South African Women's Health - November 2017

ISSN 2522-3941
ABOUT best practice, FOR FOR optimal care
careissue 1• 2 • aug/sept nov/dec 2017
www.southafricanwomenshealth.co.za

Focus on
SURGICAL BIOPSY
VS CORE BIOPSY
8
WHEN LESS IS MORE
17
IT’S IN THE DNA
35
THE ROLE OF FAT GRAFTING
IN AESTHETIC SURGERY
PROGNOSTIC & PREDICTIVE
38
VACCINES: THE LOW DOWN
44
MARKERS IN BREAST CANCER
SOUTH AFRICA’S OBSESSION
WITH FOOD
46
HOW GASTRIC BYSPASS
PATIENTS LEARN TO EAT AGAIN
NOTE: “instructions to authors” are available at www.southafricanwomenshealth.co.za
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 3

CONTENTS
NOVEMBER 2017
5 FROM THE EDITOR
6 FOCUS ON: SUB-EDITOR BIOGRAPHIES
BREAST
8 FOCUS ON: SURGICAL BIOPSY VS CORE BIOPSY:
WHEN LESS IS MORE
10 FOCUS ON: NEW TRENDS IN BREAST CANCER: MANAGEMENT
& RECONSTRUCTION SURGICAL PERSPECTIVE
15 GROOTE SCHUUR HOSPITAL BREAST CLINIC
WOMEN IN HEALTHCARE
17 FOCUS ON: IT’S IN THE DNA
19 A WOMAN’S TALE
23 SOUTH AFRICAN TAX AND DNA
25 BE BOLD FOR CHANGE 2017
27 STOPPING THE BLUR
OBSTETRICS & GYNAECOLOGY
29 HOW SOPHROLOGY HELPS PREGNANCY:
A WOMAN’S JOURNEY BEFORE, DURING & AFTER
AESTHETICS & RECONSTRUCTION
35 FOCUS ON: THE ROLE OF FAT GRAFTING
IN AESTHETIC SURGERY
HEALTH & LIFESTYLE
38 VACCINES: THE LOW DOWN
40 IZZY’S STORY
42 FOCUS ON: CHILDHOOD OBESITY AND WHY IT MATTERS
WHAT CHILDEN EAT AT SCHOOL
ONCOLOGY
44 PROGNOSTIC & PREDICTIVE MARKERS IN BREAST CANCER
SURGERY, OBESITY & METABOLISM
46 SOUTH AFRICA’S CULTURAL OBSESSION WITH FOOD &
THE PSYCHOLOGY OF WEIGHT LOSS HOW GASTRIC BYPASS
PATIENTS ‘LEARN TO EAT AGAIN’
* PLEASE NOTE: Each item is available as full text electronically and as an individual pdf online.
Disclaimer: No responsibility will be accepted for any statement made or opinion expressed in the publication.
Consequently, nobody connected with the publication including directors, employees or editorial team will be held liable for any
opinion, loss or damage sustained by a reader as a result of an action or reliance upon any statement or opinion expressed.
© South African Women’s Health This magazine is copyright under the Berne Convention. In terms of the South African
Copyright Act No. 98 of 1978, no part of this magazine may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording or by any information storage and retrieval system,
without the permission of the publisher and, if applicable, the author.
COVER PHOTOGRAPH: Shutterstock Image
Design and layout: The Source PR * Printers: Imagine It Print It
4 * SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FROM THE EDITOR
Dear Reader,
Welcome to this second edition.
I have thoroughly enjoyed the selection of articles sent via the
various sub-editors. From one extreme of “fat positives “ of fat grafting…
to obesity. Kudos to another excellent government clinic (lets hear more
from others in the next edition). Loving the traction of…Woman in medicine
…and thrilled to see a mentor (to myself and many) featured …Prof Kramer.
Thank you to the behind the scenes team.
I encourage all reading this journal to send their articles and comments.
We want to hear and read about your work...as there is no doubt to the excellent quality of medical
work and insights in our wonderful country.
Carol Benn
Editor-in-Chief
Editor-in-Chief: Carol Benn - Head, Breast Unit, Helen Joseph Hospital, Netcare Breast Centre
Associate Editor: Christopher P. Szabo - Head, Department of Psychiatry, University of Witwatersrand
Advisory Board: Karen Appelbaum - Psychologist, Netcare Milpark Hospital
Georgia Demetriou - Department of Oncology, Charlotte Maxeke Johannesburg Academic Hospital
Franco Guidozzi - Faculty of Health Sciences, University of Witwatersrand
Inge Kriel - Oncology Care Physician, Milpark Breast Care Centre of Excellence
Anna Sparaco - HPB practice, Wits Donald Gordon Medical Centre
Tess Van Der Merwe - Honorary Professor and Researcher in the Department of Endocrinology, University of Pretoria
Marisse Venter - Plastic and Reconstructive Surgeon, Netcare Milpark Hospital
Acknowledgement: Thanks to Lisa Selwood for assistance with proof reading
Advertising: The Source Public Relations
Design and Layout: Michelle Haskins Printer: Imagine it Print It
Web: www southafricanwomenshealth.co.za
Contact Person: Vanessa Beyers - vanessa@thesourcepr.co.za
South African Women’s Health is published quarterly by The Source Public Relations Group.
Its mission is to communicate the latest news and developments in the area of South African Women’s Health.
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 5

SECTION EDITORS
Focus On SECTION EDITORS
EDITOR & SECTION EDITOR: BREAST
PROF CAROL BENN
Prof Carol-Ann Benn is a Fellow of the
College of Surgeons of South Africa with
a special interest in Breast Disease. Her
capacity as Head of the Breast Unit of
Helen Joseph Hospital proves her long
commitment to clinical excellence in
this field of medical speciality.
Prof Benn offers service to society and the greater medical
community, (both local and international), through her
contributions, published and presented, and she is recognised
internationally as a leader in Breast Disease. As lecturer in the
Department of Surgery at the University of Witwatersrand, she
contributes towards the education of healthcare professionals.
Through the organisation of foreign and private funding, Prof
Benn was able to establish the Breast Health Foundation,
various Breast Health Care forums and outreach programmes
and is a representation on numerous Medical Boards and
Health Care Committees. Prof Benn has paved the way for the
improvement of women’s health care, has contributed towards
the uplifting of women in society and has opened channels for
public awareness of breast health.
She established the Netcare Breast Care Centre of Excellence at
Milpark Hospital, Johannesburg, which co-ordinates national
efforts for the specialised management of breast conditions
to all women. In addition to her positions of responsibility,
Prof Benn manages continuing research and research outputs.
Numerous awards testify to her esteemed position in the
medical field and in South African society.
SECTION EDITOR: ONCOLOGY
DR GEORGIA DEMETRIOU
Dr Georgia Demetriou has been a
Senior Consultant in the Division of
Medical Oncology at the University
of Witwatersrand Faculty of Health
Sciences and Charlotte Maxeke
Johannesburg Academic Hospital since
2004 and served as Acting Head of the Division from September
2013 to June 2014. She is Head of a General Medicine
Undergraduate Academic teaching unit for the Department of
Internal Medicine at Charlotte Maxeke Johannesburg Academic
Hospital.
She has been local Principal Investigator and National Principal
Investigator on 15 multinational clinical trials particularly in
the field Breast Cancer. Dr Demetriou serves on the Executive
Committee of the South African Society of Medical Oncology as
Treasurer of the society, the South African Oncology Consortium
Board of Directors as Chairperson of the board and on the
Executive Committee of the Breast Interest Group of South Africa
as the Chairperson of the committee.
She is an examiner, trainer and moderator for the Certificate
Medical Oncology for College of Medicine of South Africa
sub specialist qualifying degree for Medical Oncology.
Dr Demetriou has co-authored papers in peer-reviewed journals,
as well as presenting at local and international scientific
meetings. Women’s cancers and health in particular is a major
focus of work.
Correspondence: georgiademetriou@hotmail.com
Correspondence: drbenncarol@gmail.com
SECTION EDITOR: OBSTETRICS & GYNAECOLOGY
PROF FRANCO GUIDOZZI
SECTION EDITOR: HEALTH & LIFESTYLE
DR INGE KRIEL
Dr Inge Kriel is an Oncology
Care Physician affiliated with the
internationally accredited Milpark
Breast Care Centre of Excellence.
She assists breast cancer survivors
with screening for recurrence of the primary cancer and
development of new cancers, management of late and longterm
effects of cancer and cancer treatment, promotion of
healthy lifestyle behaviours, and co-ordination of care with
other oncology specialists, to ensure that patients receive the
highest quality care.
Correspondence: ingekriel84@gmail.com
Professor Emeritus Franco Guidozzi
is a Wits graduate and the erstwhile
Academic Head of the Wits Department
of Obstetrics and Gynaecology. He
is a past President of the Society of
Obstetricians and Gynaecologists,
a Past President of the College of
Obstetricians and Gynaecologists of
the Colleges of Medicine of South Africa, a past president of
the South African Menopause Society and a Past Secretary
of the South African Royal College of Obstetricians and
Gynaecologists.
He has published over 120 articles in peer reviewed and nonpeer
reviewed journals. He retired from the Wits Department
of Obstetrics and Gynaecology in 2015, is still in fulltime
private practice and enjoys reading, bonsai gardening and
attending to his koi fish. He is married to Yolande, an advocate,
has three daughters, all of whom are doctors, and loves
laughing at himself.
Correspondence: guidozzif@gmail.com
6 * SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

