taken:

• The patient will be given an appointment at a Nuclear Medicine Practice on the morning of scheduled surgery. At the practice the technologist will use a weakly radioactive dye which will be injected into the tumour. You will then have a scan with a special Nuclear Medicine Scanner which will help identify the Sentinel Node.
• The scans will be shared with your treating surgeon.
• Later on in theatre you will be anaesthetised. The treating surgeon will use a special device called a Gamma Probe which senses radioactivity and which will help identify the position of the Sentinel Lymph Node. The surgeon may also use a special blue dye which will be injected over the tumour.
• The treating surgeon may use both the Gamma Probe and the blue dye to identify the Sentinel Lymph Node. The surgeon will either use the incision to remove the primary tumour or make a separate incision in the underarm. The Gamma Probe and the presence of blue dye will indicate which node is the Sentinel Lymph Node.
• Once removed the node will be given to a pathologist either in theatre or sent to the laboratory depending on whether the surgical plan is to proceed immediately with further surgery.
• If the node is negative there will be no further surgery to remove any glands in the underarm.
• If the node is positive you will require removal of the glands in the underarm called an Axillay Node Clearance.

Note: If the blue dye is used you will notice a blueish discolouration of your urine and your tears. The radioactive dye used has no side-effects and does not change your cancer risk it has been safely used for many decades.

Increasingly patients are presenting much earlier with Breast Cancer. There may not be a lump to feel in the breast or the lump is small. In these cases the patient may not need to have the whole breast removed – a mastectomy. Rather after meeting a specific set of requirements a patient may be eligible to have a ‘Lumpectomy’ or a ‘wide Local Excision’ or what is most recently termed Breast Conserving Surgery (BCS).

The treating surgeon will assess the size of the lump and take into account a number of individual factors that may make you eligible to have surgery to remove the cancer with a rim of surrounding normal breast tissue. The rim of surrounding normal breast tissue is removed so as to ensure a ‘buffer zone’ of tissue and reduce the chance of a cancer recurrence at the same site.

The factors that will be taken into account include:

• The cancerous area needs to be small and not affecting overlying skin – usually smaller than 3cm but this does depend on the size of the overall breast.
• The position of the cancerous lump and whether BCS will give a very good cosmetic result.
• There should only be one area of cancerous concern and there should not be multiple areas of concern in the breast.
• The patient must be willing to undergo radiotherapy in the post-operative phase.
• The patient must understand that you may require a second operation if the cancerous cells involve the edges of the tissue removed. The surgeon cannot see cancer cells with the naked eye and even though a wide area of seemingly normal tissue is removed when the pathologist assess the tissue removed during surgery they may see cancer cells at the tissue edge.
• The patient will still undergo a Sentinel Lymph Node Biopsy or Axillary Node Clearance whichever is appropriate.

Breast Conserving Surgery is completely safe and as stated before using post-operative radiotherapy ensures that your chances of a recurrence are minimized.

The advantages of Breast Conserving Surgery (BCS):

• A smaller operation
• Quicker recovery
• A better cosmetic outcome

The disadvantages of Breast Conserving Surgery (BCS):

• Radiotherapy after surgery is an essential component of treatment
• The potential need for further surgery – a wider margin of normal tissue may need to be removed or the patient may require a mastectomy – removal of the breast

A mastectomy is when the cancerous tumour of the affected breast and all the breast tissue on that side is removed. In most cases this involves removing the breast tissue via an elliptical incision starting on the inner aspect of the affected breast and extending above and below the nipple to the outer aspect of the breast. In most cases the overlying skin and nipple – areola complex are also removed and either a sentinel lymph node biopsy or axillary node clearance is done at the same time.

The procedure leaves you with a flat chest and a single scar. The surgery is done as an inpatient under a general anaesthetic. There will be a surgical plastic drain which will be placed in the wound to help reduce post-operative swelling and help remove excess fluid from the surgical site. The drain will remain in until the fluid drainage is less than 50 mls per 24 hour period.

You will receive physiotherapy to mobilise your arm and the physiotherapist will give you exercises that you will have to practice on your own to prevent stiffness and help reduce swelling. You will usually be an inpatient until the drain is removed.

