Breast cancer is the most common cancer in women and the most prevalent cancer globally. About 1 out of 27 women will develop breast cancer during their lifetime.

 Who is at risk of developing breast cancer?

• Increasing age: 50 % of women with breast cancer are over 40 years old

Other risk factors are:

• Hormone replacement therapy 
• Genetics: A family history of breast cancer, although most women diagnosed with breast cancer have no family history.  The genes most commonly affected in hereditary breast and ovarian cancer are the breast cancer 1 (BRCA1) and breast cancer 2 (BRCA2) genes.
• Harmful alcohol use
• Tobacco smoking
• Obesity
• The interval between the first period and first birth – if the gap is 16 yrs +, there is a higher risk of breast cancer than with a 5-year break.
• A history of radiation exposure
• Oral contraceptives

Can I prevent breast cancer?

• Avoid using hormone replacement therapy in menopause.
• Breastfeed your babies as long as possible.
• Keep your weight under control.
• Be physically active – exercise!
• Use alcohol in moderation, and don’t smoke tobacco.
• Avoid radiation exposure.

What are the signs of breast cancer?

• A lump or thickening in the breast. Usually, it is painless, although it can be tender to touch.
• In some cases, the shape or appearance of the breast or the nipple changes.
• The skin colour can change, for example, redness, dimpling, or pitting.
• Abnormal discharge from the nipple.

Note: 90% of lumps found in the breast are non-cancerous. They are called cysts or fibroadenomas. Infections cause some nodes.

Good practice: The best way to check for breast cancer is to self-examine every month of your life. For females who still menstruate, the best time of the month is a few days after your period.

If you discover a lump in your breast, please go for a check-up without delay. Don’t wait 1-2 months and hope it will disappear. Some breast cancers grow faster than others. Ideally – you want it removed before it reaches stage two or three.

What are the stages of cancer?

• Stage 0 means there’s no cancer, only abnormal cells with the potential to become cancer. It is also called carcinoma in situ (CIS). (CIS is a group of abnormal cells that are found only in the place where they first formed in the body.)
• Stage I means the cancer is small and only in one area. It is also called early-stage cancer.
• Stage II and III mean the cancer is more extensive and has grown into nearby tissues or lymph nodes.
• Stage IV means cancer has spread to other parts of your body. It’s also called advanced or metastatic cancer.

What is the survival rate of breast cancer?

Breast Cancer Stage*	5-Year Breast Cancer-Specific Survival Rate
I (1)	98%-100%
II (2)	90%-99%
III (3)	66%-98%

How is breast cancer diagnosed?

Mammogram

Note – the mammogram result is not absolute – it misses 30% of breast tumours. That is why personal physical breast checks are so essential every month.

The sonar of the breast

Biopsy of the tumour: you will be given a local anaesthesia injection at the biopsy site to reduce pain. It feels like a bee sting, but it is necessary to diagnose the tumour or lump as benign or malignant positively.

What to do next if I have breast cancer?

If the biopsy returns and you have a malignant tumour, you must see your referring doctor ASAP.

The next step is to see an oncologist, who will explain all you want about breast cancer and the treatment options. The type of treatment depends on the type and stage of your cancer. For surgery, the oncologist will refer you to a surgeon. In other cases, they might suggest radiation or chemotherapy, and surgery will follow.

What are the types of surgery for breast cancer?

Lumpectomy or partial mastectomy: Only the tumour is removed from the breast.

Pro’s

• You preserve much of the appearance and sensation in your breast.
• It is a less invasive surgery – so your recovery time is shorter.

Con’s

• The appearance of your breasts might not be identical anymore.
• Chances are that you need radiation (5 days/week x 5 -7 weeks) to ensure the cancer is gone.
• Radiation affects when you can have reconstruction and later surgery where breasts are lifted or balanced.
• Cancer can return in the breast – which might require a total mastectomy. In addition, the same breast cannot tolerate the second series of radiation.
• Sometimes, additional surgery is needed after a lumpectomy if cancer has, for example, spread to the Lymph nodes.
• There might be another small tumour growing in your breast that they miss.

