Busting breast cancer myths

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IB: Ingrid Booth, digital content specialist, Investec

KS: Kristy Scott, private banker, Investec

CB: Professor Carol Benn

GD: Professor Georgia Demetriou

GS: Grant Statham, clinical psychologist, Maureen Kark and Associates

SS: Sinenhlanhla Sithomo, Investec Life head of business insurance

• 0:00: Kristy’s breast cancer story

  Kristy Scott: I’m Kristy Scott.  I’m 35 years old.  I work at Investec banking.  I was diagnosed with breast cancer in January 2016. We were actually getting married at the beginning of March, so the 5th of March.
  

  So, December 2015, I am sitting on our veranda, stretching having a nice glass of wine and I scratch under my arm and I just felt this tiny pea-sized lump.  It was right before the December holidays and I kind of, you know, it’s one of things you want to get it checked, but there is no history of breast cancer in our family so it wasn’t anything. I was only 31 so I wasn’t going for mammograms. There was no need to do those tests that people do do at a certain age.

  They actually found it was slow growing, we caught it early.  Luckily that’s why I say I’m the most grateful person ever because I think the fact that it was an invasive tumour means that if I’d found it a few months later it could have been a very different picture.

• 0:49: Introduction

  Ingrid Booth: That was Kristy Scott, a Private Banker at Investec, sharing her breast cancer story as part of a very brave and candid new Investec Life campaign that addresses women’s health. It centres on the stories of brave women who have fought and won battles against cancer, in the hope that what they have to say might uncover insights and information that help other women make informed decisions to prioritise one of their greatest assets – their health.

  As it is Breast Cancer Awareness month, the first podcast in our three-part series is with some of the country’s top breast cancer experts who will talk about exciting new treatments including the freezing of cancer cells. We will also deal with the psychological and financial impacts of a diagnosis and tackle some of the hype around Cannabis as a “cure” for cancer and whether starving cancer cells of sugar can help.

  My name is Ingrid Booth and I am part of the Digital Content team at Investec. The topic of today’s podcast is very close to my heart as I am also a breast cancer survivor who was diagnosed at the age of 35.

  If you find this podcast insightful, please subscribe to our channel and stay tuned for part two, where we look at lung cancer in women and ask the question why so many non-smokers are getting the disease. Part three is about women with liver cancer and we look at why South Africa has the highest prevalence of this disease in the world.
  

  But back to the topic at hand… 
  

• 02:13: Professor Georgia Demetriou explains what breast cancer is

  IB: I’m ashamed to say that when I was diagnosed with breast cancer in 2016 I knew very little about the disease, even though my mother had gone through it in her 40s. I had to do a lot of research to understand what was happening in my body. So I’d like to start this podcast with a very straightforward explanation of what breast cancer is, and who better to ask than renowned oncologist Professor Georgia Demetriou.

  Professor Georgia Demetriou: So cancer cells themselves are just like rogue cells in our body, that either divide too quickly and don't get mopped up by our normal mop up mechanism, in terms of our defence mechanism that kills bad cells. And we all have some bad cells that get mopped up and get taken out.  But that rogue cell, that for some reason escapes the control mechanism, and then one cell becomes two, two becomes four, four becomes eight and over time you then start to feel a palpable lump.  So that in layman's terms is what a cancer is. It's a cell that's got a proliferation advantage.  It grows easier and better and faster and you're unable to knock it out of the system.

  So within breast cancer for example, you might get a small lump developing within the breast, and then because you've got blood vessels and lymph drainage to that area, eventually as it gets bigger and bigger and bigger, it gets into the blood vessels.

  Once you've got little cancer cells that get into the bloodstream, or into the lymph vessels, it can start moving around the body, so then you get either the lymph nodes under the armpit that are involved, or a stray cell can go and sit either in the blood, in the bone marrow, in the liver, in the lungs and it can start growing there.

  And as cancer grows, because it's got almost a growth advantage over your normal cells that are much slower at dividing and growing, it starts to take up the normal space that normal cells take up and it takes over normal function.  

• 03:59: Is the breast cancer rate increasing globally?

  IB: Is it just me, or are you hearing about more and more cases of breast cancer amongst your friends and family? I read a report in The Lancet that estimates that the number of women being diagnosed with breast cancer could double to almost 3.2 million by 2030.

  To find out why this is the case, I spoke to Professor Carol Benn, one of South Africa’s leading breast surgeons and founder of the renowned Netcare Milpark Breast Care Centre of Excellence.

