By Dr Fatima Hoosain, specialist surgeon and Principal of Apffelstaedt, Hoosain & Associates, with a clinical focus on breast and endocrine surgery.
When people think about breast cancer screening, the conversation often begins and ends with one message: screen more women.
As clinicians, we know it is not quite that simple.
There is no question that screening saves lives. Regular mammography reduces breast cancer mortality and gives us the opportunity to diagnose disease when it is smaller, more treatable and associated with significantly better outcomes. Few interventions in medicine demonstrate such a clear benefit.
The challenge is that good breast care is not defined simply by how many mammograms we perform. It is defined by the quality of the decisions that surround them.
This was the focus of my presentation at the recent Board of Healthcare Funders (BHF) Conference, where we explored how clinicians can balance the burden of breast cancer with evidence-based screening decisions while remaining mindful of both underdiagnosis and overdiagnosis.
Those competing risks are encountered by every clinician involved in breast care.
We all worry about the patient whose cancer is diagnosed later than it should have been. Earlier diagnosis frequently means less extensive surgery, more treatment options and, ultimately, better outcomes. The survival difference between early-stage and advanced disease is substantial, making timely diagnosis one of the most important contributors to long-term prognosis.
At the same time, screening is not without consequences.
Not every abnormality detected on imaging will become life-threatening, yet every suspicious finding understandably creates anxiety. Additional imaging, biopsies and sometimes treatment may follow. Our responsibility is therefore not simply to detect abnormalities, but to interpret them appropriately within the context of each patient’s overall clinical picture.
This is why breast screening should never be approached as a uniform process. Risk matters.
A woman with an inherited genetic mutation or a strong family history should not necessarily follow the same screening pathway as someone at average risk. Likewise, imaging should answer a clinical question. Mammography remains the cornerstone of breast screening, but dense breast tissue, patient age and individual risk factors may require supplementary investigations such as ultrasound or MRI. More imaging is not automatically better medicine. Appropriate imaging is.
These decisions have become even more complex within the South African healthcare environment. International guidelines provide an excellent evidence base, but they do not remove the practical realities we face every day. Access to imaging differs between regions. Advanced investigations may not always be readily available. Medical scheme funding, co-payments and affordability inevitably influence what is possible for many patients. These factors cannot be ignored when discussing best practice because they form part of the reality in which clinical decisions are made.
Fortunately, the treatment landscape continues to evolve.
Advances in oncoplastic surgery, targeted therapies, immunotherapy and modern radiation techniques have transformed outcomes for many patients diagnosed with breast cancer. These developments are encouraging, but they should not distract us from one fundamental principle: the earlier we diagnose clinically significant disease, the greater the opportunity to offer patients treatments that are both effective and less invasive.
Diagnosis, however, is only the beginning of the journey.
Long-term follow-up remains an essential part of breast cancer care. Ongoing surveillance, adherence to endocrine therapy where appropriate, management of treatment side effects and supporting patients through the psychological and financial impact of a cancer diagnosis all influence outcomes. Good breast care extends well beyond the operating theatre or oncology unit.
As our healthcare system continues to face increasing clinical and financial pressures, I believe we need to move beyond simplistic conversations about screening uptake alone.
The more important discussion is whether we are making consistently good clinical decisions. Are we identifying the patients who stand to benefit most? Are we investigating appropriately? Are we avoiding unnecessary intervention when the evidence suggests it is unlikely to improve outcomes?
Those are not easy questions, but they are the ones that matter.
Ultimately, breast cancer screening is not about doing more. It is about doing what is right for the patient sitting in front of us. That remains the most important clinical judgement we make.