1. Mastectomy: complete removal of the breast

Pro’s

• If you have both breasts removed, you have a slimmer chance of breast cancer flaring up in the future. Many women prefer a bilateral mastectomy for peace of mind.
• Symmetry in our bodies is essential for our mental well-being;  if both sides look the same after the mastectomy, adjusting and accepting the loss is more manageable.  It is another reason a bilateral mastectomy is the better choice whether you choose reconstruction or not. It is mentally much tougher to process a mastectomy when you have one breast left. Even if you decide to have reconstruction on the one side, your breasts will differ in size every time your weight changes or your own breast sags as you age, and the reconstructed one stays firm.

Con’s

• A mastectomy is major surgery, and the recovery time is extensive (4-6 months) before you feel yourself again.
• Reconstruction mainly needs to be done much later, 1-2 years.

What to keep in mind:

 Tell your surgeon beforehand if you want a ”flat look” and do not consider having reconstruction. They do leave excess skin if you plan to have reconstruction afterwards. Excess skin doesn’t look good left as it is and forces you to proceed with reconstruction. 

Flat closure (aesthetic flat closure), which creates a smooth chest wall by smoothing out any lumps and bumps and trimming excess skin, can be done when the breasts are removed.

Preparing for a bilateral mastectomy

1. At home: Do what you must do in your home before going in for the operation since you will have a limited capacity of your arms for at least two to three months after the procedure. 

2. Buy from the chemist:

• Get small plasters (2 cm x 2 cm) to cover the drain wounds if the bandages come loose and for after drain removal.
• A laxative, for example, MOVICOL® to prevent constipation caused by painkillers. Any painkiller containing codeine causes constipation. 
• Get alcohol swabs to clean around drain wounds before putting on new plasters.  

3. Don’t hesitate to contact CANSA (0800 22 6622) and tell them you are going for a mastectomy. They have ladies (who also had mastectomies) who will visit you post-operatively with goodies and information sheets to make your journey easier.

4.  Make contact with an Orthotist and prosthetist, for example:

• Jannette Botha: Orthotist & Prosthetist; Almost U Prosthetics – Home – Women With Breast Cancer
• M-STORE ( https://themstore.co.za/contact/). They supply post-operative bras. 

What to expect after a bilateral mastectomy

Your hospital stay might only be 24 hours before discharge. You will be discharged with the drains still in place – it is advisable to keep them in for 2-3 weeks after the operation till they drain very little fluid. It is necessary to help the skin adhere flat to the muscle layer. Early drain removal can cause fluid build-up between the layers that feels like a water sac. It has to be removed by needle aspiration.

Patients often have to return more than once to have more fluid aspirated after removing drains. 

Don’t fear – it is not painful because there is no feeling in the area over the breast where the fluid is aspirated. 

Note: You should not lift your arm above shoulder level until cleared by your surgeon.

 How to empty your drains

https://youtu.be/bopoBLj8Vjk

Empty the drains every morning and evening and record how much each left and right side drained. 

What to do post-operatively:

PHYSICALLY:

• Personal care: Get up every morning, wash your hair, put on make-up and dress – even with the drains still in place. The more independent you are, the better your morale and self-image.
• Do your prescribed exercises consistently every day. You will receive a list of movements and activities you should do daily in the leaflets CANSA donates free of charge.
• Do not engage in repetitive work with your arms – like sweeping, washing floors, or vacuuming. It will cause more swelling under your arms. It is best to refrain from such activities for 3-4 months. 
• Make an appointment with a lymph drainage therapist (occupational therapist or physiotherapist) soon after removing the drains. 

Why?

Scar tissue/ligatures or cording can form where the drain pipes are and feel tight and painful. The skin over your breast muscle needs to be kept loose, and a therapist must massage the scars to reduce keloid formation. 