You may have had or are about to have a mastectomy, either because you’ve been diagnosed with breast cancer or are at very high risk of developing it in the future. If so, your doctor may have told you about options to rebuild your breast or breasts — a surgery called breast reconstruction. Typically, breast reconstruction takes place during or soon after mastectomy, and in some cases, lumpectomy. Breast reconstruction also can be done many months or even years after mastectomy or lumpectomy. During reconstruction, a plastic surgeon creates a breast shape using an artificial implant (implant reconstruction), a flap of tissue from another place on your body (autologous reconstruction), or both.

Whatever your age, relationship status, sexual activity, or orientation, you can’t predict how you will react to losing a breast. It’s normal to feel anxious, uncertain, sad, and mournful about giving up a part of your body that was one of the hallmarks of becoming a woman: a significant part of your sexuality, what made you look good in clothes, how you might have fed your babies. No one can ever take that away from you. Moving forward, you now have the opportunity to determine what you want to have happen next. But first you must do some careful thinking and delving into your feelings in order to figure out what is best for you. In this section, we’ll talk you through each of the reconstruction options, what’s involved, and any risks, as well as alternatives to reconstruction.

Asking yourself some questions can help you start to think about what type of reconstruction you want — if you want reconstruction at all:

• How important is rebuilding your breast to you?
• Can you live with a breast form that you take off and put on?
• Will breast reconstruction help you to feel whole again?
• Are you OK with having more surgery for breast reconstruction after mastectomy or lumpectomy?

It’s also important to know that while breast reconstruction rebuilds the shape of the breast, it doesn’t restore sensation to the breast or the nipple. Over time, the skin over the reconstructed breast can become more sensitive to touch, but it won’t be exactly the same as it was before surgery.

Treatments given to weaken and destroy breast cancer before surgery are called neoadjuvant treatments. Most neoadjuvant treatments involve one or more chemotherapy medicines. Targeted therapy medicines, hormonal therapy, or radiation therapy also can be used as neoadjuvant treatments.

Neoadjuvant chemotherapy isn’t routinely used to treat early-stage breast cancer, but may be used if the cancer is large or aggressive. When neoadjuvant treatment dramatically shrinks a cancer, lumpectomy instead of mastectomy may be an option for some women.

Based on what they were observing in their practices, doctors suspected that chemotherapy before surgery was increasing lumpectomy rates. But until now, no one had looked at national statistics.

Yale University researchers found that women with larger breast cancers who had chemotherapy before surgery were more likely to have lumpectomy than mastectomy.

The study was published online on Feb. 25, 2015 by the Journal of the American College of Surgeons. Read the abstract of “Neoadjuvant Chemotherapy for Breast Cancer Increases the Rate of Breast Conservation: Results from the National Cancer Database.”

The researchers looked at records in the National Cancer Data Base, a database that is maintained by the American Cancer Society and the American College of Surgeons’ Commission on Cancer. The database includes information on about 80% of the cancers diagnosed in the United States.

Between 2006 and 2011, the researchers found that 354,204 women had been diagnosed with stage I to stage III breast cancer and treated with surgery and chemotherapy:

• 59,063 of the women had chemotherapy before surgery
• 295,141 had chemotherapy after surgery

The researchers found that the proportion of women being treated with chemotherapy before surgery steadily increased from 2006 to 2011:

• 13.9% of the women had chemotherapy before surgery in 2006
• 20.5% of the women had chemotherapy before surgery in 2011

Certain factors were linked to a woman being more likely to have chemotherapy before surgery:

• the breast cancer was larger in size
• cancer cells were in one to three lymph nodes
• a woman being younger than 50
• grade 2 or grade 3 cancer
• the breast cancer was estrogen-receptor-negative

Overall, the study found that 35% of women who had chemotherapy before surgery had lumpectomy.

Women diagnosed with breast cancers that were larger than 3 cm (about 1.25 inches) who had chemotherapy before surgery were 70% more likely to have lumpectomy than mastectomy.

“We’ve seen data published from clinical trials showing that neoadjuvant chemotherapy results in increased lumpectomy rates, but this is really one of the first studies using a large national database that reflects what is also going on in the community hospital setting,” said Brigid Killelea, M.D., M.P.H., F.A.C.S., the lead investigator of the study.

