Breast cancer imaging in South Africa in 2018
South African Journal of Radiology
It is with great pride that I present the South African Journal of Radiology (SAJR) breast issue. Breast cancer is the most common cancer diagnosed in women in South Africa, and together with cervical cancer, constitutes the leading cause of cancer death. 1 Early diagnosis of breast cancer is key to reduce mortality. 2 Breast imaging is an ever-growing subspecialty of radiology, both in South Africa and worldwide. The goal is to detect cancer changes as early as possible and to be able to
... tely differentiate cancer from non-malignant breast pathology. The ability to rule out cancer, either by confirming the benignity of a lesion or by excluding the presence of any abnormality at all, is as important as showing features of malignancy. 3 The intention with this SAJR issue is to provide a platform for local radiologists to publish breast imaging articles, and, in particular, to identify various aspects of breast radiology that are of importance in the South African context. One of these is the high human immunodeficiency virus (HIV) prevalence in the population. So far, it has not been shown that women with HIV are at a higher risk of developing breast cancer or that they necessarily present at a later stage than non-HIV patients. 4 There is, however, strong evidence that women with HIV develop breast cancer at a younger age. This is corroborated by Dr Minnie et al. in their retrospective study. The implication is that breast cancer screening, or at the very least, education about breast cancer, needs to be directed at younger women. HIV should possibly be considered an independent risk factor for earlier breast cancer development, and consequently, screening from a younger age. Unfortunately, there is a desperate shortage of radiology services in the public sector in South Africa, and as a result, most women do not have access to screening mammography. 5 At present, the guidelines from the National Department of Health regarding screening for breast cancer do not cover mammography at all, and instead, promote clinical breast examination as the primary screening test. 5,6 Therefore, we must acknowledge that mammography screening in this country is available only to a small percentage of the population, those with private medical aids and possibly those in large city centres where tertiary-level public hospitals do offer mammograms. The topic of screening mammography remains contentious after nearly 50 years of mammography. Nonetheless, screening has been definitively shown to reduce mortality from breast cancer and the optimal starting age and intervals for mammography are becoming clearer. Dr Lipschitz has examined the literature, and composed a lucid, thoughtful breast cancer screening guideline. One of the most frequent diagnoses for palpable breast lumps, especially in the younger age group, is that of fibroadenomas. Despite the likely benignity of breast lumps in younger women, we are seeing a growing number of high-grade cancers in young women, some of which mimic fibroadenomas. 7 Taking into account the paucity of mammography equipment in most public health systems across the African continent, the reluctance to use mammography in younger women and the unfeasibility of performing biopsies on all masses, Dr Olarinoye-Akorede et al. have submitted a very useful study undertaken in Zaria, Nigeria, on the utility of breast ultrasound in younger patients with palpable breast lumps. In experienced hands, and abiding by certain proven descriptors, ultrasound is both highly sensitive and specific in determining malignancy in solid breast masses. 8 Breast density as a risk factor for breast cancer is a topic that is often under-appreciated by radiologists and referring clinicians. Current data suggest that density alone is a risk factor for cancer development, while also causing a masking effect of underlying malignancy. 9 In the United States of America (USA), it has become law in most states that women are informed of the density of their breasts on mammogram so that they can elect for additional imaging. 10 In South Africa, most practices that offer mammography also offer breast ultrasound. Similarly, tomosynthesis mammography, which also reduces the masking effect of dense tissue, has been widely adopted. Breast cancer imaging in South Africa in 2018 Read online: Scan this QR code with your smart phone or mobile device to read online.