CMScript

Member of a medical scheme? Know your guaranteed benefits!

Issue 12 of 2022

Breast Cancer
In 2020, breast cancer was the leading cause of new cases of cancer in the world with 2.26 million cases reported
annually. South Africa also showed a similar trend with 14.3% of new cases of cancer in both men and women of
all ages being attributed to breast cancer, putting it as the leading cause of new cancers reported.

Breast cancer is a disease in which the cells of the breast

do not grow normally; they grow out of control. The breast
is made up of different parts:
• The ducts – are small canals that carry milk from the
lobules to the nipple. They are the most common place
for breast cancer to start and cancers that start here
are called ductal cancers.
• The lobules – are glands in the breast that make breast
milk. Lobular cancers start in the lobules.
• The nipple – is the opening in the skin of the breast
where the ducts come together to allow milk to come
out of the breast. The nipple is surrounded by the areo-
la, which is a thicker and darker skin. Paget disease of
the breast is a less common type of breast cancer that
can start in the nipple.
• The fat and connective tissue – surround the ducts and
lobules and help to keep them in place. Phyllodes tu- es to certain genes such as BRCA1 and BRCA2 have
mour can start in the connective tissue of the breast a higher risk of breast and ovarian cancer
and is also a less common type of breast cancer. • Reproductive history – starting menstrual periods be-
• The blood vessels and lymph vessels – these carry fore the age of 12 and starting menopause after the
blood and lymph fluid into and out of the breast. An an- age of 55 increases women’s risk of breast cancer due
giosarcoma is a type of breast cancer that can start to longer exposure to hormones
from the cells lining these vessels • Personal history of breast cancer or non-cancerous
breast disease – women who have had breast cancer
Causes/Risk factors are more likely to have it again. Some non-cancerous
There are many factors that are associated with an in- breast diseases such as atypical hyperplasia or lobular
creased risk of breast cancer. Some of them can be carcinoma in situ are associated with a higher risk of
changed to decrease risk and some cannot. getting breast cancer.
• Family history of breast or ovarian cancer – having a
Risk factors that cannot be changed: first-degree relative (mother, sister, daughter, father,
• Being female – women have a much higher risk of get- brother or son) or multiple family members from her
ting breast cancer than men mother’s or father’s side who have had breast cancer
• Getting older – the risk of breast cancer increases with (or ovarian cancer in the case of female relatives) in-
age and most breast cancers are diagnosed after the creases a woman’s risk of getting breast cancer.
age of 50 • Previous radiation therapy treatment – radiation thera-
• Genetic mutations – women who have inherited chang- py to the chest or breast before the age of 30 increases
 a woman’s risk of getting breast cancer screening mammogram such as a lump or an area of
• Having dense breasts– dense breasts have more con- the breast that looks abnormal.
nective tissue than fatty tissue which can make it diffi- • Breast Magnetic Resonance Imaging (MRI) – used with
cult to see a tumour (growth) on a mammogram mammograms to screen women who are a high risk of
breast cancer. It takes detailed pictures of areas inside
Risk factors you can change the breast. Can also be used to diagnose breast can-
• Not being physically active cer.
• Being overweight or obese after menopause
• Taking hormones Pathological investigations include:
• Reproductive history • Biopsy – tissue or fluid is removed from the breast
• Drinking alcohol and looked at under a microscope to check for signs
of cancer. The different biopsies that can be done are
Signs and Symptoms fine-needle aspiration, core biopsy or open biopsy.
Signs and symptoms of breast cancer will differ from per- • Blood tests – done to check the overall health status of
son to person. Some people will not have any symptoms or the patient
signs. Some of the signs of breast cancer include (but are
not limited to): Staging
• A new lump in the breast or underarm Diagnosis of breast cancer also includes staging of the
• Thickening or swelling of part of the breast breast cancer. Staging describes how far the cancer has
• Irritation or dimpling of breast skin grown. It is important for planning treatment options and
• Redness or flaky skin in the nipple area or the breast gives an indication of prognosis. The TNM system is com-
• Pulling in of the nipple or pain in the nipple area monly used to stage breast cancer and it stands for:
• Nipple discharge other than breast milk • Tumour (T) – what is the size of the tumour in the
• Any change in the size or shape of the breast breast and what are its biomarkers (biological mole-
• Pain in any area of the breast cules found in the tumour that are a sign of abnormal
growth)?
Screening for breast cancer • Nodes (N) – has the tumour spread to the lymph
Screening means to check for disease before signs or nodes? If it has spread; where has it spread to, what is
symptoms appear. Screening can lead to early detection of the size and how many nodes are involved?
breast cancer, and this is associated with an improved like- • Metastasis (M) – has the cancer spread to other parts
lihood of successful treatment. It is important that everyone of the body?
is familiar with how their breasts look and feel so that any The answers to the above questions and results from in-
changes are more easily noticeable. vestigations are combined to determine the stage of breast
cancer.
Some screening tests for breast cancer include:
• A clinical breast examination – a doctor or nurse exam- There are 5 major stages in breast cancer:
ines the breast for lumps or other changes that can be • Stage 0 (zero) – this stage describes cancer that is
signs of breast cancer. only in the ducts and lobules of the breast tissue and
• Mammogram – an x-ray of the breast. has not spread to the surrounding tissue of the breast.
It is also called non-invasive or in-situ cancer – this
Diagnosis means it is in the part of the breast where it originated.
Breast cancer is diagnosed based on clinical assessments,
imaging and pathological investigations. Clinical assess- Stage I (one) – in this stage cancer cells are breaking
ment includes taking a medical history which looks at pa- through to or invading normal surrounding breast tissue. It
tient’s health history and family history and doing a physical is further divided into IA and IB
examination to check for general signs of health, including • Stage IA – the tumour measures up to 2 centimetres
checking for signs of breast cancer. (cm) and the cancer has not spread outside the breast
and no lymph nodes are involved
Imaging modalities that can be used include • Stage IB – there is no tumour in the breast; instead,
• Breast ultrasound- pictures of the inside of breasts are small groups of cancer cells are found in the lymph
made using sounds waves. These are then reviewed nodes or there is a tumour in the breast that is no larger
for abnormalities. than 2cm and here are small groups of cancer cells in
• Diagnostic mammogram – more detailed x-ray of the the lymph nodes.
breast done if there are concerns arising from your