The study didn’t look at overall survival among the women who had neoadjuvant chemotherapy. Previous studies have shown that there is no difference in overall survival between women who get chemotherapy before breast cancer surgery and women who get chemotherapy after surgery.

The researchers think that treatment advances, including the development of targeted therapies such as Herceptin (chemical name: trastuzumab), Tykerb (chemical name: lapatinib), and Perjeta (chemical name: pertuzumab) that are given along with chemotherapy medicines, have made neoadjuvant chemotherapy more effective in treating breast cancer.

Although most women who have a choice prefer less invasive lumpectomy surgery, there are many factors to consider when deciding between lumpectomy and mastectomy, including:

• do you want to keep your breast?
• do you want your breasts to match as much as possible in size?
• if your whole breast isn’t removed, will you be extremely anxious about the cancer coming back?
• where you live
• where you go for treatment

If you’ve been diagnosed with breast cancer, you and your doctor will consider a number of factors when making treatment decisions, including:

• your age
• the size of the cancer
• the grade of the cancer
• the cancer’s hormone-receptor status
• the cancer’s HER2 status
• how many lymph nodes have cancer cells in them (if any)
• your personal preferences

After discussing all the information and all your treatment options, you and your doctor can make the best treatment decisions for your unique situation.

If you are married or living together in a committed relationship, your spouse or partner is likely to feel the greatest impact from your diagnosis with breast cancer. It’s natural for your partner to fear for your health and well-being and feel concerned about what will happen over the long term. Since the two of you run a household together, you’ve probably grown accustomed to certain roles and responsibilities. Your partner may wonder what will happen if you cannot always handle your usual tasks, whether that means earning income, caring for children, paying bills, preparing meals, or any of the other activities of day-to-day life.

Breast cancer can intensify whatever patterns of communication existed in your relationship before. If you and your partner have always been able to talk through difficult issues, that ability will probably work well for you now. If open communication has been difficult, you might need to do some extra work to talk about cancer and what it means for your relationship and your household.

Although every relationship is unique, you may find it helpful to:

• Involve your partner in medical appointments when possible. By coming with you to doctor’s appointments, your partner will gain a first-hand understanding of your diagnosis, the treatment options, and any side effects you might experience. Your partner will be better prepared for how you’ll be feeling, and you won’t need to explain everything your doctor said after every appointment. And if your partner has a question, he or she can ask your doctor directly.
• Be clear about your needs. Tell your partner exactly what you need. On some days, you might want to hand off certain household tasks that you typically handle, such as cooking or supervising homework if you have children. You might ask your partner to field phone calls from concerned friends, talk through treatment options with you, or simply sit with you at the end of a long day. Try not to assume that your partner will be able to sense how you’re feeling or what you need.
• Ask your partner what he or she needs. As you, your family, and friends focus on your treatment and recovery, it is easy for your partner to feel lost or overburdened. Talk to your partner about what he or she needs to get away and recharge. Encourage regular exercise, outings with friends, or any other activities your partner enjoys.
• Schedule time alone, just the two of you. This can be especially challenging if you have children, but it’s important. Schedule regular times for you to get away from distractions so you can talk — not just about cancer, but about anything you have been thinking or feeling.
• Accept the fact that you may have different coping styles. Each person responds to a cancer diagnosis differently. You may want to do lots of research, while your partner may prefer to rely solely on the doctor’s guidance. One of you may be consistently upbeat and optimistic, while the other may need to ask all of the “What if?” questions. Talk about your differences and tell your partner what works best for you.
• Figure out what adjustments will be needed in the household, and then ask for help together. While you’re going through treatment, there are likely to be times when you cannot help with tasks such as household chores, shopping, errands, and caring for children and pets you may have. You may have to cut back on work time, which could impact household income. Your partner might need outside support to keep the household running smoothly. Work together to figure out what kinds of help you need, and then approach family members, friends, and neighbours for assistance.
• Prepare for possible changes in your sexual relationship. Surgery, chemotherapy, and other treatments for breast cancer can affect you both physically and emotionally. Your body may feel and look different, and at times you may feel weak, nauseous, or tired. If you are a premenopausal woman, chemotherapy and some hormonal therapies can cause temporary menopausal symptoms or push you into permanent menopause, lowering the levels of estrogen in your body. Your sex drive may lessen, and you could experience vaginal dryness and irritation. Talk honestly and openly with your partner about these changes and ask for understanding while you are going through treatment. To learn more, please read this article on Sex and Intimacy section.
• Get professional help if you need it. A cancer diagnosis can place a great amount of stress on even the strongest relationships. A therapist, counselor, or social worker can help guide you and your partner through difficult conversations if you are having trouble communicating. If you’re interested in finding a professional to talk to, ask your doctor for recommendations.

