“Exercise decreases your risk of developing cancer by 42% and maintaining a BMI under 30 definitely helps. Of course, I don’t need to mention habits like alcohol and cigarettes.”

Carol-Ann Benn is a Fellow of the College of Surgeons of South Africa with a special interest in breast disease. She was head of the Breast Unit of Helen Joseph Hospital and is currently lecturer in the Department of Surgery at the University of the Witwatersrand. She has also run courses on breast health in Mauritius, including live surgery workshops. We got hold of her while she was giving a lecture at the University of Mauritius as part of the Medical Update series on the ‘New Trends in Breast Cancer Management and Reconstruction-surgical perspective’ and asked her to walks us through one of the most dreadful diseases – breast cancer.

There is generally a lack of support for women across the border. Is your profession, which entails working with women, the exception?
No, there are still huge challenges for women in all fields. It took me 15 years to have women make up 50% of the surgical department. I still get this from the head of the department: what are we going to do? Three women are pregnant. Why is it a problem? What we need more is women working with women. It amazes me to see that when we become more senior, we do not support juniors. That is shocking. Often when people become senior and have worked so hard to get there, they do not want someone else to replace them. For me, every single person you train to make better makes you better and grows a stronger, more productive team.

To get to the daunting topic of breast cancer, what exactly are the major risk factors? Genetics?
Sixty-five per cent of persons who get breast cancer have no genetic risk factors. About 8-12% have isolated single genes, and 20 % have a family history on the mother and father’s side. We realise now that breast cancer is neither ageist, racist nor sexist. You have to remove the idea that there are people at risk.

Then what should we do?
The first step is to understand your environment and who is presenting what problem. We have to start with community-based health education. Examine your breast, check for glands, make sure that there is no change in your nipple, no nipple discharge.

If you pick up something, what do you do?
If you are under 35, go for a breast ultrasound, and if you are over 35, you go for a mammogram and an ultrasound. Not everything will need to go for a biopsy. So, what you need to monitor is if there is change. For example, a young woman of 27 who presents with a breast lump that you think is a benign breast lump, what you can say is come back three months later, and if it has grown, then you do a needle biopsy.

How do you exactly diagnose breast cancer?
It should not be in the hands of the surgeon. A radiologically guided needle biopsy, a core biopsy is the way to go so you can get a tissue sample and know what type of cancer it is. Screening in different countries and in different communities is going to be different. It is about health economics. It is about what the health concerns in your country are. For example, if it is less breast cancer, more lung cancer, or prostate cancer, you might invest in screenings for those cancers. We must understand what the big 6s are in cancers: breast, cervical, stomach, colon, prostate and lung, and you need to have screening programmes for those cancers in your country. It is no different from understanding your general health care risk, hypertension, diabetes, stroke. As you get older, you need to screen more often.

Everyone? Even healthy individuals?
Younger, healthier people, with healthier lifestyles would require less screening, but it does not mean that they are not at risk for diseases. Again, it goes back to knowing your norm and getting checked if something does not look right. It is about community-based health education and knowing what financial help is available for what screening, when to screen. Patients must ask questions, work out what their different access to units are. In some countries and in some communities, the process is quite rigid. You have to go to a regional clinic, then to a specialist clinic. I’ve always based things on the concept of open access care, whereby you don’t need a referral, but that specialist unit must offer comprehensive and cost-effective care. I always say that health service is like a plane; whether you are sitting at the back or in first class, you should be able to have a safe journey to reach the other side.

You mentioned earlier the need to have an ultrasound in addition to a mammogram. Why?
I lecture and write about unseen cancers. People say I went for my mammogram and they did not see my cancer, and then you tell your friend not to go for a mammogram. Mammography is a two-dimensional view of a three-dimensional object. The denser the tissue is, the harder it is to see. So, in younger people, the tissue is so densethat you are less likely to pick things up. Ultrasound allows you to look at things more carefully and more slowly. You want the two together for your best ability to pick up an anomaly. Proper breast diagnostic radiology involves a mammogram and an ultrasound involving the breast and the glands.

Are there ways to prevent breast cancer?
You can’t prevent things completely, but you can decrease your risk. The two best ways to decrease your risk is exercise. Exercise decreases your risk of developing cancer by 42%, and maintaining a BMI under 30 definitely helps. Of course, I don’t need to mention habits like alcohol and cigarettes. Even in the subset of the population which is at high genetic risk of breast cancer, not 100 % of people with these mutations get breast cancer. It is only about 65% of those who have isolated single genes that develop breast cancer over their lifetime. Because there is genetics, there are environmental ways to cut down on the genetic penetrations.

Some people say that contraceptives increase the chances of developing breast cancer. Myth or reality?
Every couple of years, something comes up in the literature as this is a significant risk factor. Change this to decrease your cancer risk. In the last two years, it was women taking contraception for a long period of time or above the age of 35 and into their forties that have a higher risk of cancer. It is not a single factor but a multitude of factors. People who have children after the age of 35 are at a slightly higher risk of cancer. But in fact, 65% of people have no risk. When it comes to contraception, I say contraception is critical for women, and you must know when to be on it and for how long. I don’t support putting young girls on contraception or being on it for large periods of time when you are post your child-bearing age or because your partner does not want to have a vasectomy. So, there are two things with contraception, for safe sex and using contraception when it is needed. Young girls who have painful menses or endometriosis may require oral contraceptives, as endometriosis has an impact on fertility as they get older. In terms of Hormone Replacement Therapy (HRT) for menopause, I am not anti-HRT, but I always say don’t take a Panadol if you don’t have a headache. They are cheat codes. How do you naturally improve your sleep, BMI, vaginal oestrogen. If you are severely symptomatic as you are going into menopause – you are really battling with this change – then you go on HRT for a small period of time, 2-5 years, and then you wean off it. HRT is not the Elixir of eternal youth.