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Stage II (two) – also subdivided into IIA and IIB from getting the hormones they need to grow
• Stage IIA – no tumour found in the breast, but can- • Biological therapy – this works with your body’s im-
cer (larger than 2mm) is found in one to three axillary mune system to help your body fight cancer cells or to
lymph nodes (the lymph nodes under the arm) or in control side effects from other cancer treatments
the lymph nodes near the breast bone (found during a • Radiation therapy – high-energy rays (similar to x-rays)
sentinel node biopsy) or the tumour measures 2cm or are used to kill the cancer cells or keep them from
smaller and has spread to axillary lymph nodes or the growing.
tumour is larger than 2cm but not larger than 5cm and
has not spread to the axillary lymph nodes Treatment of breast cancer also includes breast reconstruc-
• Stage IIB – the tumour is larger than 2cm but less than tion surgery or breast replacement, and follow-up care.
5cm and has spread to 1 – 3 axillary lymph nodes or
the tumour is larger than 5cm but has not spread to Breast reconstruction is done to rebuild the shape and look
axillary lymph nodes. of the breast. It can be done at the time of treatment of
the breast cancer or later on. Breast reconstruction can be
Stage III (three) – subdivided further into 3 stages done using implants or using the patient’s body tissue. Im-
• Stage IIIA – the tumour of any size has spread to 4 to plant breast reconstruction involves small bags filled with
9 axillary lymph nodes or to internal mammary lymph salt water and/or silicone gel being placed under the breast
nodes. It has not spread to other parts of the body. It skin and muscle. When the patient’s own tissue is used, it
can also be a tumour that is larger than 5cm and has is called a flap. Breast reconstruction from flaps involves
spread to 1-3 axillary lymph nodes taking tissue from under the shoulder blade, abdomen or
• Stage IIIB – the tumour has spread to the chest wall or buttocks to form the breast.
caused swelling or ulceration of the breast, or it is di-
agnosed as inflammatory breast cancer. It may or may External breast prosthesis can also be used to replace the
not have spread to up to 9 axillary or internal mammary breast should a woman opt not to have breast reconstruc-
lymph nodes but it has not spread to other parts of the tion surgery.
body.
• Stage IIIC – the tumour of any size has spread to 10 Follow-up care for breast cancer should be tailored to each
or more axillary lymph nodes, the internal mammary patient’s case depending on the type of cancer the patient
lymph nodes, and/or the lymph nodes under the collar had, the type of treatment they received and their overall
bone. However, it has not spread to other parts of the health. The purpose of follow-up care is to see how the pa-
body. tient has responded to treatment, to encourage an active
lifestyle, to check whether or not the breast cancer has pro-
Stage IV (four) – this is metastatic breast cancer. The tu- gressed and to manage any health problems the patient
mour can be any size and it has spread to other organs may have as a result of treatment.
such as the bones, lungs, brain, liver, distant lymph nodes
or chest wall. Follow-up care of patients with early or locally advanced
disease (Stage 0-III) includes taking a medical history and
The higher the stage, the worse the prognosis and the having physical examinations every 3-4 months for the first
smaller the survival rate. 2 to 3 years. It is then extended to 6 to 12 months up to
5 years, then annually thereafter. Mammography every 12
Treatment months is also part of follow-up care. Any woman on tamox-
Breast cancer can be treated in the following ways: ifen (hormonal treatment for breast cancer) should also
• Surgery – operation in which the doctor removes the have an annual gynaecological examination. Follow-up
cancer cells by either doing a lumpectomy or mastec- care for patients with stage IV breast cancer includes palli-
tomy. In a lumpectomy, the tumour and some normal ation of symptoms to maintain quality of life for the patient.
tissue around the edge of the tumour is removed. In
a mastectomy, a large part of the breast or the whole Prevention
breast is removed. Lumpectomy is usually done in pa- There is no guaranteed way to prevent breast cancer but
tients with stage 0, or I breast cancer and mastectomy there are some things that can be done to reduce risk.
is indicated in widespread disease. • Maintaining a healthy weight
• Chemotherapy – either through pills that you take oral- • Be physically active and exercise regularly
ly, or medicines given in your veins, chemotherapy is • Avoid alcohol or limit alcohol intake
medicine used to kill or shrink the cancer cells. • Breast-feed
• Hormonal therapy – this therapy stops the cancer cells • Limit postmenopausal hormone therapy

