Breast Cancer Control Policy – 4. Treatment and Palliative Care

 

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KNOW YOUR RIGHTS: ALL WOMEN WITH BREAST CANCER SHOULD BE EVALUATED BY A MULTIDISCIPLINARY TEAM TO DETERMINE THE MOST APPROPRIATE TREATMENT. FOR EARLY BREAST CANCER, BREAST-CONSERVING SURGERY (BCS) OR MASTECTOMY SHOULD BE CONSIDERED. IF YOU’RE HIGH-RISK, YOU ARE ALSO ENTITLED TO ADJUVANT SYSTEMIC THERAPY, INCLUDING TAMOXIFEN OR TRASTUZUMAB, POST-SURGERY.

 

“Breast cancer management relies on a firm foundation of a multidisciplinary team. The “core” team comprises a surgeon, pathologist, radiologist, medical oncologist and a radiation oncologist. The intention is that from the start of a patient’s treatment there is an individual plan, tailored to the exact stage and type of breast cancer that the patient has.” – The Breast Health Foundation1

Breast cancer is treated in several ways, depending on the type, and how far it has spread. It’s likely you could also get more than one kind of treatment, but the options include:

  • Surgery, when doctors will cut out the cancer tissue.
  • Chemotherapy, when they use medication to shrink or kill the cancer cells. This medication could be in the form of pills, be given as a drip into your veins, or a combination of both.
  • Hormonal therapy, which blocks the cancer cells from getting the hormones they need to grow.
  • Biological therapy, which works with your body’s immune system to help it fight the cancer cells, or to control side-effects you may be experiencing from other cancer treatments.
  • Radiation therapy, which uses high-energy rays similar to x-rays to kill the cancer cells. 2

Treatment of breast cancer is a key area of the new policy, and stipulates that if you have early breast cancer you should undergo either breast-conserving surgery (BCS) or a mastectomy.

 

Are there timeframes for treatment?

  • You must be referred for surgery or adjuvant radiation within 42 days of your medical team making a decision about the next step in your treatment.
  • You must be offered radiation once you’ve undergone breast-conserving surgery – within 90 days.
  • Post-mastectomy radiation must be made available to you within 60 days.
 

You also have the right to:

  • Reconstruction options, which should be discussed with you at your consultation with your surgical team before your operation.
  • If you’re eligible, you must receive post-surgery therapy such as the hormone therapy drug tamoxifen. This includes trastuzumab where applicable.
  • If you have metastatic breast cancer, you must get the appropriate systemic therapy for symptom control. It’s not curative, but will improve your quality of life. 3
 

Where are the proposed Specialised Breast Units (SBUs) by Province?

PROVINCEPROPOSED SPECIALISED BREAST UNITS
-- Pending Accreditation --
Eastern CapeFrere Hospital
Livingstone Hospital
Free StateUniversitas Annex
GautengSteve Biko Academic Hospital
Charlotte Maxeke Johannesburg Academic Hospital
Chris Hani Baragwanath Hospital
Helen Joseph Hospital
Dr George Mukhari Academic Hospital
Kwazulu-NatalGrey's Hospital
Inkosi Albert Luthuli Central Hospital
LimpopoPolokwane Hospital
Western CapeGeorge Hospital
Groote Schuur Hospital
Tygerberg Hospital

It is envisaged that all these centres will undergo an accreditation process to ensure they meet the minimum standards as set in this guideline (or identify the level of support required to meet the standard).

 

What is HER2 Positive breast cancer and why is this treatment so important?

This type of cancer affects 20% of all people with breast cancer, but is more common in black women younger than 40. It progresses faster, and has a higher rate of death and recurrence.

The World Health Organisation has listed trastuzumab as an essential medicine for the treatment of early and metastatic breast cancer since 2015. Just two years later, South Africa included this essential medicine for early breast cancer. One year of treatment with the medication, marketed in the private health sector by SA Roche as Herceptin©, costs R343 000. In the public health sector, the medication is known as Herclon©, and costs R118 000.

The Cancer Alliance is pursuing the issue in light of the fact that health economists estimate that a trastuzumab “bio-generic” can be profitably marketed at just R3 500 for a year’s treatment. Read more here. 4

 
 

What about treatment follow-up and surveillance?

You are entitled to the following checks:

  • Three-monthly check-ups for the first two years at an oncology department.
  • Check-ups every six months for years three to four, then annually thereafter.
  • These check-ups must include a thorough history and eliciting symptoms, physical examination, annual mammography with ultrasound recommended, annual gynaecological examination for patients on tamoxifen, and nutritional support from a dietician.
  • Specialist physiotherapy for patients at risk of swelling as a result of lymphoedema.
  • You may also be assessed and receive treatment for movement-related pain and limited range of movement post-surgery. 5
 

What about Psychological Support and Palliative Care?

Palliative care is a multi-disciplinary approach to specialised medical and nursing care for people with life-limiting illnesses. It focuses on providing relief from the symptoms, pain, and physical as well as mental stress at any stage of illness, including recurrent and/or metastatic disease for end-of-life care.

Palliative care will, in terms of the policy, be delivered in your home or in hospital, but it also dictates that mobile outreach services must be created to care for you if you live in a remote area, and cannot travel long distances.

Usually supported by volunteers, these services may be independent or attached to a hospital or clinic.

See all the details about South Africa’s National Policy Framework and Strategy on Palliative Care – 2017-2022 here.

Psychological Care:

All women diagnosed with breast cancer should be screened for emotional distress to identify common psychosocial issues that include:

  • Disruption of body image.
  • Fear of recurrence.
  • Treatment-related anxieties.
  • Sexual dysfunction.
  • Marital/partner communication.
  • Feelings of vulnerability.

The level of support will depend on your needs, which will change as your level of functioning changes and declines.

How will an Emotional Distress Assessment benefit you?

  • It will ensure that if you need palliative care support at any stage of your illness, it will be available.
  • It will identify your anxieties as well as any early psychological or social concerns, allowing you to get appropriate psychosocial help.
  • It will improve your quality of life and ensure the highest possible level of functioning in the early and later years after primary treatment, and if you have recurrent disease.6
 

Patient navigators:

This is another level of care being introduced, in terms of which nurses or counsellors will become so-called Nurse & Patient Navigators (NPNs), acting as a contact between you, the patient, and the healthcare system.

Among other responsibilities, they will:

  • Provide patients with relevant education.
  • Track biopsy results, interventions and outcomes.
  • Facilitate referrals.
  • Assist you with treatment decision-making.
  • Help organise transport arrangements when necessary.
  • Check on you if you miss appointments.
  • Provide ongoing psychosocial support.

REFERENCES

  1. The Breast Health Foundation (2018). Can Breast Cancer be treated? What treatments are available? Retrieved on October 1, 2018, from http://bit.ly/2WazJBv
  2. Centers for Disease Control and Prevention (CDC) (2018). How is breast cancer treated? Retrieved on October 1, 2018, from http://bit.ly/2DwTf3I
  3. National Department of Health (2018). Clinical Guidelines for Breast Cancer Control and Management. NDOH Internal document – P53-58
  4. Cancer Alliance (2018). HER-2 Breast Cancer Fact Sheet. http://bit.ly/TobekaDaki
  5. National Department of Health: Clinical Guidelines for Breast Cancer Control and Management. NDOH Internal document – P14-63.
  6. National Department of Health (2018). Clinical Guidelines for Breast Cancer Control and Management. NDOH Internal document – P58-62.

 

Return to Breast Cancer Policy Toolkit.