BREAST CANCER CONTROL POLICY BREAST CANCER CONTROL POLICY June 2017 1 BREAST CANCER CONTROL POLICY 2 BREAST CANCER CONTROL POLICY FOREWORD ..........................................................................................................................................4 ACKNOWLEDGEMENTS ......................................................................................................................5 ABBREVIATIONS AND ACRONYMS ...................................................................................................6 SECTION A: BACKGROUND AND THE SOUTH AFRICAN CONTEXT ..............................................7 CHAPTER 1: INTRODUCTION AND BACKGROUND .........................................................................7 CHAPTER 2: THE SOUTH AFRICAN CONTEXT .................................................................................8 2.1 EPIDEMIOLOGY ....................................................................................................................8 SECTION B: POLICY FRAMEWORK .................................................................................................10 CHAPTER 3: GENERAL POLICY DIRECTION ..................................................................................10 CHAPTER 4: POLICY GUIDING PRINCIPLES AND FRAMEWORK FOR CANCER PREVENTION AND CONTROL ..................................................................................11 SECTION C: STANDARDS OF CARE ................................................................................................13 Key Area 1: Prevention and early detection, screening and genetic assessment ................................14 Objective 1: Screening and early diagnosis .....................................................................................14 Objective 2: Risk assessment ..........................................................................................................15 Objective 3: Genetic services ...........................................................................................................17 Objective 4: Management of women known or suspected to have a breast cancer susceptibility gene mutation .......................................................................................19 Key Area 2: Timely access to care .......................................................................................................19 Objective 5: Specialist breast units for the diagnosis and management of breast disease ..............19 Objective 6: Clear referral pathways and access points to breast diagnosis ...................................21 Objective 7: Clear referral pathways and access points in breast cancer care ................................24 Key Area 3: Assessment, diagnosis and staging ..................................................................................25 Objective 8: Triple assessment .........................................................................................................25 Objective 9: Staging .........................................................................................................................28 Objective 10: Supportive care (including psychology) ......................................................................29 Objective 11: Patient navigation .......................................................................................................30 Key Area 4: Treatment of breast cancer ...............................................................................................31 Objective 12: Surgery (early and advanced breast cancer) .............................................................31 Objective 13: Breast reconstruction (immediate versus delayed) ....................................................34 Objective 14: Systemic therapy in early stage breast cancer ...........................................................35 Objective 15: Systemic therapy in locally- advanced stage breast cancer .......................................37 Objective 16: Systemic and local therapy in metastatic breast cancer .............................................38 Objective 17: Radiotherapy in breast cancer ....................................................................................40 Key Area 5: Palliative care in breast cancer .........................................................................................42 Objective 18: Palliative care management for patients ....................................................................42 Key Area 6: Follow-up and surveillance in breast cancer .....................................................................43 Objective 19: Appropriate cost-effective strategy for follow-up .........................................................43 Objective 20: Lymphedema care ......................................................................................................43 Key Area 7: Data, monitoring and research..........................................................................................44 Objective 21: Monitoring and research .............................................................................................44 Key Area 8: Community outreach and engagement .............................................................................44 Objective 22: Community engagement and CSOs ...........................................................................44 REFERENCES .....................................................................................................................................46 APPENDCES .......................................................................................................................................50 Appendix A: What is a breast unit? ...................................................................................................50 Appendix B: International breast cancer staging ..............................................................................52 Appendix C: Breast cancer patient protocol .....................................................................................53 Appendix D: Breast proforma ...........................................................................................................54 3 BREAST CANCER CONTROL POLICY FOREWORD The Breast Cancer Prevention and Control Policy is an important document aimed at prioritising breast cancer awareness, prevention, treatment and care in South Africa. It provides the clinical support for women, who are both at-risk of developing the disease later in life and are currently undergoing treatment, to survive and live healthy lives. Breast cancer, along with cervical cancer, has been identified as a national priority in South Africa. Breast cancer is the most prevalent cancer and a leading cause of death among South African women. The increasing incidence of breast cancer is a major health concern with 19.4 million women aged 15 years and older at-risk of contracting the disease. Per the National Cancer Registry in 2012, 8 203 new cases of breast were observed. Given the recent advances in medicine and technology, however, we have a tremendous opportunity to attack breast cancer energetically and effectively with a revised national programme. Against this background I am delighted to release the revised policy on breast cancer prevention and control. And it is being launched during an exciting period in the history of healthcare in South Africa –the introduction of the National Health Insurance. This updated policy entails the implementation of interdependent strategies: (i) increasing early recognition of breast cancer, (ii) treating breast cancer more effectively, and (iii) providing timely treatment and palliative care for invasive cancer. It also includes the administration of Trastuzumab for early stage cancer at designated sites nationally. We envisage that this policy, along with the accompanying programme implementation strategy and clinical guidelines, will be applied in the public sector at all levels of the health system thereby positively contributing to reducing breast cancer’s incidence and mortality rates as well as improving the quality of life for women in South Africa. Dr Aaron Motsoaledi Minister of Health 4 BREAST CANCER CONTROL POLICY ACKNOWLEDGEMENTS The national Department of Health would like to acknowledge the exceptional contribution of the writing group of breast cancer clinicians responsible for the KwaZulu-Natal breast cancer policy and Breast Interest Group of Southern Africa (BIGOSA). The majority of evidence for this policy is derived from their intellectual input and literature review. The authors of this document would like to make clear however, that any conclusions in this document and standards derived from this evidence are not necessarily the opinion of this writing group and should not be taken as such. The contributors consisted of breast surgeons, plastic and reconstructive surgeons, oncologists, radiologists, nuclear physicians, pathologists, geneticists and obstetrics and gynaecology specialists. In addition, experts in the various fields, including civil society organisations and other interest groups, were also contacted when necessary for further opinions. It is also worth noting that although considerable reference was made to the Malaysian guidelines because both countries are classified as middle-resource countries and demonstrate many similarities, this Breast Cancer Prevention and Control Policy document is aligned to the healthcare situation in South Africa