SECTION EDITORS
Focus On SECTION EDITORS
SECTION EDITOR: AESTHETICS & RECONSTRUCTION
DR MARISSE VENTER
Dr Marisse Venter is a Plastic and
Reconstructive Surgeon at Netcare
Milpark Hospital. She has a special
interest in breast reconstruction and
cosmetic surgery. She qualified from
the University of Cape Town in 2002.
Her specialization encompassed 4 years of general surgery
and a further 4 years of plastic surgery at the University of the
Witwatersrand from where she qualified as a plastic surgeon.
She is registered with the Health Professions Council of South
Africa as a Plastic and Reconstructive Surgeon, a member
of the Association of Plastic and Reconstructive Surgeons of
Southern Africa (APRSSA) and International Society of Aesthetic
Plastic Surgery. Dr Venter has won numerous national and
International awards for her research done on adipose
tissue. Dr Venter has dedicated her life to the beautifying of
women through breast reconstruction, facial, breast and body
cosmetic surgery. All women deserve a body they would be
comfortable with.
Correspondence: dr.mventer@gmail.com
SECTION EDITOR: SURGERY, OBESITY & METABOLISM
(CEMMS)(SA).
PROF TESS VAN DER MERWE
Advisory Board member, Tess van
der Merwe, is an Honorary Professor
and Researcher in the Department of
Endocrinology, University of Pretoria
and CEO of the 11 Centres for Metabolic
Medicine and Surgery of South Africa
She is also the Director of the Waterfall City Hospital Metabolic
Medicine and Surgery Centre Research group and is a full time
clinician at this hospital.
She was the Honorary Secretary of the International Association
for the Study of Obesity for a period of 8 years and currently
remains the Africa consultant for this association.
In addition, she is the Chair of the South African Society for
Surgery, Obesity and Metabolism (SASSO) and has served this
organisation for more than 25 years. Professor van der Merwe
established the CEMMS (SA) in 2005 and to date remains as
the CEO of CEMMS(SA).
SECTION EDITOR: WOMEN IN HEALTHCARE
DR ANNA SPARACO
Anna Sparaco is a Wits graduate,
having obtained a BSc Honours in
anatomical sciences under the tutelage
of Prof PV Tobias. After lecturing for
2 years in anatomical science,she
entered her medical training at the Wits
Medical School. After graduating, she spent 3 years in London
at Guys and St Thomas’ culminating in gaining entrance into
the Royal College of Surgeons of England. On returning to South
Africa, she entered into a Hepatopancreaticobiliary fellowship
and concurrently was asked to join the Johannesburg transplant
team and engaged in assisting in developing the liver transplant
program.
To this end, and having been awarded the Miller Travelling
Fellowship, she spent 3 months at the University Medical Centre
in Omaha, Nebraska. Subsequently, she joined Prof Rene
Adam at the Hospital Paul Bruix in France where she learnt
about liver resection and finally visited Professor Buchler in
Heidelberg where she was exposed to aggressive pancreatic
surgery. She currently has a predominantly HPB practice at
the Wits Donald Gordon Medical Centre and has recently
co-founded the Centre for Digestive Diseases and Liver Health
at the Rosebank Hospital.
With the establishment of the Women’s Health Journal, she
was invited to subedit a section entitled “Women in Healthcare”.
This coincided with the creation of the Women in Healthcare
group who’s aim is to create a virtual and social networking
platform for all women in medicine. Birth was given to this
group because of the realisation that the current networking
structure - both formal and informal - are predominantly directed
towards the male gender as they have been the predominant
participants in the work space and in fact still continue to be
so. WIH will endeavour to host networking functions and also to
host workshops that deal with social media and your practice,
flow of money through your practice, medical aid fraud and
so forth. The WIH section in the journal will aim at providing
similar such information and also to look at the role and profile
of women in medicine.
Correspondence: anna.sparaco@surgicalspecialist.co.za
Correspondence: tessvdm@iafrica.com
NOTE: “instructions to authors” are available at www.southafricanwomenshealth.co.za
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 7

FOCUS ON
SURGICAL BIOPSY VS CORE BIOPSY
Lucy Van Schalkwyk
Breast complaints, specifically breast masses, should be investigated by
the tried and tested process of triple assessment: the findings from three
modalities – clinical examination, radiology (mammogram & ultrasound)
and breast biopsy - are combined to arrive at a final diagnosis.
he breast biopsy may be obtained by several
different methods, which can broadly be
classified as percutaneous or surgical.
Percutaneous biopsies are performed
by passing a hollow core biopsy needle through
the skin of the breast into the suspicious lesion to
extract a core of tissue (hence the synonym core
biopsy), allowing for a histopathological diagnosis.
Vacuum assisted biopsy, also a form of percutaneous
breast biopsy, relies on a large gauge core needle
attached to a vacuum-powered biopsy system to
obtain several large cores of tissue. Surgical biopsy
entails removal of a portion (incisional) or the whole
(excisional) of a suspicious breast lesion via a skin
incision, for diagnostic purposes.
SURGICAL BIOPSY IS USUALLY
PERFORMED UNDER GENERAL
ANAESTHESIA, BUT MAY OCCASIONALLY
BE PERFORMED UNDER LOCAL
ANAESTHESIA.
Due to its accuracy, which approaches 100%, 1
surgical biopsy was historically considered the
gold standard for the tissue diagnosis of breast
abnormalities. Nowadays, surgical biopsy has
largely been superseded by the percutaneous
methods. The British Association of Breast Surgeons
surgical guidelines state that in at least 90% of cases,
preferably >95% of cases, breast cancer should be
diagnosed by percutaneous means 2 .
ACCURACY
It is hardly surprising that surgical biopsy is slightly more
accurate than needle biopsy – the tissue retrieved by
a needle biopsy only represents a small area of the
entire lesion, while surgical biopsy removes a larger
portion or the entire suspicious lesion. The accuracy
of needle biopsy can however be improved by
imaging guidance, such as stereotactic or ultrasound
guidance, which allows for visual confirmation of
accurate sampling 3 .
MINIMALLY INVASIVE
Core needle biopsy is performed via a 3 – 4 mm
stab incision in the breast, while surgical biopsy is
performed though standard surgical incisions on
the breast. While most surgeons attempt to place
these incisions in cosmetically acceptable areas, for
example peri-areolar or in the inframammary fold,
poorly placed incisions are still encountered and can
result in significant cosmetic disfigurement. Obtaining
a diagnosis via percutaneous biopsy may spare many
patients with benign pathology unnecessary scars on
their breasts 4 . Core biopsies also cause less long-term
distortion and scarring of the breast parenchyma 5
- post-surgical fibrosis and fat necrosis can make
the interpretation of subsequent mammograms
challenging and may be difficult to distinguish from
a malignancy.
FEWER COMPLICATIONS
Core biopsies are minimally invasive, and are usually
performed under local anaesthesia in the outpatient
setting - this significantly decreases the time to return
to normal activity, compared to surgical biopsy (core
biopsy: average 1.5 days, surgical biopsy average
3.5 days). Core biopsies are associated with a
significantly lower complication rate than surgical
biopsies (surgical biopsy: 2 – 10% vs core biopsy:
0.09 – 0.72%) and when complications do occur
with core biopsies, they tend to be minor (e.g. minor
bleeding, bruising, haematomas and mild pain) and
are managed conservatively 4 .
Scars from multiple poorly orientated surgical
incisions on both breasts.
Photograph courtesy of Professor Carol Ann Benn
Scars from multiple poorly orientated surgical incisions on both breasts.
Photograph courtesy of Professor Carol-Ann Benn
8 * SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
PRE-OPERATIVE
DIAGNOSIS
BREAST
SINGLE SURGERY
Perhaps one of the greatest advantages of core
needle biopsy over surgical biopsy is that patients
diagnosed with breast cancer on a core biopsy are
more likely to have their cancer managed in a single
surgery 6-8 . The American National Accreditation
Program for Breast Centres (NAPBC) states in its
latest standards manual that breast units seeking
accreditation should avoid surgical biopsy as an
initial diagnostic approach, as it does not allow for
treatment planning and is associated with a high reexcision
rate 9 .
IN SUMMARY:
WHILE SURGICAL BIOPSY IS STILL
APPROPRIATE IN SELECTED PATIENTS,
PERCUTANEOUS CORE BIOPSY OFFERS
MANY SIGNIFICANT ADVANTAGES AND
IS NOW CONSIDERED THE STANDARD
OF CARE FOR BREAST DIAGNOSIS.
References:
1. Bruening W, Fontanarosa J, Tipton K et al. Systematic Review: Comparative
Effectiveness of Core-Needle and Open Surgical Biopsy to Diagnose Breast
Lesions. Ann Intern Med. 2010;152(4):238-246.
Pre-operative diagnosis affords the surgeon the
opportunity to consult with appropriate specialists
in the multidisciplinary cancer care team, such as
radiologists, pathologists, oncologists, geneticists and
plastic surgeons. It allows for planning of the surgical
approach, the appropriate margin, the staging of
the axilla and an appropriate reconstruction prior
to placing knife to skin. Many patients are deprived
of the benefit they would have derived from neoadjuvant
chemotherapy by surgical biopsy 10.
Despite the advantages of core needle biopsy,
surgical biopsy is still indicated in certain situations,
often as a supplementary procedure to a
percutaneous biopsy 11 :
• Lesions that are difficult to characterise on
core biopsy such as atypical hyperplasia, lobular
carcinoma in situ (LCIS), papillary lesions,
sclerosing lesions and fibroepithelial lesions. For
these lesions, a larger specimen is required to
confirm the diagnosis.
• A suspicious nipple discharge in the presence of
a normal mammogram.
• Where the suspicious lesion is in a position in the breast
that is difficult to access with the biopsy needle, e.g. in
close proximity to the chest wall, skin or a breast
implant.
• Where the findings of the triple assessment
are discordant, e.g. clinical examination and
mammogram are suggestive of carcinoma, but
the result of the core biopsy is benign.
2. Surgical Guidelines for the Management of Breast Cancer, Association
of Breast Surgery at BASO 2009, Eur J Surg Onco. Retrieved from http://
associationofbreastsurgery.org.uk/media/63420/surgical-guidelines-for-themanagement-of-breast-cancer-abs-baso-2009.pdf
on 30/11/2017
3. Dillon M, Hill AK, Quinn C et al. The Accuracy of Ultrasound, Stereotactic, and
Clinical Core Biopsies in the Diagnosis of Breast Cancer, With an Analysis of
False-Negative Cases. Ann Surg 2005 Nov; 242(5): 701–707.
4. White RR, Halperin TJ, Olson JA et al. Impact of Core-needle Breast Biopsy on
the Surgical Management of Mammographic Abnormalities. Ann Surg 2001
Jun;233(6):769-77.
5. Dahabreh IJ, Wieland LS, Adam GP, et al. Core Needle and Open Surgical
Biopsy for Diagnosis of Breast Lesions: An Update to the 2009 Report [Internet].
Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 Sep.
(Comparative Effectiveness Reviews, No. 139.) Results. Available from: https://
www.ncbi.nlm.nih.gov/books/NBK246884/
6. Kaufman CS, Delbecq R, Jacobson L. Excising the Reexcision: Stereotactic
Core-needle Biopsy Decreases Need for Reexcision of Breast Cancer. World J
Surg 1998 Oct;22(10):1023-7
7. Yim JH, Barton P, Weber B et al. Mammographically detected breast cancer.
Benefits of stereotactic core versus wire localization biopsy. Ann Surg 1996 Jun;
223(6): 688–700
8. James TA, Mace JL, Virnig BA et al. Preoperative Needle Biopsy Improves the
Quality of Breast Cancer Surgery. J Am Coll Surg 2012 (215) 4 : 562–568
9. The National Accreditation Program for Breast Centers 2018 Standards
Manual. Retrieved from http://www.facs.org on 27/11/2017.
10. The American Society of Breast Surgeons, Consensus Guideline on Image-
Guided Percutaneous Biopsy of Palpable and Nonpalpable Breast Lesions, Nov
2017. Retrieved from http://www.breastsurgeonsweb.org on 30/11/2017
11. The American Society of Breast Surgeons, Statement on Surgical Biopsies.
Retrieved from http://www.breastsurgeonsweb.org on 27/11/2017.
Lucy Van Schalkwyk: Correspondence: Please contact the relevant sub-editor, as well as cc the Editor-in-Chief
for more information.
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 9