  Professor Carol Benn:  You know mortality, how we look at mortality, depends on where you are in the world and it also depends on what century you're in. So, in the 16th century people died of things such as the plague, kids died going up chimneys, and people barely lived till 40.  So as our centuries go if you look at death we talk about people living now to an age of 110 and 120.  What’s happening is there’s more chance for cells to undergo change, and if you’re not dying of, say for example, in Africa, Malaria and in childbirth and of violence, then it's people live for longer and their cells change. There's more chance that the cells will undergo bad division, misbehave and there you get cancers, so we're seeing an increase in all cancers across the board.

• 5:06: What is fueling the growth in breast cancer?

  IB: In South Africa, one in eight women will be diagnosed with breast cancer in their lifetime. I asked Professor Benn why the disease is so prevalent amongst women.

  CB: It’s not one thing.  People look at sugar, they look at diet, lifestyle. Everyone is trying to find a cause and a blame. So, it isn't one thing, it's a multitude of factors, it’s kind of like a reverse lotto.  It's genetics, it's certain aspects of your cell microenvironment.  It’s environmental factors.  All those things play a role. So what’s quite interesting now in the literature is women in their 30s and 40s taking contraceptive pills increases cancer risk, but again you can't pinpoint that one thing.

  So I always say to people you're an individual, you need to know your body you need to know your family history, on your mother and your  father's side and you must test accordingly, and screen accordingly, and that means the Big Five that we should probably screen for are cervical, men-prostate, that would be the equivalent, breast, stomach, colon and skin. 

• 6:13: What can you do to reduce your breast cancer risk?

  IB: As women, surely we don’t need to passively accept our breast cancer odds. I asked Professor Demetriou what can we actively do to lessen our risk?

  GD: Try and eat healthy, don't stress eat all the bad carbs, the saturated fats, refined sugars and modify the risks that you can.  Alcohol as well, often going through a stressful time, people have an extra drink or two that can increase risk, so modify the risk factors you can.   If we could all modify life and wave that magic wand, we would, but it’s not feasible. You can have that little piece of chocolate, but don't go and have 100 gram slab every single day.   It's about moderation in everything, trying to be as healthy as possible, and knowing we all have an oops day.

• 6:50: Does sugar feed cancer?

  IB: When I was diagnosed, I did a lot of Googling to find out why women get breast cancer – not the best idea in retrospect. People blamed everything from cell phones to coffee to deodorants and even hair relaxers. But the thing that came up the most was the idea that sugar “feeds” cancer and that you need to eliminate it from your diet. I asked Professor Benn to separate fact from fiction.

  CB: There’s this big thing about sugar and cancer. So, what we've got to realise is physiologically, at a cell level, all cells are having and they’re going through these tiny little vessels, the same amount of sugar that gets carried.  So, if you think that you're going to starve your cancer of sugar, you’re starving your brain, you’re starving your heart, you’re starving everything else at the same time.

  Obviously, the field of the future is oncology and oncology medicines and what happens in that little, what we call “tumour microenvironment”, and how the little blood supplies and that works. So it’s not one thing and we can't starve it, you might need other ways of killing the blood supply and, so, just be careful what you’re thinking and learning because unless you have a detailed understanding of anatomy and physiology you are making a mistake by thinking I can starve a cancer and not starve everything else.
  

• 8:04: Can Cannabis cure cancer?

  IB: So that deals with sugar, but when it comes to the treatment of breast cancer, there’s also lots of myths floating around. When I was diagnosed, I was bombarded with offers of Cannabis oil from well-meaning friends and family. I was interested to hear that Professor Benn doesn’t completely discount the use of natural remedies in the treatment of cancer…

  CB: So I think the thing is, things in nature are drugs in themselves, so some of the really good oncology drugs are derived from natural substances.  I always talk about the flowers, so I think if you look at the poppy, the poppy bad is heroin, the poppy good is all your drugs, your pain medicines.  

  Look at from the cannabinoid point of view, there are very  useful aspects in the actual substance that can be used along pain  pathways and there are some very, very good specialists doing a lot of work, but it's not a cure drug for something. So there's an aspect of oncology that I find fascinating that I often think is not given enough time and effort and that's supportive care.  

  Managing side effects and managing aspects around treatment that are hard for patients and secondly, that you live with for many years down the line.  And it can be, that Marijuana is a big thing at the moment - the cannabinoids can be hugely helpful around supportive care.  