“Men can develop breast cancer. Internationally, it is 1% of the total number of breast cancer patients. In Sub-Saharan Africa, we have a slightly higher rate-from 2-3%. It would be interesting to find out the rate of male breast cancer in Mauritius.”

The word ‘cancer’ no longer sounds like the death sentence it used to be, does it?
We’ve always put a stress on an early diagnosis. So, if you are going for screening, then you pick up cancers early. Now we have become more personalised in oncology treatment, not so much rushing people into surgery but understanding the behaviour of cells and by understanding the behaviour of cells, we can personalise the treatment you will get. You can start oncology treatment for a few months. There is a de-escalation of surgery, more breast-saving surgeries, less radiation needed, and genetic profiling of tumours. Understanding the make-up of the cancer, not simply what it looks like: some tumours might look scary on the outside but are not aggressive; others, which do not concern, might be more aggressive. We understand the brain of the cancer cell better, so we can personalise the treatment. Then there is a massive change in targeted treatment for cancer-immune oncology treatment and new breakthroughs in different classes of drugs; everything revolves around understanding what is happening at the cell level. And also, when you are having a treatment, you have to think about the escape mechanisms for the cancer cells that may change their behaviour. As soon as we understand that they have changed their behaviour, we re-biopsy them, and then look at the genetic sequencing of the cancers so we can personalise the treatment. Even people with metastatic cancers have longer and better outcomes. Seven out of 10 people, even with advanced cancers, can be alive for 10-15 years after their cancer treatment.

How different is one cancer from another?
There are many types of cancers. Breast cancer today for ease is subdivided into four different behavioural types, and the different types are treated differently. Many types of gene sequencing and liquid biopsies are available to assist in diagnosis and understanding “cancer cell behaviour to allow for more personalised cancer treatment. What is happening in the blood, in the cancer cells etc., play a role in what, when and how to treat these small terrorists. You can work out many predictions about which hormonal treatment works and which chemo works. And when cancers fail to respond to certain lines of treatment, you can re-biopsy and check those cancers and then work out what your next line of treatment should be. So, that’s really the future. It’s not only just the genetic and just the behaviour of the cells, but it is also understanding the microenvironment around the scavenger cells. A combination of understanding cell growth and what is happening around the cells is going to result in better cancer treatment.

Does genetic testing play a role in the early detection of breast cancer?
Yes and No. If the vast majority of people who have breast cancer, have no isolated single gene mutations, then you have to think about whether the cost of doing genetic testing on the person is of value. If you do a full genome sequence, medically, we are not smart enough to come up with all the combinations; however, computers are and looking at AI to see the combinations that allow for big banks of data to be collected. You can then get AI to start looking at all the combinations. Often, it is not a single gene, and it is a combination of factors. Many times, it is not only about the genetics but also about the microenvironment and the macroenvironment. So, from a futuristic perspective, it would be absolutely of value because it will allow us to understand that in certain subsets of breast cancers, if people carry certain genetic mutation combinations, there will be more responses to certain treatments. You have to separate the person’s genetics from the cancer’s genetics. They are two different issues.

Is breast cancer a woman ‘thing’ or can men develop it too?
Men can develop breast cancer. Internationally, it is 1% of the total number of breast cancer patients. In sub-Saharan Africa, we have a slightly higher rate-from 2-3%. It would be interesting to find out the rate of male breast cancer in Mauritius. Breast Cancer is very much a pink disease, and maybe men don’t come forward, and I think it is important to document what we see in different parts of the world. The treatment is identical. Men also have mastectomies, but we can do nipple-saving surgeries and “breast” saving surgeries. There are significant psycho-social effects on men, especially in South Africa, where there is a culture where men are often bare-chested. So, we do immediate reconstruction on most male breast cancers (I have published on this).

I hear of some family tragedies resulting from breast cancer and some of its treatment. You have, I am sure, firsthand experience of these, don’t you?
Well, breast cancer does not only affect women but also affects their relationship with their kids and their partner. The partner in a heterosexual relationship is often very affected since men are always trying to fix things, and they are not sure what to do, particularly in terms of intimate relations. Often women tell me that their relationships ended in divorce following reconstruction or failure to reconstruct. When someone is going through breast cancer, their partner should be able to encourage them throughout the treatment.

Are the physical changes the hard part of the process?
How do you accept that you are going through changes? Losing your hair, going through radiation. Just think about how your body changes as you age. This is a process which will happen, irrespective. You need to accept it. Then, it’s about having honest discussions, communicating around changes and how you and your partner have to work through them and change your dynamics.

Does breast cancer also affect fertility?
Today, we protect young women’s fertility when they go through oncology treatment. We do fertility treatment before someone starts the oncology process. We switch off the ovaries during oncology treatment. We freeze the eggs – cryopreservation – before treatment so they can attempt to conceive after treatment.

Is the stigma around breast cancer still real?
There can be a community stigma, particularly when you are looking at different cultures. You’ve got to make sure that people do not think of cancer as a curse or some form of divine punishment or that they are the cause of the cancer because of their lifestyles. I actually think that the psycho-social dimensions of cancer and its navigation are more important than just dealing with the treatment or the cure. We now have so many options, but if we don’t understand all the barriers, cultural and others, the aggressiveness of going through treatment, and the lack of empathy with what it means to go through treatment, then we may be failing our patients. We have to understand that we are not just treating a breast but a whole person who is part of a family and part of a community. We have to learn to talk more and talk more sensibly.