FOCUS ON
NEW TRENDS IN
BREAST CANCER
MANAGEMENT & RECONSTRUCTION
SURGICAL PERSPECTIVE
Carol Benn
INTRODUCTION
Breast cancer treatment has evolved over the
last 50 years, from a disease treated mainly in the
hands of the surgeon to now being a showcase for
multi-disciplinary team management. Advancement
in the understanding of oncological care has resulted
in swings from large radical surgery (Halstedian
mastectomies) to breast conserving surgery.
Greater understanding of tumour biology has seen
tremendous strides in the use of oncological drugs,
and the paradigm shift around understanding cancer
spread.
SCREENING ADVANCES IN BOTH
MAMMOGRAPHY, ULTRASOUND AND
MRI SCANNING HAVE RESULTED IN
EARLIER DETECTION OF CANCERS
RESULTING IN SMALLER SURGICAL
EXCISIONS IN SOME INSTANCES AS
WELL AS DISCUSSION AROUND OVER
OPERATING AND “UNNECESSARY
MASTECTOMIES.”
Advances in patient advocacy, understanding the
psychological makeup of the patient and the value
of breast reconstruction, particularly in immediate
one-stage procedures, have necessitated a more
comprehensive multi-disciplinary team approach to
care.
The standard surgical therapeutic option for patients
with stage 1 and two breast cancers in the 21st
century is breast conservation with radiation therapy.
This combination has outcomes with less morbidity
and at least equivalent recurrence of disease,
compared to the classical radical mastectomy.
Breast conservation is well supported by level 1 and
2 data (National Cancer Institute, 2014) (NCCN
Guidelines 2016) and is not just the thrust of women’s
empowerment groups and
patient preference. Survival
outcomes are identical for
both mastectomy and breast
conserving surgery. Thus
some patients may elect
mastectomies.
Greater public awareness
regarding breast selfexamination,
clinical breast
Carol Benn
examination, and mammographic screening
have led to the detection of smaller and earlier
stage breast cancers. Despite this, the incidence
of advanced breast cancers has not decreased
in countries with screening programmes while the
incidence of advanced breast cancers remains high
in LMICs without access to screening.
Advanced radiological methods, including
mammography, ultrasound, and MRI scanning,
have detected smaller cancers allowing surgical
excision with better breast conservation. Central to
the acceptance of breast conservation therapy
(BCT) is the importance of avoiding disfiguring
cosmetic results. The conserved breast must have
an acceptable aesthetic appearance. A better
understanding of the psychological makeup of
the cancer patient, including the importance of
breast reconstruction, as an immediate one-stage
procedure, has resulted in clinicians offering a wide
variety of surgeries with the expectation that treating
surgeons will achieve cosmetically more desirable
results. Breast conserving surgery should, therefore,
be considered both an oncological, as well as a
cosmetic procedure, and the extent of surgical
margin from the tumour will play a pivotal role in
achieving this. Poor cosmetic results, due to extensive
surgical resection without reconstructive techniques
and radiation change, have been reported in at least
20% of patients.
10 * SOUTH AFRICAN WOMEN'S HEALTH ISSUE 1 2017

PLANFOCUS
A CLEAR
WHO GETS WHAT SURGERY?
Today there is little reason for a woman not to choose
BCT.
The absolute oncological indications for a
mastectomy today are 2
• Infla[1]mmatory breast cancer
• Multicentric breast cancer
Relative oncological contraindications are
• Paget’s disease
• Lobular Carcinomas
• BRCA positive
A woman may elect to have a mastectomy or a
bilateral mastectomy, but this is a psychological
choice, not an oncological choice (with many
reasons being cited):
• Strong family history
• Desire to avoid radiation due to logistics
or personal reasons
• Sense of failure in radiology to detect a tumour
either due to past experience or not wanting
future mammograms
• Aesthetic desires involving prosthetic reconstruction
ON
WHAT IS THE NEW STANDARD OF CARE IN
MANAGEMENT?
All patients should be discussed in the following multidisciplinary
meetings;
Clinical radiology meeting:
In which correlation between the radiology and the
core biopsy pathology is documented; including the
need for further investigation.
An oncology multidisciplinary meeting:
The patient is discussed in the presence of all treating
disciplines that play a role in the care of the patient
(attending members should be from the disciplines
of medical oncology; radiation oncology; radiology;
pathology; surgical oncology; genetics; oncology
care physicians; nurse navigation (allied care
specialists: lymph oedema; physio; nutritionists).
ALL DECISIONS AROUND THE ABOVE
MEETINGS SHOULD BE FED BACK TO
THE PATIENTS WITH A CLEAR PLAN OF
ACTION AROUND TREATMENT.
BEFORE ANY WOMAN DECIDES ON
HER SURGERY A DETAILED DISCUSSION
EXPLAINING THE FOLLOWING POINTS
NEED TO BE MADE.ONCE A DIAGNOSIS
OF A BREAST CANCER IS MADE; THAT
CANCER DETERMINES THE OUTCOME,
AND IRRESPECTIVE OF THE BRCA
OR FAMILY HISTORY A BILATERAL
MASTECTOMY BECOMES CHOICE NOT
AN ONCOLOGICAL DECISION.
The survival is equal whether a mastectomy or BCT is
performed.
• All woman should be counseled around the
oncology rules
• All woman should be discussed in a Multidisciplinary
meeting
• A clear plan should be presented to the patient
before starting treatment
• All woman should be offered the opportunity for
a second opinion
BREAST CANCER TREATMENT DOES
NOT INVOLVE “EMERGENCY CANCER
SURGERY EVER.”
Breast conservation is not a contraindication in
women with big tumours or woman with locally
advanced breast cancer. Before discussing different
surgical techniques for surgery and reconstruction lets
look at oncology principles that may guide surgery
choices.
Each unit should have a written documentation of :
• local treatment guidelines
• which international guidelines are followed
• which cases should be discussed that may fall
outside of guidelines or require specific
non-guideline based treatment choices and why
DIAGNOSIS AND PATHOLOGY
Radiology diagnostics includes not just mammography
but also the use of breast tomosynthesis; ultrasound
not just of the breast but the axilla to determine;
document and perform possible needle biopsies to
record lymph node involvement; Breast MRI also plays
a critical role in determining extent of disease and
response to oncology treatment.
The gold standard of a core biopsy is critical in
determining the biological profile of the breast
cancer. Some units may have expertise with fine
needle aspiration cytology providing the same data.
Breast cancers are divided into four major subtypes:
• Luminal A:
• Luminal B
• Her 2 enriched
• Triple negative
RADIATION THERAPY DISCUSSIONS
All patients should have documentation of the
need for radiation with breast conserving surgery.
Discussions around whether the patient fits criteria
for intra-operative radiation should be assessed
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 11

FOCUS ON
THE PROS AND CONS
according to (ASTRO 2017 guidelines). Need for
radiation due to axillary nodal disease (1 or more
involved). Whether the unit accepts and follows the
Z11 protocol for radiation; thus avoiding more axillary
surgery; as well as the AMAROS trial outcomes. The
pros and cons of hypofractionated treatment and
whether the patient fits criteria. Can radiation be
avoided in certain elderly luminal A tumours.
ONCOLOGY DISCUSSIONS
Guidelines as to which patients do not
require chemotherapy according to
genetic profiling must be documented.
Which patients do not require chemotherapy with
node positive disease (For example: may decide
extremely low Ki luminal A; low-grade lobular
carcinomas )?
Which early-stage breast cancer patients will start
with primary chemotherapy (For example triple
negatives; Her 2 enriched; High Ki luminal B)?
Does your unit use specific chemotherapy regimes
for different tumour subtypes? (For example TAC for
triple negatives)
How does your unit document response to primary
chemotherapy ( clinically and radiologically)?
Poor responders to primary chemotherapy are
managed by:
• Second line chemotherapy
• Surgery
Incomplete responders post chemotherapy and
surgery are offered
1. More oncology treatment options
(CREATE for tripl negatives)
2. Watch and wait
What endocrine treatments are offered to what
patients and for how long?
1. Do you use extended adjuvant endocrine for all?
2. Do you offer your young breast cancer patients an
Aromatase inhibitor plus GnRH?
SURGICAL PRINCIPLES
Each unit should have documentation of :
• What is considered an optimal surgical margin
for that unit so audit of local recurrences can be
monitored
• Which patients are candidates for sentinel lymph
node biopsies and the timing of these procedures:
* At definitive surgery
* Before initial surgery (in patients desiring prosthetic
reconstruction wishing to avoid radiation;
patients with small triple negative or Her 2
enriched tumours that documentation of
the extent of radiation is needed prior to
starting primary chemotherapy
• Patients who are candidate for intra-operative
radiation therapy
• Patients who can have sentinel lymph node
biopsies post-primary chemotherapy once
ultrasound documentation of the change of nodal
status is confirmed
ONCOPLASTIC PLANNING OF THE CANCER
SURGERY; WITH WHAT TECHNIQUES ARE
TO BE USED; WHO WILL BE PERFORMING
THE SURGERY AND INTRA-OPERATIVE
ASSESSMENT DOCUMENTATION OF THE
SURGICAL MARGINSA PLAN OF ACTION AND
PRE-SURGICAL DISCUSSION INVOLVING AT
LEAST 2 SEPARATE CONSULTATIONS AROUND
ONCOPLASTIC AND RECONSTRUCTIVE
OPTIONS SHOULD BE DISCUSSED WITH
THE PATIENT AS WELL AS WHO WILL BE
PERFORMING THE SURGERY; OUTCOMES AND
POTENTIAL COMPLICATIONS. ALL PATIENTS
UNDERGOING PRIMARY ONCOLOGY CARE
SHOULD HAVE V MARKERS PLACED PRIOR
TO STARTING TREATMENT WITH CAREFUL
DOCUMENTATION OF EXTENT OF DISEASE.
ALLIED CARE
Does your unit have radiology and oncology
navigators helping patients on their cancer journey
Do you offer an oncology care physician survivorship
program?
Are all young breast cancers offered a fertility service
and discussion prior to starting treatment?
What is the unit protocol on which patients are
referred for genetic counseling and testing (and
when)?
Which patients are referred for an onco-psychology
consult (and when)?
Which patients are referred for lymph oedema physio
(and when)?
What is the unit policy on complementary oncology
care and how is this managed
Lets now discuss principles of oncoplastic surgery and
reconstruction.
THE DEFINITIONS
Oncoplastic surgery is defined as techniques used at
the time of breast conserving surgery. Whereas this
term has been used for many years it is my opinion that
it should be termed onco-reconstructive techniques.
12 * SOUTH AFRICAN WOMEN'S HEALTH ISSUE 1 2017