  You don't know that 30 years down the line just like 30 years ago Thalidomide was the disaster drug for pregnant women who were taking it and had babies that were born without limbs and as now, Georgia can tell you, has a huge extensive use in oncology care. So there's good and bad in everything. So it's not all bad, but there's nothing that is the be-all and the end-all and the only answer and treatment to something and that includes the medicinal  cannabinoids.
  

• 9:57: Why natural remedies need to go through the right approval processes

  IB: Professor Demetriou agrees that while there is a place for natural remedies in the treatment of side-effects of cancer patients, it’s important that everything her patients take has gone through the right approval process.

  GD: There's a drug called Vinorelbine which comes from the periwinkle plant. Taxanes that we use first line, second line and often in breast cancer come from the Yew Tree.  So we're not anti looking at plant products, and all other things that can help us, but we want to know that it's come through a process where we’re using evidence-based medicine.  Not my aunty or my uncle said I should do it so my philosophy is yes, cannabis and cannabis oil will help for sleep, it will help for pain, but if patients are taking it to cure the cancer it's not going to do that.

  So I always say… I don't know where you getting it from… I will block my ears and close my eyes but as long as you’re doing something that doesn't interfere with what I'm doing, I'm not going to be close minded and say don't.  Just be sure that whatever, whether it's alkaline powder or if it’s cannabis oil or if it’s grapeseed or vitamin C, tell me what you're taking.  Some of the stuff can make my chemo less effective. I don't want to give you side effects if you're not going to get maximal benefit.  But let me know. If it doesn't harm what I do then I would not be against it.

• 11:13: If more younger women are getting breast cancer, why is the age for mammograms still 40?

  IB: From my own breast cancer experience, I’ve become a lot more aware of younger women getting this cancer and am puzzled as why the accepted age for your first mammogram is 40. Professor Benn explains that there is no need to wait, if you pick up anything suspicious in your breasts, you should go for a screening, but not necessarily a mammogram.

  CB: So I think that cancer and breast cancer is neither ageist, racist or sexist. I have a run of young boys under the age of 35, which is almost unheard of, that I'm seeing with male breast cancer breast cancer at the moment.

  The thing about screening, it's about health economics. So in the US now we screen from 50 and in the UK 50 every three years. I'm a great believer, if you're 23 and you’re worried that something doesn't feel right, go for a sonar.  

  Sometimes in young people mammograms don't pick things up, but sonars do and MRIs. So, if you have that niggle in your head that something doesn't feel right go for the right investigations. 

• 12:07: “Why me? I’ve been healthy my whole life”

  IB: We have all heard the slogan “early detection saves lives” and yet women are still surprised when they are diagnosed with breast cancer. Kristy certainly was.

  KS: I think that it’s no longer, breast cancer is no longer just a disease for our mom’s friends, you know, actually now its younger and younger and I don’t know if it’s the stress or the food we are eating.  I mean Carol [Benn] said to me she is like.. I said what caused this? why? what?, I’ve done nothing, but I’ve been healthy my whole life... and she said it’s just genetics, you know, it’s one of those things. It’s luck of the draw.

• 12:40: Why do we bury our heads in the sand when it comes to self-examination and screening?

  IB: So if it can happen to anyone, why aren’t more women undertaking self-examination or screening? Clinical psychologist Grant Statham believes that in order to drive more screenings, the narrative around them needs to change. I asked him why so many of us bury our heads in the sand when it comes to breast cancer.

  Grant Statham:  So I think there’s a couple of factors that contribute to that, and I think primarily the first one is that we tend to underestimate risk.  So, as human beings we use a lot of cognitive strategies to absorb and work with information… and we have a propensity to what’s termed optimism bias, so we never really think it is going to happen to us until it actually does.  

  The whole concept of optimism bias is really that we underestimate risk for things that we don’t want to happen to us and we tend to overestimate risk or potential for things that we do want to happen, so if I had to give you the odds of one in eight for breast cancer, you probably feel like your odds are not that high; whereas if I had to say that you’ve got a had a one in eight chance of winning the lottery, you’d probably feel quite excited and that’s just really the way we process information and assimilate it into our existence. 
  

  I think the second thing is that this is really around the behaviours around diagnostic and self-examination, and the motivation being poor.  You know if we look at it, in its simplest form, self-examination and diagnostic behaviours or screening tests is quite idiosyncratic in the sense that we are effectively actively looking for something that we don’t want to find, and for many people that feels sort of counter-intuitive.
  