If you care for young children (ages 3 to 9) as a parent or grandparent, it may be tempting to shield them from the fact that you have breast cancer. Experts agree that this is not a good idea. Even very young children can sense when family members seem stressed or anxious, or when usual routines are disrupted. They will notice changes in your appearance and your energy level, and they will know that you are spending time at the hospital.

Although young children do not need detailed information, they do need honesty and reassurance. Without any direct explanation from you, children may imagine a situation that is actually much worse than reality. Being honest with them builds a sense of trust that will be helpful in facing not only this situation, but also other challenges that life inevitably brings.

• Plan out the conversation in advance. Decide what you are going to say and how you are going to say it. This will give you a framework for the conversation. Involve your partner or another adult the children trust if you think their presence will be helpful.
• Use direct, simple language to define what cancer is, where it is in your body, and how it will be treated. Experts agree that naming the illness is important — “cancer” should not be a forbidden word. Even very young children can grasp simple explanations of what cells are and how they sometimes don’t “follow the rules” and grow as they should. You might also explain that the doctor has to remove all or part of your breast where the cancer is, and then use special strong medicines make sure the cancer is all gone from your body. A doll or stuffed animal could be a useful visual aid.
• Make sure children know that the cancer isn’t their fault and they cannot “catch” it. Young children often see themselves as the center of their worlds. They may worry that the situation is their fault or that they did something to cause the cancer. Also, children tend to associate sickness with catching colds or sharing germs. Be sure to explain that no one can catch cancer from someone else.
• Tell children how treatment for cancer will affect you. Prepare them for the physical side effects of treatment, such as losing a breast, hair loss due to chemotherapy, or feeling sick or tired at times. You might explain that medicines for cancer are powerful, and that side effects show that the medicines are hard at work inside your body. Tell children that you might feel sad, angry, or tired, but that these feelings are not their fault. Always let children know when you will need to be away from home in the hospital or at the doctor’s office.
• Reassure children that their needs will be met. Experts agree that young children need reassurance and consistent routines in times of crisis. Let your children know that you may not always be available to take them to school and special activities, play with them, or prepare their meals. Hugging, lifting, and bathing them may be off-limits for a while, too. Tell them about the trusted friends, relatives, or other care providers who will be helping out until you feel strong again.
• Keep usual limits in place. When there is an air of uncertainty around the house, it can be tempting to let children have more treats, watch more TV, play more computer games, or buy more toys. However, maintaining the same sense of structure you always have is likely to reassure your children more than giving them special privileges or treats. Keep their usual routines as consistent as possible.
• Invite children to ask questions and learn more. Let children know that you will answer any questions they may have. If your children are old enough, you might consider bringing them to one of your doctor’s appointments or allowing a visit during treatment. This can help to take away some of the mystery surrounding cancer and its treatment.
• Let children know you will still make time for them. Carve out a special time in the day just for them. Simple activities like reading a book or watching a movie can help them know that you are still there for them, even when you’re tired or not feeling well.
• Set a positive, optimistic tone without making promises. Even if you are sad or frightened, try to project a positive tone during your conversations with young children. Children may feel overwhelmed if you seem overly anxious or emotional. Make sure they know that your doctors and nurses are doing all they can for you and that most people with breast cancer do get better. Reassure them without making definite promises about the future.
• Let teachers, school counselors, coaches, and other caregivers know what is going on. Other trusted adults who spend time with your child need to know about the diagnosis. Changes at home often cause changes in children’s behavior in other settings. These adults can help you know how your child is doing, and they can become a source of additional care and support.