FOCUS ON
ONCOLOGY PRINCIPLES
ALLIED CARE
Does your unit have radiology and oncology
navigators helping patients on their cancer journey
Do you offer an oncology care physician survivorship
program?
Are all young breast cancers offered a fertility service
and discussion prior to starting treatment?
What is the unit protocol on which patients are
referred for genetic counseling and testing (and
when)?
Which patients are referred for an onco-psychology
consult (and when)?
Which patients are referred for lymph oedema physio
(and when)?
What is the unit policy on complementary oncology
care and how is this managed?
Lets now discuss principles of oncoplastic surgery and
reconstruction.
THE DEFINITIONS
ONCOPLASTIC SURGERY IS DEFINED
AS TECHNIQUES USED AT THE TIME OF
BREAST CONSERVING SURGERY.
Whereas this term has been used for many years
it is my opinion that it should be termed oncoreconstructive
techniques.The basis of this surgery
is around understanding techniques used during
breast plastic surgery; as soon as the word plastic is
associated with cancer, there is often an unrealistic
patient expectation.Reconstructive breast surgery is
the term used for reconstruction post mastectomy be
it immediate; immediate-delayed or delayed.
THE FIRST RULES
1. Breast reconstruction and oncoplastic surgery
should be discussed with all patients prior to
surgery.
2. The vast majority of patients can undergo
immediate reconstruction at the time of their
cancer surgery (thus avoiding multiple procedures)
3. Understanding the oncology principles and
rules in your unit avoids unnecessary complications
around reconstruction (such as which patients
require radiation)
THE PRINCIPLES:
Tumour Factors
• Understand the size of the tumour;
• The position of the tumour;
• The radiological and tumour information
• The relationship with nipple areolar complex
complex
• Distance to skin
Breast Factors
• the size of the breast;
• the consistency of the breast tissue (fatty breast
can be harder to perform oncoplastic techniques
on if one does not have experience the tissue pulls
apart and areas of fat necrosis result from
inadequate blood supply
• The degree of ptosis
• Previous breast surgery
• Presence of prostheses (type; size and age)
Patient Factors
• Medical illness that may affect surgery
• Habits: such as smoking
• Medication that may affect surgery
THE TECHNIQUES
Breast conserving surgery techniques are twofold:
Volume displacement:
Involves moving the breast tissue around with types
of parenchymal flaps. From small rotational flaps to
the use of a variety of breast reduction or mastopexy
techniques.
Volume replacement
This involves the use of importing loco-regional tissue
in the vicinity of the breast cancer excision. In our
unit LICAp flaps; Thoraco-epigastric flaps and regional
local flaps are used commonly (with latissimus dorsi
flaps used mainly for immediate or immediatedelayed
medium breast reconstruction in patients
post-primary chemotherapy.
MASTECTOMY BASED RECONSTRUCTION
Most mastectomies in our unit are skin sparing
with 60% of this being nipple and skin sparing. This
can be either prosthetic or autologous. Prosthetic
reconstruction is mainly direct implant reconstruction
in our unit without ADM (acellular dermal matrixes).
The use of expander or prosthetic with ADM is reserved
for a small subset of patients who have skin loss
particularly in the lower poles. Prosthetic reconstruction
is done once need for radiation has been accessed
and is avoided in patients requiring radiation.
AUTOLOGOUS RECONSTRUCTION
The latissimus flap reconstruction:
It is the leading workhorse in our unit in patients
presenting with locally advanced breast cancer
post-primary chemotherapy including in our
inflammatory breast cancers. Most of these patients
require immediate, delayed reconstruction involving
a nipple and skin sparing mastectomy (a 48hour
pathology turn-around on margins (10mm) with
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 13

margin clearance; reconstruction with the lat and
OSM 48 hours later.Detailed patient counseling is
suggested with a small subset of patients requiring
free flaps and strict “no time delay to either radiation
or chemotherapy being maintained within the unit of
a minimum of 3 weeks and max allowed of 6 weeks.
The Goldilocks reconstruction:
Done with a modification of Nipple and skin sparing
through a lateral Type 4 approach; with the addition
of bilateral TE flaps is offered in some patients with
breast ptosis; and over a c cup breast size.
Special scenarios:
The unit has a high number of locally advanced
patients that are managed including those with
stable or responsive metastatic disease that are
offered surgery with reconstruction.
A less is more approach is taken with metastatic
patients requesting some form of reconstructive
surgery; with the most conventional techniques being
BCT with parenchymal flap reconstructions.
Pregnant breast cancer patient requiring surgery
also are offered local small parenchymal flap
reconstruction. Elderly patients are also offered
oncoplastic and breast reconstruction as long as
anesthetic safety has been predetermined.
IN CONCLUSION
This era of breast cancer management offers for
surgeons dynamic and different treatment options
for patients. Today’s oncology surgeon needs to
be trained in all aspects of breast cancer care
from radiology to radiation. He/she needs to have
comprehensive training in different plastic and
reconstructive techniques to recognize which
patients for which procedures and to ensure that they
work with a team of competent specialists including
plastic /and reconstructive surgeons so as allow best
patient outcomes for their patients.
References:
• Extent of Primary Breast Cancer Surgery: Standards and ... - NCBI - NIH.” 22
Oct. 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3518938/. Accessed
4 Dec. 2017.
• Survival is Better After Breast Conserving Therapy than Mastectomy ....” 6 Mar.
2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4595537/. Accessed 4
Dec. 2017.
• “Clinical Practice Statements - American Society for Radiation Oncology.”
https://www.astro.org/Clinical-Practice-Statements.aspx. Accessed 4 Dec. 2017.
• “Radiation field design in the ACOSOG Z0011 (Alliance) Trial..” 18 Aug. 2014,
https://www.ncbi.nlm.nih.gov/pubmed/25135994. Accessed 4 Dec. 2017.
• “Regional nodal management in the light of the AMAROS trial.” https://www.
ncbi.nlm.nih.gov/pmc/articles/PMC4430731/. Accessed 4 Dec. 2017.
Carol Benn: Head, Breast Unit, Helen Joseph Hospital. Correspondence: drbenncarol@gmail.com
PUBLICATIONS | SCIENTIFIC
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Due to improvements in screening and patient
awareness, approximately 50% of breast lesions are
impalpable at the time of diagnosis. The current
gold standard to assist the surgeon in finding an
impalpable lesion is a hookwire, or guidewire. These
are usually placed in the morning of surgery. Wire
guided localisations have been used since the 1960’s
and have limitations.
Since the Sentimag ® system was launched at the end of 2012, the system has been used to treat
over 10,000 patients and has produced a strong base of clinical results that confirms its safety
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Malignancy Concordance
Standard

FOCUS ON
GROOTE SCHUUR
HOSPITAL
BREAST CLINIC
Francois Malherbe
The Groote Schuur Hospital breast clinic was founded in 1951 by Professor Jannie Louw and
since then has grown into a world class centre of excellence with all the modern diagnostic
and treatment facilities needed to treat patients presenting with both benign and malignant
breast pathology.
roote Schuur Hospital (GSH) has a
population of 3.1 million people within
its catchment area which includes the
western part of Cape Town and the
West Coast region. The main referral base includes
44 clinics, of which 35 are City Health facilities, and
general practitioners. GSH serves as a safety net for
patients in the Northern Suburbs of Cape Town, other
provinces, and patients beyond our borders.
IN 2016 WE DIAGNOSED 572 NEW
PATIENTS WITH BREAST CANCER.
ALTHOUGH BREAST CANCER IS THE
MOST DEVASTATING DIAGNOSIS, THE
MAJORITY (87%) OF THE 4339 NEW
PATIENTS SEEN IN 2016 PRESENTED WITH
BENIGN BREAST DISEASE.
The clinic is staffed by 2 permanent surgical
consultants, 1 senior registrar / breast fellow, 2
part-time surgical consultants, 2 part-time general
practitioners with an interest in breast diseases, 1
oncology registrar, 1 breast radiologist, 2 cytology
technologists, 2 mammographers and a social worker.
The clinic is open every Friday on the G-Floor in
the outpatient building on the GSH premises. The
clinic offers breast imaging, biopsy and oncology
consultation of newly diagnosed positive breast
cancers. Social and counselling services are also
available on-site to assist newly diagnosed patients.
Francois Malherbe
In 1982 an on-site, real time
cytology service was established
under the guidance of Professor
Dent, Dr Hacking and Dr
Learmonth. To this day it is still one
of only a few such services offered
around the globe. Patients with
palpable breast lumps receive a
same day fine needle aspiration
and cytology results
IT RELIEVES A LOT OF THE ANXIETY
ASSOCIATED WITH WAITING FOR A
RESULT AFTER A BIOPSY FOR A BREAST
LUMP.
Referral criteria include all patients with a clinical
suspicion of breast cancer. Therefore all women or
men older than 30 years with a palpable breast
lump, a spontaneous or bloody nipple discharge,
new onset nipple retraction, ulceration or any
other clinical features that raise the suspicion of a
breast cancer will be attended to on the same
day of referral. We make provision to see 80 new
patients each week but during the busy period
of October to December this number can often
double. If the clinic is overwhelmed by the
number of referrals,we make use of a triage
system and provide the younger patients and
patients with mastalgia without a breast lump
with an elective date, usually within 2 weeks.
15 * SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
OUR BIGGEST CHALLENGE IS
MANAGING THE BREAST IMAGING
Cyto-technologists hard at work
Our biggest challenge is managing the breast
imaging service with the available resources.
Currently the waiting time for a routine mammogram
IN A PATIENT WHO DOES NOT HAVE
A PALPABLE LUMP STANDS AT 22
WEEKS, WHILE THE WAITING TIME FOR
A ROUTINE ULTRASOUND IS 10 WEEKS.
We have recently acquired an ultrasound machine
in the clinic and young patients are now receiving
an ultrasound examination done by one of the
senior clinicians on the day of their first visit
which is making a significant impact on the
ultrasound waiting times.
With the support of Pink Drive we are trying to reduce
the mammogram waiting times but the sheer volume
of patients seen makes this extremely difficult.
At the Groote Schuur Breast clinic we strive to detect
breast problems at the earliest stage, differentiate
between benign and malignant breast problems, plan
effective management and follow up and counsel
the patient and his/her attendants adequately.
APPOINTMENTS CAN BE MADE VIA
THE GSH OUTPATIENTS CALL CENTRE AT
(021) 404 5566 OR ANY QUERIES CAN
BE DIRECTED TO OUR EMAIL ADDRESS
GSHSURGONC@GMAIL.COM
Nursing Staff in the clinic
Francois Malherbe: Graduated with a FCS(SA) and MMed(UCT) in 2011. Since 2014, after a short period working as a general
surgeon at New Somerset Hospital in Cape Town, he has been back full time at the Groote Schuur Hospital breast and surgical
endocrine unit. His clinical interests are oncoplastic breast surgery, breast cancer research, surgical oncology and endocrine
neoplasms (thyroid, parathyroid, adrenal). Correspondence: francois.malherbe@uct.ac.za
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 16