  And that’s really where the motivation to engage in those behaviours is quite low. You know, particularly if we ascribe negative outcomes to what we might find, particularly if it’s fatalistic and sort of catastrophic thinking. So the consequence of finding something is really, you know, perceived to be quite dire, so nobody wants to be engaged in those behaviours.  So, we need to be  thinking about things a little bit differently, and we really need to start changing the narrative that we ascribe, to create breast cancer awareness and to make sure that everybody is invested in considering their own risk.  
  

• 14:43: Using genetics to learn more about cancer

  IB: Breast cancer treatment has come a long way in the last decade. Some of the most exciting developments are in the field of genetics. Professor Benn believes that the need for surgery will become less and less in the future as we gain a better understanding of cancer cells’ behaviour.

  CB: We are starting to look at where we actually take the genetics of the cancer cell so where we understand breast cancers moved from treating it in terms of stages.  Everyone used to want to know how big was your cancer? Was it in the glands? What stage are you? With any cancer. And there would be a very reciped approach to treatment, and the recipe would be have some form of surgery, have some form of oncology.

  Today now, well particularly with breast cancer, we divide the breast cancer into four different behavioural types - the biology of the cells.  And by looking at those types, they treat it differently.  So, different cancers will be treated with different things. Some with target therapy, some with tablets, some with surgery.  There are different ways.

  The future generation is going to be where you can actually treat cancers elsewhere with similar drugs that you use to treat breast cancer, because what you are doing is, you are understanding the genetics at a cell level.  It’s like a cancer in a petri dish and try and work out what is the right medication.

• 15:60: Medical breakthroughs in breast cancer surgery

  IB: There are several other medical breakthroughs and procedures that Professor Benn is investigating from cryosurgery that uses extreme cold to freeze and kill cancer cells, to the Abscopal Effect of radiation therapy which is the ability of localised radiation to trigger systemic antitumor effects.

  CB: I'm looking forward to, in the next year or so, bringing things such as cryosurgery in where you can freeze cancer cells and we have these effects called abscopal effects, where you kill the cancer where it is and your body's own immune natural killer cells almost develop a way of understanding that that is bad and helping kill things elsewhere.  

  So there are huge breakthroughs happening.  We have special radiation machines in theatre that we can take the cancer out, put a little bit of radiation in one area.  It's really becoming less and less and less and understanding what's happening in terms of a cell behaviour.
  

• 16:52: Breakthroughs in oncology

  IB: And it’s not only in surgery where doctors are increasingly looking at cancer from a cellular level. This approach is extremely powerful in the field of oncology, says Professor Demetriou.

  GD: It's a very exciting time for us, just having come back from the European Oncology meeting all the new things, the exciting things, the things that allow us to say I don't have to throw the atomic bomb at one cell,  I can potentially target on  a cellular level.  It comes with side effects always but somewhat more manageable side effects, often medication that people can be on for a longer period without having such severe effects.

  Certainly, hair loss starts to become less and less of something that we going to have to worry about. We are going to get to the point where people don't have to go around saying “this bad hairdo is because of my oncologist”. They can go around and say OK, yes I've got some side effects, but it's manageable and I can carry on with my day, and quality of life is actually really, really quite good.
  

• 17:51: Why financial stress should also be a consideration with a breast cancer diagnosis

  IB: As Grant said earlier, there’s a lot of women who ignore the need for screenings, taking a “this won’t happen to me” approach. Like Kristy, this is equally true of the financial aspects of a cancer. Professor Benn believes that assessing a patient’s psychological and financial stressors is critically important.

  CB: The future is in technology where we have groups, psycho-oncology groups, so in other words when people come in, they fill out immediate questionnaires that rate in terms of what their stressors are. So one of the most important fields for me in all aspects of medicine particularly oncology, and I've really  learnt this from my son who is a diabetic, is this concept of patient navigation, financial navigation around what their financial crises are. Their home, their family, their psychology.

  IB: For Kristy, at 31, taking out additional insurance cover didn’t feel like a priority.

  KS: I was very fortunate to have my mom on the phone cos as much as you might get registered for these oncology benefits for example, everything is coded wrong and you’re have to chase up every last cent and not to mention that you want to see the right specialist when you dealing with something like this, you need to see the right specialist.  And I mean, these guys are charging four time cover or whatever, three times, and I think it’s quite scary not to mention with the breast cancer side of things the hormonal stuff.  Now suddenly you’ve got fertility and I, at the time being 31 years old, it didn’t even cross my mind to have any additional cover.

• 19:15: What insurance cover can women get for breast cancer?