Although much of the advice for talking to young children also applies with children in middle school and high school (ages 10 to 18), these older children have additional needs. Given how often breast cancer gets talked about in the news and on television, older children are likely to be aware of the seriousness of the disease. In addition to your honesty and reassurance, they may crave more information than younger children do.

• Be truthful about your diagnosis and course of treatment. Shielding children from the hard facts can harm their sense of trust in you. Even though you do not want to worry them, you do need to let them know what is happening to you.
• Schedule regular family meetings or other discussion times. Older children can be involved in talks about how family activities and responsibilities will change while you are undergoing treatment. You may need to ask them to handle more household tasks than they normally do. A family meeting gives everyone a chance to have a voice in the changes that are taking place.
• Anticipate children’s questions about the future. Older children are likely to have heard that people can die of cancer. It is natural for them to be afraid that you could die and to wonder what will happen to them. Make sure your children know that most people with breast cancer do get better and live long, healthy lives. Even if the cancer is advanced, treatments often can keep it under control for some time. Reassure them that, no matter what happens, their needs will be met by you, your spouse or partner, or other caring adults in their lives.
• Anticipate children’s questions about their own health. Your children may fear that, since you have cancer, they may get it one day, too. This is an especially common fear among teenaged daughters of mothers with breast cancer. Even if breast cancer does not seem to run in your family, breast cancer still happens to 1 in 8 women in the United States during the course of their lifetimes. Therefore, it’s a good idea to bring up the issue at your daughter’s next doctor’s appointment. Talk to the doctor together about some steps your daughter can take now — such as eating a healthy diet, exercising regularly, and not smoking or using alcohol — to help lower the risk of developing breast cancer later in life.
• Give children permission to keep up with school and social activities. Even though older children and teens can take on more responsibility at home, they are still children. Let them know that they should continue focusing on their schoolwork, other activities, and time with friends. Children need to maintain that sense of normalcy, but they might only do so if you let them know it’s what you want.
• Realize that older children may express feelings that seem inappropriate, such as embarrassment or anger. Preteens and teens may express emotions that seem unkind or even completely out of line. They may be embarrassed by changes in your appearance, such as hair loss or weight loss and avoid going out with you or bringing friends home. They may be angry about the ways that your illness limits them and their activities. Although their reactions may upset you, remember that teens are at a time in their lives when they value appearances and their growing sense of independence. If you’re able to show acceptance of your own appearance, you can set a healthy example for your child.
• Connect them with books and other resources. Talking about cancer can be hard, even in families where communication is strong. You may want to look for books or other publications written especially for young people who have parents with cancer. Your child also may find it helpful to confide in an adult outside the immediate family, such as another relative, close friend, or even a professional counselor. Reach out to relatives and friends and ask them if they can be available.

A diagnosis of cancer can be one of the most stressful experiences of life. In addition to the worries over survival and treatment, many people find that they have additional concerns over the cost of medical treatment. Many people find that they have let medical aid run out, or are not covered in a way they thought they were.

In South Africa, 80% of patients are managed within the government health service, and 20% have medical insurance that means they can be treated in private hospitals. If you do not have a medical aid get information here and here about having treatment in government hospitals. All medical aids, even hospital plans, have to provide some cancer cover.

This will include in-patient care but may also 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 that you are on, and it may require registration for a cancer scheme after diagnosis. It is important that you do this as soon as possible and make sure the medical aid are clear with you about what is covered. If you decide this is a time that you wish to start contributing towards a medical aid.

In most circumstances medical aids are not allowed to refuse to cover you for a pre-existing condition including a diagnosed cancer but they may impose a waiting period from 3 months to one year where they will not cover you.

You should not delay cancer treatment during this timeframe. Always mention these conditions to the medical aid so that you get access to the appropriate care and do not disqualify yourself with non-disclosure. Many companies encourage good health by funding screening mammography and Pap smears even to patients without day-to-day benefits.

If you are undergoing cancer treatment, you will have to take time off work at some point. This may be for appointments, treatments, recovery or just because you need some time out. If you are lucky your work will understand and support you in this, but even if that’s the case, a concern over work and time off can cause great anxiety to most patients, and questions I get asked often are: How will this affect my work? What if I can’t manage?