FOCUS ON
17 * SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

IT’S IN THE
FOCUS ON
DNA
WOMEN IN HEALTHCARE
Anna Sparaco
What a formative year. This is the year
that the double X chromosome took
traction. As the title of the formidable
Judy Dlamini books states “Equal but
different.” This year saw the introduction of the
Women Health Journal and Women in Healthcare
Africa consolidated its footprint.
In this issue, Prof Bev Kamer reflects back on her career
in Health Sciences and influences that have made
her who she is. Donne Botha, dynamic manager at
Boston Scientific, gives us some industry perspectives
and touches on stressors. Our resident coach Colleen
Qvist reminds us to be grateful and mindful of our
blessings and achievements.
In a series of 3 financial workshops hosted and
generously supported by Mundipharm, Women in
Healthcare Africa tackled our biggest fear – money
management in our practices. The main concerns
were around understanding tax. Joanne Williams,
from Leading Accounting, summarizes some of the
discussion.
WE FINISH 2017 FEELING THAT SOME STRIDES
HAVE BEEN MADE IN RECOGNIZING
THAT THE XX CHROMOSOME MAKES US
DIFFERENT BUT THAT THESE DIFFERENCES
MAKE US STRONGER. WE ARE DIFFERENT,
BUT WE ARE EQUAL EVEN IF WE ARE LATE
ENTRANTS TO THE PROFESSIONAL SPHERES.
Anna Sparaco
IN 2018 – WATCH THE WIHC-A SPACE –
2 SOCIAL NETWORKING EVENTS AND
SEVERAL WORKSHOPS ARE PLANNED.
WE HOPE YOU ENJOY A GOOD REST
AND HAVE A FESTIVE TIME OVER
THIS DECEMBER AND COME BACK
REFRESHED AND READY TO INCREASE
THE TRACTION AND DEEPEN THE
FOOTPRINT.
Anna Sparaco: HPB practice, Wits Donald Gordon Medical Centre Correspondence: anna.sparaco@surgicalspecialist.co.za
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 18

FOCUS ON
A WOMAN’S TALE:
REFLECTING ON MY PERSONAL
JOURNEY THROUGH A
HEALTH SCIENCES
ACADEMIC CAREER
Beverley Kramer
When I reflect on my life’s journey, as a mother, wife and academic,
the town where I began life comes immediately to mind.
Igrew up in a small East Rand town where mining
was the lifeblood, and my family’s livelihood was
linked to that as well. I am somewhat amazed
that I made it out of that town and progressed in
both thought and action to where I am today. I loved
the town, my childhood there, the friendships that I
developed; I could easily have remained there, lost
forever in a timewarp. My story, however, is not really
about my journey, but rather my mother’s journey, and
how it affected my life.
My mother began life in a mill on a stream in Lithuania,
the daughter of a poor Jewish miller and his wife. She
was one of five children growing up in a beautiful,
but religiously intolerant country. At the age of 15, in
order to escape the malevolent political and religious
climate in Lithuania and the impending advance of
the Nazis, she was sent by her parents on her own,
by boat to South Africa. She joined two of her young
siblings who had previously been sent to South Africa
and settled here.
The sudden separation from her parents was
traumatic, the trip was long and frightening, but with
her exuberance for life, she made friends on the boat,
and this lessened her fear. My Mom’s schooling had
been interrupted when she was sent to South Africa.
She was never able to complete her education and
regretted it all her life. Two years after reaching South
Africa she was married to
my father, a kind and hardworking
man who had also
escaped from Lithuania
but with his family, to find a
better life in South Africa.
My Father was much older
than my Mother and worked
extremely hard. He spent six
and sometimes seven days
Beverley Kramer
a week in his concession
store on the local mine to put
food on the table. More importantly, my Mom wanted
her three daughters to be well-educated, and thus
we hardly ever saw my Dad as he laboured to scrape
together every penny so that one day his daughters
would be able to get a university education. My Mom
cooked, baked and sewed for us.
HER MAXIM WAS “I WILL SCRUB FLOORS
TO GET YOU AN EDUCATION”. MY MOST
VIVID MEMORY OF MY MOTHER’S
THOUGHTS ON EDUCATION WAS:
“STRIVE TO GET THE BEST EDUCATION
THAT YOU CAN. PEOPLE CAN STRIP YOU
OF EVERYTHING, BUT THEY CAN NEVER
STRIP YOU OF YOUR EDUCATION.”
19 *
SOUTH AFRICAN WOMENS HEALTH ISSUE 2 2017

FOCUS ON
I am sure this is a saying that reverberates with many
even today. This left a lasting impression on me, but
only later in life did I realize what this had meant in
the context of her life.
I was deeply saddened for my mother who had been
stripped of her childhood, stripped of her family (she
never found out what had become of her family
who remained in Lithuania once the Nazis invaded),
stripped of her home country and also stripped of
the opportunity to complete her education. Her inner
strength was something that shone through.
My childhood was mostly uneventful, playing in
the street with other children from a variety of
backgrounds. They accepted that my religion was
different to theirs and that I couldn’t play late on a
Friday as my family celebrated the coming of the
Sabbath. Children in those days were accepting and
keen to share their differences. We walked back and
forth to primary school, to the shops, to the homes of
our friends, without the fear of being preyed on by
the scourge of predators who target unsuspecting
children today and remove from them the ability to
have a relaxed childhood. We seldom wore shoes
or had many toys to play with, but life was good. I
remember spending school holidays reading or sitting
on the fence watching cars go by.
THIS IDYLLIC CHILDHOOD WAS
HOWEVER SHATTERED IN MY LATTER
PRIMARY SCHOOL YEARS WHEN I
CAME INTO CONTACT WITH A TEACHER
WHO HATED JEWS, OR PERHAPS HE
HATED EVERYONE, AND JEWS WERE
JUST WITHIN HIS REACH. THIS TEACHER,
THOUGH I SHUDDER AT THE THOUGHT
OF CALLING HIM A TEACHER, TOOK
GREAT PRIDE IN REGULARLY MAKING
ME STAND UP IN CLASS, TO POINT OUT
TO THE STUDENTS THAT I WAS DIFFERENT,
I WAS A JEW. I DIDN’T KNOW MUCH
ABOUT RACISM IN THOSE EARLY YEARS,
BUT I CERTAINLY SOON LEARNED THAT
IT WAS ABHORRENT.
High School in our small town was wonderful. It was
great seeing friends each day. Being introduced to
science was fascinating. I soon found that my love
of books, which had started with reading at the age
of three, had paid off. I had developed an excellent
general knowledge and a yearning to learn. I tried to
absorb as much information as I could, remembering
from my mom that education was everything.
Homework was not easy, as my Mom struggled to help
me and once again, I felt saddened for her as she
struggled with the English language and tried vainly
to help us. My Dad was a whiz at mathematics, but
we had to wait until late at night for his return if we
needed help in that area.
WHAT I SOON LEARNED FROM BOTH OF
THEM THOUGH, WAS THAT THERE WAS
NO SUCH THING AS “CAN’T”. I HAVE
THUS TRIED EVERYTHING FROM ART TO
ANATOMY, FROM PEWTER WORK TO
POTTERY, IN THE REALIZATION THAT WHAT
ISN’T KNOWN, CAN SOON BE LEARNED!
It was customary in those days in our small town to see
gangs of prisoners in chains working on the verges of
the roads or even in the suburbs. These were prisoners
who had been imprisoned for “minor” misdeeds or
who had a short time left before release. All of these
prisoners were black.
My Mom would send us out with mugs of steaming
coffee and liberally buttered bread, which was richly
rewarded with huge smiles and even an occasional
song. When I asked my Mother why she did this, she
would tell me that we should always help those
less fortunate than ourselves, that we should never
discriminate against others no matter what the colour
of their skin or their religion. She would tell me stories
of the horrific discrimination against the Jews by the
Nazis.
SHE TAUGHT ME THE HORRORS OF RACIAL
DISCRIMINATION, AND I LEARNED THAT
IT WASN’T ONLY YOUR RELIGION THAT
COULD CAUSE PEOPLE TO HATE YOU.
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 20