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What is covered as PMB level of care? References
Treatable breast cancer is included in the Prescribed Min- 1. American Cancer Society. 2021. About Breast Cancer.
imum Benefits (PMB) regulations under DTP 950J. Treat- [online] Available from: https://www.cancer.org/cancer/
able cancers are defined in the PMB regulations as solid breast-cancer/about/what-is-breast-cancer.html [Ac-
organ malignant tumours where: cessed 27 July 2022].
i. they involve only the organ of origin, and have not 2. American Society of Clinical Oncology. 2021. Breast Can-
spread to adjacent organs cer - Stages. [online] Available at: https://www.cancer.net/
cancer-types/breast-cancer/stages [Accessed 28 July
ii. there is no evidence of distant metastatic spread
2022].
iii. they have not, by means of compression, infarction, or
3. Centers for Disease Control and Prevention. 2022. Breast
other means, brought about irreversible and irreparable Cancer. [online] Available from: https://www.cdc.gov/can-
damage to the organ within which they originated (for cer/breast/basic_info/index.htm [Accessed 27 July 2022].
example brain stem compression caused by a cerebral 4. Council for Medical Schemes. 2020. Final PMB definition
tumour) or another vital organ guideline for early and locally advanced breast cancer.
iv. or, if points (i) to (iii) do not apply, there is a well demon- [online] Available from: https://www.medicalschemes.
strated five-year survival rate of greater than 10% for the co.za/wpfd_file/final_pmb_definition_guideline-_for_ear-
given therapy for the condition concerned. ly_and_locally_advanced_breast_cancer/ [Accessed 28
July 2022]
Regardless of which benefit option a member or beneficiary 5. Council for Medical Schemes. 2014. CMScript on Breast
is on, the medical scheme must pay for the diagnosis, treat- Cancer. [online] Available from: https://www.medi-
ment, and care costs of treatable breast cancer. Screening calschemes.com/files/CMScript/CMScript13Of2014.pd-
through a physical breast examination, consultations with f?platform=hootsuite&platform=hootsuite [Accessed 27
doctors and other health professionals, surgery, radiology, July 2022]
6. John Hopkins Medicine Department of Pathology. n.d.
pathology, chemotherapy, and radiation therapy and breast
Staging & Grade - Breast Pathology. [online] Available
reconstruction are included in what the medical scheme
at: https://pathology.jhu.edu/breast/staging-grade/ [Ac-
must cover.
cessed 29 July 2022].
7. International Agency for Research on Cancer. 2021.
Preventative or prophylactic mastectomy for the undis- South Africa Fact Sheet 2020. [online] Available
eased breast is PMB level of care for women who have from: https://gco.iarc.fr/today/data/factsheets/popula-
breast cancer in only one breast. The reconstruction of the tions/710-south-africa-fact-sheets.pdf
undiseased breast is also PMB level of care.

Trastuzumab is a biologic medication that is PMB level of The Communications Unit would like to thank
care if certain clinical criteria is met. the Clinical Unit for assisting with this edition of
CMScript
Referral to genetic services is PMB level of care for women
who are being investigated for breast cancer and have a Contact information:
family history that meets criteria for referral. [email protected]
Hotline: 0861 123 267
The following are not included in the PMB regulations and Fax: 012 430 7644
medical schemes can fund at their own discretion:
• Preventative or prophylactic mastectomy in women The clinical information furnished in this article is
who do not have any breast cancer. intended for information purposes only and profes-
• Screening mammograms – most schemes will cover sional medical advice must be sought in all in-
one mammogram a year on certain benefit options.It is stances where you believe that you may be suffering
important to find out if your medical scheme will cover from a medical condition. The Council for Medical
the mammogram as screening before you go
Schemes is not liable for any prejudice in the event
• Some biologics - some schemes will pay based on
of any person choosing to act or rely solely on any
strict clinical guidelines and the benefit option the mem-
information published in CMScript without having
ber belongs to.
sought the necessary professional medical advice.
If the cancer has spread, only treatment that does not pro-
vide a five-year survival benefit of more than 10% is not
PMB level of care. In such instances, clinically appropriate
healthcare services must be funded.

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