  IB: The financial aspects of a cancer diagnosis are generally not given the same airtime as the medical and emotional side of it. Cancer can be a very costly disease to treat, from accessing expensive new treatments to dealing with a lack of income to paying for additional childcare. I spoke to Sinenhlanhla Nzama, head product actuary at Investec Life about what women can do to alleviate the additional stress that comes from worrying about money in a cancer diagnosis.

  Sinenhlanhla Nzama: The reality is that cancer is a life-threatening illness or condition, and given that it's a major illness in South Africa, really the costs involved that you need to be aware of, actually earlier before you get diagnosed, are the costs for consultations of medical specialists, like oncologists or surgeons if you need to do a surgery and the surgery costs, there's the cost of that depending on the kind of cancer that can be operated on.   

  Also look at diagnostics such as mammograms that may be needed, may not be as high-cost - the medical aid will typically cover some of those.  But then you also have other treatment regimes, like drugs that may be needed or chemotherapy and radiation, so all those combined can actually be quite a significant amount of costs that you need to be aware of.

• 20:25: The high costs of cancer treatment and the insurance options available

  IB: New generation immunotherapy drugs can cost up to R1 million, while a mastectomy plus an older generation immunotherapy drug could cost you in excess of R500,000. Not to mention a six-week cycle of chemo or radiation that can both exceed R100,000. When you consider the high costs of cancer treatment, it’s imperative to have the right cover in place. I asked Sinenhlanhla to talk me through the options.

  SS: Actually, there are three types of product that you find, typically, in South Africa, to look after your health.  One is the medical aid, the other one is what you call gap cover, and then it's severe illness cover, or dread disease cover.

  So medical aid is set up such that it can pay for the costs of treatment or consultations, and it pays directly to the healthcare provider or the doctor who's treating you, but however medical aid is typically capped, so it’s not necessarily always paying in full, and especially for the high-cost conditions like a cancer or heart conditions. And also it may be prescriptive in terms of which drugs it will pay for, regardless of what your doctor may be recommending, again because it needs to be cost-conscious, because the benefits of the medical aid are shared amongst all the members.

  While the second product offering that you find out there in the market is what you call gap cover, that is typically to ensure that if your medical aid does not pay for everything while you are in hospital, it can pay for those medical specialists to look after you, while you’re in hospital. But the law changed and now it only can only pay up to 150,000 a year, so it is really not sufficient for something like a cancer, it will just be wiped out very, very soon.

  And then you've got severe illness cover which is a type of an insurance product.  It really acts as two parts: one to supplement your medical aid wherever it's got gaps for a major condition like a cancer, but also to ensure that you can have financial support all round so you can ensure that you can have home nursing or someone support you, to look after yourself, and your kids, if you have got kids that is critically important to ensure your recovery,  but also pays for anything else that you may need over and above your medical aid may typically pay.  So overseas treatment is one of the examples, traveling to specialist clinics is another one.  So it's really a financial instrument more than just paying for the treatment itself.
  

• 22:40: What is the difference between medical aid and severe illness cover?

  IB: One of the main differences between medical aid and severe illness cover is that while medical aid will pay the healthcare provider directly, severe illness cover pays you.

  SS: Severe illness is one of those great products that pays on diagnosis. So as long as the diagnostics confirm that you have got a cancer, the pay-out is triggered automatically.   

  With severe illness it pays directly to you in your bank account so the next time you go and see your treating specialist you actually structure your treatment regimes without the constraints of medical aid pay-outs, but with the supplementary pay-outs you've already got from your insurer.

• 23:13: Conclusion

  IB: Being diagnosed with breast cancer, you have multiple stressors from the medical process to the psychological and financial aspects of the disease. Reassuringly though, treatment options are progressing rapidly with women like Professor Benn and Professor Demetriou leading the charge. Today, if the cancer is located only in the breast and you catch it early, the 5-year survival rate of women with breast cancer is 99%.

  For Kristy, on her own personal journey, breast cancer has taught her a lot of valuable lessons...

  KS: There is this sort of belief that you always have to be perfect - you just feel this desire to be perfect and everything to be perfect and I think that this was almost something that it was actually quite liberating to say you know what I’m no longer perfect, I now have scars, I have you know, and it’s just actually, you know, it gives you the ability to be a bit more vulnerable and just to say that this is actually something that I have gone through.

  IB: Thank you for listening to this Investec Focus podcast. Please take the time to rate this conversation and to subscribe to wherever you get your podcast fix. And stay tuned for parts two and three of our Investec Life podcast series, where we speak to young women who have survived lung and liver cancer and ask the experts to weigh in on these often-overlooked diseases.

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