FOCUS ON
UNIVERSITY
WAS HEAVEN
With the intention of one day becoming a surgeon, I
left high school and traveled to Johannesburg on the
train to attend Wits University. This change was a total
culture shock to me. The other 1 st year students in my
class were confident, competent and they certainly
knew a lot more about our topics and life than I did. I
was scrutinized as I came into the class everyday……
from the tips of my shoes to the last un-brushed hair
on my head…….after all, dashing backwards and
forwards between Johannesburg’s Park Station and
Wits played havoc with one’s hair!
I traveled on the train, back and forth to Johannesburg
for seven years, in the cold and the heat, and learned
that the train was a perfect place to study life. It was
also where I learned that an umbrella was a girl’s best
friend! Travelling home in the early evening after late
laboratory sessions were slightly hazardous, as mean
guys in long raincoats would often sit too close to one
on the half empty carriages. A tap with a well-placed
umbrella was all it took to get the “gentleman” in
question to vacate the seat.
UNIVERSITY WAS HEAVEN. I HAD
NEVER BEEN EXPOSED TO SO
MUCH INFORMATION, TO SO MANY
INTRIGUING THINGS. THERE JUST
WASN’T SUFFICIENT TIME TO TAKE IT
ALL IN AND ALSO BE EXPOSED TO
STUDENT LIFE. STILL NOT KNOWING
WHETHER I WANTED TO DO MEDICINE
OR SCIENCE, I WAS INTRODUCED TO
THE MARVELS OF THE HUMAN BODY, TO
ANATOMY.
From my first day of dissection, i became fascinated
by the body’s intricacies, by the incredible way
in which it developed, how nerves and vessels
managed to find their way to where they were going
and did so almost always along the same pathways.
Human anatomy and embryology became my
fascination, and all thoughts of surgery vanished.
Having completed my initial degree, i stayed on in
the Wits Medical Department of Anatomy, first as a
student and then as staff.
My initial contact with anatomy in 1968 at the Wits
Medical School on Hospital Hill, started me on a
journey that is yet to be completed. From 1970 while
doing my B.Sc Honours in anatomy, I was appointed
as a Graduate Demonstrator and slowly rose through
the academic ranks until I was appointed as Head
of one Department (General Anatomy in the Wits
Faculty of Dentistry) and then as Head of the Wits
Department of Anatomy and Human Biology in the
Faculty of Health Sciences (when the Faculties of
Dentistry and Medicine amalgamated in 1996). This
later became the School of Anatomical Sciences,
which I initially chaired.
Having been Head of Department and School for
17 years, I stepped down to continue with research.
However, always open to a challenge I applied
for and was appointed Assistant Dean: Faculty
of Health Sciences in 2008 and retired from this
position at the end of 2016. I continue to teach in
anatomy and undertake research. I am still involved
with international anatomy and anatomists in my
role as President of the International Federation of
Associations of Anatomists.
While all these positions sound wonderful and
glamorous and a step up the academic ladder, they
were paralleled by my even more precious normal life
of being a wife, mother, and grandmother. Each of us
who is a mother and wife will know of the toughness
of the decisions we sometimes need to make, the
challenges which arise when in a full-time position.
AFTER THE BIRTH OF MY FIRST CHILD,
MY STAUNCHEST SUPPORTER OF MY
EDUCATION, MY MOTHER, ASKED
WHETHER IT WASN’T TIME FOR ME TO
GIVE UP WORK AND STAY AT HOME
WITH MY BABIES!
The 1970s were still a time when women had babies
and stayed at home to look after them. I don’t think
that my mother accepted easily that i wanted to work
and be a mother! My years as an academic were
mainly good (I love academic work and research,
21 *
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
MY MOTHER’S WISDOM
enjoy a challenge), often hard and also had some
terrible moments. In my more senior years, I worked 13
hours a day, six days a week. In order to build up the
Department of General Anatomy, to ensure a smooth
transition when the Dental and Medical Anatomy
Departments were amalgamated and to develop
the Research and Postgraduate portfolio in the Wits
Faculty of Health Sciences, there was much to do.
The wellbeing of individuals, while bringing two
hugely different groups of staff together, needed
careful management during the amalgamation
of the Medical and Dental Anatomy Departments.
Managing personality differences and a scientific
breech was a harrowing experience when a fallout
occurred between senior scientists in the
School. Dealing with barriers from senior staff, when
one is trying to grow an environment, was just not
comprehensible. These and other challenging
experiences often left me feeling isolated and alone.
I was thankfully able to draw on my inner strength and
optimism, and on the friendship of some wonderful,
wise academics who offered advice and collegiality
during these times. The lessons I had learned from my
mother on racial and gender equality, on fairness and
nurturing, sustained me during these difficult periods.
AS WOMEN, WE TEND TO NURTURE,
TO GROW, TO DEVELOP OTHERS. IF I
SEE THAT SOMETHING NEEDS TO BE
DONE, I GET UP AND DO IT. WERE
OTHER ACADEMICS HELPFUL ALONG
THE WAY? MANY STAFF WERE HELPFUL,
SUPPORTIVE AND COLLEGIAL, BUT
SOME WERE QUITE HORRID. MY
FOCUS AND DRIVE WERE SOMETIMES
CHALLENGED, AND AS I WAS A
WOMAN, IT WAS EXPECTED THAT I
WOULD BACK DOWN.
Somewhere inside me the core of strength derived
from my Mom and two female academics I had
worked with, sustained me. There were a number
of autocratic male academics for, or with, whom I
worked, who couldn’t see academia as a “team”
effort, but rather as a platform for their ego. This
made academia not only hard but also infinitely more
challenging! I was sometimes crucified for speaking
out when I disagreed with what was happening, but
know it was the correct thing to do. I hope that I leave
this courage to “stand up and speak out “as a legacy
to other women in academia.
I MUST PAY TRIBUTE TO WONDERFUL
MENTORS DURING MY ACADEMIC “LIFE”;
KNOWLEDGEABLE AND WARM MEN AND
WOMEN WHO SAW SOMETHING IN ME
THAT THEY FELT WARRANTED NURTURING.
FROM THEM, I LEARNED THE LOVE OF
GROWING PEOPLE. I HAVE HAD GREAT
JOY IN HAVING BEEN A ROLE MODEL
TO SOME, A MENTOR TO MANY AND
A TEACHER TO THOUSANDS. I LOVE
“PAYING FORWARD” AND HAVE DERIVED
ENORMOUS PLEASURE FROM SEEING THE
WONDERFUL ACHIEVEMENTS OF MANY
OF MY STUDENTS AND SOME OF THE
YOUNG STAFF THAT I HAVE MENTORED.
Over the last few years, I have found that academic
collegiality has been changing (is this due to the
pressure which academics experience?), barriers are
being erected just because they can be, teamwork
is not something to which everyone aspires, and
bullying is on the increase, particularly bullying of
senior women. I am particularly concerned about
the latter. As one climbs the academic mountain, the
higher the position, the more “power” is ascribed to
the position. I believe that the higher the position, the
greater is the responsibility to use that “power” wisely.
This translates into building an academic environment
that would benefit all, especially the next generation
of academics.
I REMAIN AN OPTIMIST, HAVE NEVER
LEARNED WHEN TO STOP BANGING MY
HEAD ON THE PROVERBIAL BRICK WALL
AND THINK THAT I HAVE ACHIEVED AT
LEAST HALF OF WHAT I WOULD HAVE
LIKED TO ACHIEVE IN LIFE. MY GREATEST
GIFTS HAVE BEEN MY WONDERFUL
SONS AND MY GRANDCHILDREN, WHO
I HOPE WILL, IN TURN, DERIVE FROM ME
SOME OF MY MOTHER’S WISDOM.
Professor Beverley Kramer: B.Sc.Honours, PhD, FAS (Hon), FAAA, Professor Emeritus, Director: Carnegie-Wits Alumni Diaspora
Programme, President: International Federation of Associations of Anatomy (IFAA), School of Anatomical Sciences, Faculty of
Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Correspondence: Beverley.kramer@wits.ac.za
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 22

FOCUS ON
SOUTH AFRICAN
TAX AND DNA
Jo-Anne Williams CA (SA)
Just as DNA is a code and contains the key
information for building and maintaining the
organs in our body, similarly our tax legislation
is comprised of various codes and like DNA
you can use it to build and plan your decision around
how tax affects you.
BY GAINING A BASIC UNDERSTANDING
OF THESE SA TAX DNA CODES WE
CAN PLAN FOR TAX AND AVOID
UNDUE STRESS AND PREVENTING
DEVIATIONS FROM THE TAX CODE
(NON-COMPLIANCE) THAT COULD
CAUSE CANCEROUS CELLS, LIKE IN THE
HUMAN BODY, BUT IN THE CASE OF THE
TAX CODES THESE CANCEROUS CELLS
PRESENT AS PENALTIES AND INTEREST.
We shared some of the DNA of South African tax at
our Tax Workshop, hosted by Women in Healthcare
Africa.
This article highlights some areas in the tax codes
covered in the workshop.
THE PROVISIONAL TAX CODE
PROVISIONAL TAX, as with PAYE, forms part of the
Income Tax Code structure and is important for all
Companies and any individual who earns multiple
sources of income or has not had sufficient PAYE
withheld on a month to month basis. As with DNA
each individual varies slightly from the other but the
base tax code is mostly the same and just needs to
include all the variable financial DNA information
from a tax payer to function properly.
Two important dates for when Provisional Tax would
be paid is typically the last working day in August
and February. The only time this will differ is if your
company has a financial year end other than
Jo-Anne Williams CA (SA)
February. The tax paid for
provisional tax should be
based on an estimate of
what your total Income
Tax will be for that tax year
and it is recommended
you pay it on time, as well
as the correct amount to
avoid any cancerous results
(Penalties and Interest!).
THE INCOME TAX CODE
For a company, the main code which applies to
most companies is an Income Tax Rate of 28%. This is
calculated after taking income (Revenue and other
income) and deducting any valid business expenses.
There is a separate tax code for Small Businesses, but
as most services in healthcare are provided by the
owner or Practitioner, not all these businesses will
be able to apply this tax code to their business, as
with DNA each individual is different and need to
be assessed to see if their particular financial DNA
(information) matches up to a certain income tax
DNA code.
FOR INDIVIDUALS, THE INCOME TAX
DNA CODE IS MADE UP OF SEVERAL
TAX PERCENTAGES TO APPLY TO AN
INDIVIDUAL’S TAXABLE INCOME, DUE
TO SOUTH AFRICA’S TIERED TAX RATE
SYSTEM FOR INDIVIDUALS. AS SUCH
A LOT MORE INFORMATION FROM A
PERSON FINANCIAL DNA IS REQUIRED
TO DETERMINE WHICH AND HOW THE
SA INCOME TAX DNA CODE WOULD
BE APPLIED TO THEM TO ALLOW FOR
PROPER PLANNING AND AVOIDING
ANY DEVIATION FROM THE SA INCOME
TAX CODE.
23 * SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
SA TAX
DNA
THE VAT CODE
When looking at the VAT (Value Added Tax) Code,
we discussed the various aspects around the VAT
DNA code such as when it becomes mandatory to
apply for VAT and how to apply this VAT DNA code in
the structure of a medical practice. Although you can
voluntarily apply the VAT code if you generate sales
above R50,000 it becomes mandatory to register for VAT
when your business is anticipating generating income
of R1 million or more during any 12-month period.
deduction of VAT charged by other business for goods
or services rendered by them to your business, usually
in a bi-monthly cycle.
EMPLOYEE TAX CODES
When hiring staff (including yourself in the case of
a company), there are 3 main Employee Tax codes
which will form part of the employees tax DNA for your
practice, a monthly payment due to SARS by no later
than the 7th of each month.
IT MUST HOWEVER BE NOTED THAT
IN APPLYING THIS VAT DNA CODE
WITHIN YOUR BUSINESS THERE ARE
A LOT OF COMPLEXITIES THAT NEED
TO BE COMPLIED WITH, AND IT IS
RECOMMEND TO HAVE A VAT CODE
SPECIALIST, NAMELY AN ACCOUNTANT
OR TAX PRACTITIONER, TO ASSIST IN
PREVENTING DEVIATIONS FROM THE
VAT CODE THAT COULD LEAD TO
CANCEROUS RESULTS (PENALTIES AND
INTEREST) DUE TO THE INCORRECT
INFORMATION AND THE INCORRECT
APPLICATION OF THIS VAT DNA TO THE
CIRCUMSTANCES OR FINANCIAL DNA
IN YOUR BUSINESS.
A high-level view, the VAT (Value Added Tax) code is
a rate of 14% which needs to be charged on sales/
services rendered to patients, which is then paid
over to the South African Revenue Services after the
Jo-Anne Williams CA (SA): Co-Founder and Tax Director at Leading . Edge Accounting, specialising in accounting and tax for
Small and Medium size businesses. Correspondence: Please contact the relevant sub-editor as well as cc the Editor-in-
Chief for more information.
THE FIRST OF THE EMPLOYEE TAX CODE IS PAYE
(PAY AS YOU EARN), PAYE is calculated using the
Individual Tax Rate table. It is determined by adding
any salary and benefits (medical aid contributions,
use of a motor vehicle, ect…) and then applying the
rates from the Individual Tax code to the total of these
amounts.
THE SECOND EMPLOYEE TAX CODE IS UIF
(UNEMPLOYMENT INSURANCE FUND), which
is payable for anyone employed and working more
than 24 hours a month. The rate applied is 2%, where
1% is deducted from the employee’s salary and the
other 1% is paid by the employer (limits are applied
to the total amount that can be deducted for UIF).
THE THIRD EMPLOYEE TAX CODE IS SDL (SKILLS
DEVELOPMENT LEVY), this applies to businesses
where the total salaries are anticipated to be more
then R500 000 in the next 12 months. The application
of the SDL code amounts to 1% being payable by
the employer on the total amount in salaries paid
per employee.
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 24