Therapy helps reduce swelling, regain whole arm movement, and soften the scar tissue. Go for as many treatments as possible – not just 4 or 5. It takes months for the swelling to go down and the scar tissue to soften and stretch.

More information on cording:

https://www.mobieg.co.za/medical/cancer/cording-a-side-effect-of-mastectomy/

 

Get a post-operative bra that offers mild compression. It feels more comfortable to wear a post-operative bra after a mastectomy than not. Different types are available, and they help reduce swelling and lump formation. Note: most of the swelling occurs under your arms and on the bottom edge of where your breast once was.

There are different options on silicon prostheses that you can fit.

Some prostheses slide into a pocket in a bra. 

Another option is a stick-on silicon prosthesis you can wear with a bra, illustrated in the photo by Amoena®.

Get a Lymphoedema compression garment for your arms after lymph node removal as part of the mastectomy. It is advisable to wear the compression garment on your arm in the first few months when exercising, for example, when going on long walks. It prevents swelling. Wearing the compression sleeve when you walk is more comfortable than going without it – the upper arm without lymph nodes quickly feels heavy and more swollen.

Remember always to wear your compression sleeve when you fly or do long drives by car for the rest of your life. You don’t want to trigger lymphoedema – because it is difficult to get rid of it. Once you have it – it can become progressive. 

Consider getting a medical alert bracelet ( https://ice-tags.co.za/) that says you have a risk of lymphoedema after a mastectomy. List the left or right arm. You may never again have blood pressure taken or have blood drawn on that arm because it can trigger lymphoedema. 

Mental health

• Talk about what you feel. You will have to deal with the trauma of an immense operation, a very different feeling, body image, and a lot of pain, all of which causes a grief process of loss. It is a double whammy. Remind yourself to embrace the change because it saved your life. Hiding or feeling ashamed of what you went through can prolong the grief process. 
• It is okay to cry and feel sad- as often as you need to. It is part of the grief process and helps your soul heal.
• Don’t be embarrassed to show family members what you look like now. You are not a freak, just flat-chested. Feminity is not in your breasts but in being well-groomed as a woman. Sometimes, it is easier to accept the new normal of being flat-chested than to struggle with bras, fillings, and prostheses.
• Don’t be pressured by a partner to have reconstruction done soon after your surgery, especially if you had chemotherapy and radiation. You have been through a lot. Give yourself time to recover and find your feet. Let your body heal first. Then, allow your soul to heal. Every future operation involves more pain, scar tissue, and a lengthy recovery period. It is your body, and you may decide what happens to it. 
• In time – fit your old clothes and see what works and whatnot. If you go for the ”flat-chested” look, throw out ill-fitting dresses and tops and replace them with garments that compliment a flat chest.
• Self-care: A mastectomy is mutilating – much the same as an amputation. Some women have the added burden of hair loss because of chemotherapy. It is crucial to continue to love and care for yourself every day. Make time each day to do things you enjoy – read a book, take a walk, have coffee with a friend, take an afternoon nap, watch an uplifting movie, practice a hobby, have a foot pedicure, and listen to good music.

In 4 months, the wound will heal nicely – swelling will go down. Finally, you will be able to resume most of your activities. After one year, with a ”flat look”, the scars will have softened significantly. 

Plastic surgery

If you still have excess skin or bumps after surgery, it is best to see a plastic surgeon to have it removed and flattened aesthetically.

Therapists:

Maretha Logie- Traut: Breast cancer rehabilitation / Lymphoedema Therapy  OT ZONE 

Jannette Botha: Orthotist & Prosthetist; Almost U Prosthetics – Home – Women With Breast Cancer

 References:

Breast Cancer Statistics | How Common Is Breast Cancer? https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html

The Stages of Cancer According to the TNM System – WebMD. https://www.webmd.com/cancer/cancer-stages