Under South African labour law, most employees are entitled to six-weeks of sick leave in every three year work cycle. If you have been in your job less than six months, you get one day for every month (26 days) worked, on full pay.

Be careful. Cancer treatments can quickly exhaust this leave so it’s a good idea to tell your employer about your treatments. Discuss with your doctor what the full plan of treatment is for you and you can then sketch this out to your employer so they have realistic expectations.

If you do have problems, the Employment Equity Act protects workers from retrenchment due to disability, and a diagnosis of cancer which makes work difficult falls under this definition. Your boss has a duty to encourage and help you unless circumstances are exceptional.

There should never be a reason to compromise your care because of work concerns, but act early. Your breast specialist doctor should be a valuable ally in helping you with information and planning, and good multi-disciplinary care involving breast support and advocacy groups can give you advice or recommend labour law support.

Grants are available for patients who are unable to work due to their breast cancer. In these circumstances a temporary disability grant can be applied for through the South African Social Security Agency (SASSA). If the cancer or cancer treatment makes you unfit for work for more than six months then a temporary grant is suitable. This may apply to patients who are having chemotherapy or treatment for extended periods of time.

To apply the patient must be South African citizen or permanent resident and undergo means testing. The doctor treating the patient will fill in a medical assessment from which is taken to the SASSA office along with all medical reports and proof.

For dire situations of an immediate nature, a social relief of distress grant can be applied for. This is a grant designed specifically for immediate situations of distress where a patient is medically unfit for work for a period of less than six months. It is designed to provide for a family’s most basic needs and is often in the form of a food parcel for three to six months.

It is unusual for breast cancer to result in permanent disability, but this can be assessed on a yearly basis if a longer grant is required.

Some women develop breast cancer at a younger age, before they have started or feel they have completed their family. Bearing in mind how your fertility and ability to have children will be affected by your breast cancer treatment or after your treatment is an important thing to consider right at the start of your pathway, so you can make the right decisions for you.

Pregnancy after breast cancer

There are a number of options available for you to consider and this is an area with lots of research being carried out to improve those choices in the future. Make fertility a topic to discuss before you embark on treatment and if necessary you can be referred to a fertility specialist who will work with you to find the best and most realistic option for you.

You might be concerned that falling pregnant after breast cancer treatment can increase the risk of your cancer coming back especially if your cancer responds to oestrogen. In fact studies show that this is not the case, but you should take time to discuss the decision to become pregnant with your team early. There are current international studies researching women becoming pregnant after breast cancer.

The right time to consider pregnancy depends on the stage of cancer and its personality especially if it is hormone-receptor positive. At the moment it is advisable to wait at least two years after treatment.

Breastfeeding can be a wonderful experience for both mom and baby, and there is no doubt it is the best possible start for every baby. Not only does it improve growth, intellectual ability and fight off infections in baby, it improves weight loss in mom and decreases her risk of breast cancer.

The World Health Organisation (WHO) recommends breastfeeding exclusively for six months and for up to two years with solids. The American Association of Paediatrics recommends exclusively for six months then up to a year at least. Yet the most recent study of breastfeeding released this year found that on average women exclusively breastfeed for a little over one month and average total breastfeeding is less than 6 months. A Scottish study found that women keen to breastfeed prior to birth became quickly disillusioned and lacked support during feeding and are overwhelmed by the prospect of exclusive feeding. It also found that pain and problems during breastfeeding diminished the likelihood of continued breastfeeding.

Breastfeeding can be really hard, especially at first and with your first baby. The good news is you are part of a wealth of women who have been there, who understand and who want to support you, through their education and training and through their own personal experiences. In addition there are great resources on breastfeeding and on parenting in general.

Local breastfeeding support
Here are some contacts who can help. If you are having problems with breastfeeding or pain, it can feel lonely and isolating. Don’t wait until you are exhausted: get advice and support early.

If you are a breastfeeding specialist and could be included on this list please contact us and we’ll add your details. Or let us know if you have found a great resource you want to share.

La Leche League of South Africa
A volunteer-led organisation dedicated to providing information, encouragement and support to breastfeeding mothers through our unique mother-to-mother support network.

The Expectant Mothers Guide
A South African institution shepherding a mother through expecting to being a parent.