FOCUS ON
BE BOLD
FOR CHANGE 2017
Donne Botha
I recently found myself reflecting on a voyage back in time thinking
about the many wonderful women who have come before us and
continue to make a difference and strive for the equality of all women.
They have endured hardship and sacrifice
for the freedom and upliftment of others,
they have relentlessly pursued and acted
with courage to overcome ethnic, religious,
educational and gender prejudice. I couldn’t help
but giggle as I traveled through the 60s – when
females devoted their life to their husbands, children,
and homemaking. The better you perform in your
position, the cuter you were perceived. Now please
don’t misunderstand me – being a devoted wife,
mother and homemaker is very noble and something
many of us strive to perfect in part, but it should be
out of choice and not the expectation. Talking to
many women today, it is clear that women desire
different things in life and cannot be put in a box – the
opportunity to reach life goals, whether it be enjoying
or excelling at a hobby, choosing to accomplish a
physical or spiritual purpose, attaining a promotion or
high power position or devoting their time and life to
their families and caring for loved ones.
So luckily much has progressed in the workplace since
the 1960s and women have far more choice since
the beginning of time but how far have we really
come? it is estimated that women make up 45% of
the workforce yet hold only 9% of CEO positions and
just 21% of leadership jobs globally.
We know that globalization, building key capabilities,
improved profits, customer engagement, high
performance and fueling growth are just a few
examples of corporate buzz words every time we
walk into the boardroom and so if we are to achieve
these goals, we need to recognize that gender
diversity and inclusion matters and how we lead
in this transformation will make all the difference to
us and future generations. Studies have shown that
companies with top quartile
representation of women
in executive positions
perform significantly better
financially than those with
no women.
It is this business issue and
opportunity supported by
Boston Scientific and being
Donne Botha
inspired by our daughters to
be more and do more in creating equal opportunity
for women in leadership, which led to the start of
our women in leadership council in South Africa. Our
goal is to create an inclusive environment to attract,
develop and retain female talent at all levels and
help them achieve their career best.
We realize that the journey is not without barriers.
Let’s be honest; we’re trying to change 4 million
years of evolution! Finding and managing solutions
to dealing with unconscious/conscious bias, work-life
balance pressures, exposure to role models, gender
readiness perceptions and networking opportunities
are just a few examples of what we need to embrace,
however if we seek to find the opportunity for every
barrier and arm ourselves with the secrets of some of
the most influential women of yesterday and today
like courage, collaboration, embracing differences,
perseverance, networking platforms and a passion
for making a difference and self-belief, then nothing
can stop us.
Our message is simple – we are equal but different.
We don’t want to be treated with special conditions
and privilege; we want to be treated with fairness and
equality based on our skills and capabilities.
Donne Botha: Business Unit Manager, Urology & Pelvic Health at Boston Scientific. Correspondence: Please contact the
relevant sub-editor as well as cc the Editor-in-Chief for more information.
25 * SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
STOPPING THE
BLUR
Colleen Qvist
I am sure that you have been on a train or car that is traveling so fast that
all you can see out the window is a blur. The houses, buildings, people,
animals and trees flow into each other.
To many of us, this is what life feels like as we
focus on a destination and the rest blurs into
a grey streak.
We have become so goal orientated. Our days
and nights are taken up with the constant quest for
success. The promotion, buying the new car, reaching
a specific salary or weight, getting the kids through
Grade 4 or 8 or 12 or even the number of Facebook
friends all occupy our minds.
We are even focused on getting to the end of the
year so that we can turn over that last page and start
the next year.
WE ARE SO CAUGHT UP IN THE
DESTINATION AND THE GOAL THOUGH,
THAT OUR TODAY AND THE MAGIC
MOMENTS IN THE NOW ARE LOST.
WE CANNOT GET THEM BACK, AND I
WONDER IF THIS IS WHY IT FEELS LIKE
TIME IS RUSHING PAST SO QUICKLY? WE
ARE SITTING IN OUR “TRAINS” NOT EVEN
AWARE OF THE BLUR AS WE FOCUS ON
THE DESTINATION.
If all of this focus is making you feel empty and you
would like to stop to smell the coffee and to drink it
with the people who matter, I would like to suggest
two powerful interventions.
Colleen Qvist
MEDITATION
As soon as I mention
meditation to my coaching
clients, they automatically
reply that they do not know
how to do meditation and I
am sure they are picturing
sitting on a mat in a yoga
pose. I am also told that
they cannot do silence or
that they do not know how
to empty their minds.
WE ARE DEFINED BY THE RULES OR OUR
PERCEPTION OF THE RULES.
A meditation programme that has made a massive
difference in my life is Insight Timer. My daughter
introduced me to the app at the end of last year,
and it is downloaded on my cell phone. It has a
whole array of different types of meditations of
varying lengths, guided, silence, musical, nature and
I have enjoyed choosing one, and if I do not like that
particular one, I stop it and find a new one.
I have seen the difference in me (and my daughter)
as I have meditated most days. I have been aware
that my thoughts and the shopping list do not
necessarily leave my thoughts. Instead, I picture a
river, and I allow those thoughts to float on past.
27 *
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
I WOULD LIKE TO ENCOURAGE YOU TO
EXPERIMENT WITH MEDITATION AND
TO DO WHAT MAKES YOU FEEL GOOD.
LET’S SKIP THE MANUAL WITH THE 100
WAYS TO DO IT SOMEONE ELSE’S WAY.
GRATITUDE
My home has a gratitude jar in the kitchen. It is a large
see-through jar and next to it are coloured pieces of
paper and a pen. We write something we are grateful
for and pop it into the jar. Even my daughter, who
does not live here during the week comes home on
weekends to fill in her gratitude slips.
On 31 December we gather as a family and unpack
the jar and read what we have written. You will be
amazed at how many pieces of paper can fit into a
jar. It is a reminder of all we had to be grateful for and
that the year was indeed filled with blessings. Have
you noticed how people tend to decide by the end
of the year that the year was BAD and that it is time
for a new one? The sad thing is the following year will
also be BAD, and they will need another one.
WE HAVE PLACED THE OLD GRATITUDE
JAR FROM THE PREVIOUS YEAR IN THE
LOUNGE, AND IT IS AN ORNAMENT
WITH THE PURPOSE TO REMIND US
THAT GRATITUDE IS AN AMAZING
WAY TO ATTRACT MORE THINGS TO BE
GRATEFUL FOR. IN THE QUEST FOR THE
DESTINATION, WE SO OFTEN FORGET
WHAT WE HAVE ALREADY, AND I AM
HUMBLED BY THE SAYING “BE MINDFUL
THAT WHAT YOU ALREADY HAVE, OTHER
PEOPLE ARE PRAYING FOR.”
Making a lasting impact in our lives depends on us
introducing new habits, and this takes repetition
and reinforcement. Do send me the pictures of your
gratitude jar and share stories of how meditation
helps you. You may have other
methods to help you slow down to
notice the magical moments, and
you are welcome to share these too.
Colleen Qvist: Business and Personal
Coach, Facilitator and Speaker,
Founder of CQ Consulting and
The Pink Diamond Club.
Gauteng Chair for COMENSA
and serves on the Women in
Healthcare Africa Exco.
Correspondence: colleen@cqconsulting.co.za
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 28

FOCUS ON
29 * SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
HOW SOPHROLOGY:
HELPS PREGNANCY
A WOMAN’S JOURNEY
BEFORE, DURING & AFTER
Ishana Maharaj
OBSTETRICS & GYNAECOLOGY
Many women have a deep need or
sometimes a secret wish to start a family.
It’s a magical moment to become a
loving mother and experience the pure
unconditional love of her own baby.
However for some women, falling pregnant has its
challenges in today’s demanding environment,
largely due to career pressures combined with
the rigors of hectic daily lives. Adding workplace
obstacles, it becomes a challenge for women to
cope.
SOPHROLOGY IS A SIMPLE, HOLISTIC
APPROACH AIMED AT BRINGING THE
MIND, BODY & SPIRIT INTO HARMONY
Comprising of effective exercises, breathing
techniques, visualization, bits of meditation and many
additional techniques, this leads to optimal health
and wellbeing. Sophrology is beneficial to all stages
of pregnancy (i.e. Pre-Natal, Delivery & Post-Natal). It
can be done in various sitting positions, standing or
lying down if fatigued.
PRE-NATAL STAGE
“I am really trying to fall pregnant …”
Ishana Maharaj
The elements of stress,
burnout, tension and anxiety
together with an unhealthy
diet, impacts the body and
results in a less desirable
lifestyle. When the body
endures this long-term
stress, complications may
arise, and this does not help
women who want to fall
pregnant.
But there’s hope, as Sophrology comes to the rescue.
There could be various medical reasons why a woman
has difficulties in falling pregnant. Once identified,
solutions or options could be recommended by a
doctor.
Whatever solution or changes are required to reach
this goal, Sophrology helps in the following ways:
• Prepares the body for pregnancy – i.e. physically,
mentally and spiritually
• Releases stress, tension & anxiety from the body
• Supports you through the possible ups and downs
of IVF and helps you build resilience
• Harmonizes/Activates/Stimulates all cells, organs,
bones, muscles, glands and systems of the body
• Keeps you in a calm, peaceful, relaxed state
• Exercises are customized to focus on an individual’s
needs
• Enhances & improves ALL systems of the body:
i.e. Reproductive; Immune/Lymphatic; Endocrine;
Digestive; Nervous; Cardiovascular; Renal &
Muscular Systems
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 30

FOCUS ON
SOPHROLOGY COMES TO THE RESCUE
DELIVERY STAGE
You will feel prepared for any type of situation
that might emerge on the day of the birth, and
feel equipped to deal with difficult situations
• Creating a better connection with baby in the
womb through practicing visualization exercises
• Supporting the digestive system, especially during
heartburn, constipation or cramping
• Assisting with & managing pain endurance
• Staying focused on yourself & baby and
embracing each step of pregnancy consciously
“I am pregnant! However, I am anxious
and scared…”
Whether it’s your first or fourth baby to be born, each
woman’s journey is unique. Some women worry or
panic about whether they are able:
• to carry to full term of pregnancy,
• scared of the birth procedure,
• Helping to visualize your baby’s journey into the
world
• Boosting your confidence and taking the time to
integrate the changes you are going through
• Helping to remove your fears
POST-NATAL STAGE
• or how to cope with certain health complications
during their pregnancy
During the 9 months of pregnancy, a woman comes
to terms with becoming a mother. In the real world,
there is never enough time to look after ourselves.
We need to be aware of the adverse effects of stress
on the body.
OUR EXTERNAL APPEARANCE CAN
ALSO BE A SOURCE OF WORRY.
SOPHROLOGY ALLOWS PREGNANT
WOMEN TO ACCEPT AND EMBRACE
THIS SPECIAL TIME OF LIFE AND FIND
IT MEANINGFUL RATHER THAN SCARY.
IT ENABLES A PREGNANT WOMAN’S
FOCUS TO SHIFT FROM THE WORRY
ABOUT HER SHAPE TO FEELING
EMPOWERED BY THE LIFE WITHIN.
WE MUST NOT FORGET THE ROLE
OF FATHERS AS WELL, WHO MAY BE
EXPERIENCING STRESS AND ANXIETY
DURING THEIR PARTNER’S PREGNANCY.
Sophrology supports them through this process
of transition, learning about their partner’s body
changes and welcoming the arrival of the baby.
Sophrology helps by:
• Creating a more relaxed pregnancy & positive
delivery – by doing various breathing techniques.
“Motherhood …I am always tired,
experience fatigue and
sometimes feel depressed …”
Giving birth or being a mum can be the most
phenomenal and wonderful gift in life, however, your
body has been through a huge physiological roller
coaster and it needs time to recover. Many women
feel tired, overwhelmed and frustrated for they cannot
cope as well as they did before they had children.
Sophrology helps you achieve that deep state of
relaxation which is called “sophroliminal state”. This
occurs when the alpha brain waves kick in to provide
a sense of well-being.
Time is precious, especially when you have to establish
a new routine with baby. Sophrology offers simple and
31 *
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
effective techniques that can be practiced regularly
for 20 min at any time, in the comfort of your home.
The exercises offer immediate relief. Sophrology can
help you to:
• Improve & speed up your recovery process after
birth
• Balance your emotions and mood swings related
to hormonal changes
• Accept the transition and improving your quality
of life
• Sleep better so that you feel more energized and
alert
• Deal positively with family, expectations, beliefs
etc.
• Bond with your baby and feel motivated/positive
in your new role
IN CONTINENTAL EUROPE DOCTORS
RECOMMEND SOPHROLOGY AS AN
EFFECTIVE RELAXATION AND SELF-
DEVELOPMENT TECHNIQUE TO NOTABLY
HELP DEAL WITH PREGNANCY, PREPARE
FOR BIRTH, DEAL WITH ANXIETIES AND
LACK OF SLEEP.
IT CAN HELP YOU PREPARE FOR BIRTH
BY ENABLING YOU TO ACCESS YOUR
INNER RESOURCES, REINFORCING
CONFIDENCE AND POSITIVITY.
SOPHROLOGY CAN HELP YOU EMBRACE
THE EXPERIENCE OF PREGNANCY, BIRTH
AND MOTHERHOOD ACCORDING TO
YOUR PERSONAL VALUES.
Ishana Maharaj: Sophrology Practitioner - Having worked in
the corporate world for over 18 years, I resigned as a Project
Manager to relocate to Switzerland with my family, for a few
years. During my time in Geneva, I discovered Sophrology,
and was fascinated by its history, and widespread adoption
in Switzerland, France, Spain and the UK over the last 55
years. Having studied Sophrology at a leading institution in
Geneva, Switzerland, I personally experienced the benefits
of this journey. Returning to my home in South Africa as a
Sophrology Practitioner, being a Mum of 3 children (son-
17yrs & twin girls 10yrs of age), I felt blessed with a “gift”.
A special gift to share with people of South Africa. My
ultimate passion is to create an awareness, help, support,
share my knowledge and experiences of this phenomenal
wellness technique, with people. As the first Sophrologist in
Johannesburg, my practice resides in Eagle Canyon Business
Centre, Eagle Canyon Estate, Honeydew.
Correspondence: ishana@sophrology.co.za;
www.sophrology.co.za; Cell: 0827994311.
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 1 2017 * 53
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 32

FOCUS ON
FAT
G R A F T I N G
35 * SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
THE ROLE OF
FAT GRAFTING
IN AESTHETIC SURGERY
Marisse Venter
AESTHETICS & RECONSTRUCTION
The concept of transferring fat from one area of the body to another has
been around for a very long time.
Living fat tissue is harvested from one area of
the body, purified and transferred to another
to add volume. Ideally, the fat is harvested by
liposuction in an area of unwanted or excess,
e.g., the belly, love handles or thighs, it is then carefully
injected into an area where the main aim is to correct
a volume deficit.
Fat grafting is used in breast surgery and facial
rejuvenation in many ways. Volume replacement
and correction of contour deformities can be used
for breast augmentation, partial breast resection,
implant-related contour deformities, radiation injury,
scar management and facial rejuvenation, in the
same way “Polly-filler” is used to smooth dents and
irregularities.
Recent literature suggests that fat has numerous
added advantages. Fat is rich in pro-inflammatory
cytokines, growth factors, stem-cells and has multiple
cellular functions.
THUS THE BENEFITS OF FAT STRETCH FAR
BEYOND WHAT THE NAKED EYE MAY SEE
AFTER THE PHYSICAL IMPROVEMENT IS
NOTICED. OFTEN THE SURGEON AND
PATIENT COMMENT ON AN IMPROVED
SKIN TEXTURE IN THE AREA WHERE FAT
GRAFTING WAS DONE.
Marisse Venter
The effect of adipose-derived
stem cells on breast tissue in
patients with previous breast
cancer is not entirely known.
The literature has established
that fat grafting does not
interfere with the ability to
detect malignant changes
in breast tissue nor do the
stem cells cause cancer cells
to proliferate or form new
cancers.
THE EXACT EFFECTS OF FAT GRAFTING
WILL ONLY BE KNOWN OVER SOME
YEARS TO COME. WE HAVE SAFELY BEEN
PERFORMING FAT GRAFTING OVER THE
PAST TEN YEARS WITH NO ADVERSE
EFFECTS.
According to the American Association of Plastic
Surgeons: “The existing evidence suggests
autologous fat grafting as an effective option in
breast reconstruction following mastectomy while
demonstrating moderate to significant aesthetic
improvement. Also, the available evidence also
cites autologous fat grafting as a useful modality
for alleviating post mastectomy pain syndrome.
Furthermore, the evidence suggests autologous fat
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 36

FOCUS ON
grafting as a viable option for improving the quality
of irradiated skin present in the setting of breast
reconstruction.”
Usually, 40% of the injected fat cells may not survive.
Thus additional fat grafting may be required
several months later. However, the 60 -70% of the fat
transplants that do survive will be permanent. It is
not uncommon for a patient to receive multiple fat
grafting procedures.
Fat grafting is most commonly performed in theater
under general anesthesia, and occasionally may be
performed as an outpatient procedure in the rooms.
THE ADVANTAGES OF FAT GRAFTING ARE:
• using your own tissue
• fat is removed from an unwanted area
• both the liposuction and the fat injections are
done with local anesthetic
• It is not a significant surgical procedure and
involves only a few days recovery in most cases
• many women report that a fat-graft reconstructed
breast has sensation and feels soft, much like a
natural, unreconstructed breast
• There is an improvement in the overlying skin
texture, skin quality, and subcutaneous
component.
THE DISADVANTAGES OF FAT GRAFTING ARE:
• No significant clinical studies with long-term follow
up have been done on fat grafting, but small
studies report good results, i.e. there is a currently
ten-year data out.
• The injected fat may be reabsorbed by the body
you may lose some volume over time
• Some of the fat injected into the breast area may
die, which is called “necrosis” (symptoms of
necrosis may include pain and bleeding, the skin
turning dark blue or black, numbness, fever, and
sores that ooze a bad-smelling discharge or pus)
• Contour deformities may occur at the liposuction
site and have all the complications associated
with liposuction
• Asymmetry and irregularity between the sides
lip-filled
• Prolonged swelling & bruising in facial area
• 1% incidents of blindness have been reported
which is permanent
THE PROCEDURE
This is mostly performed under a general anesthetic,
although occasionally the procedure may be
performed under local anesthetic. The reconstructive
surgeon may mark the appropriate areas for
liposuction before the procedure. Small (5mm)
access incisions are made for liposuction. These
small incisions are closed by absorbable suture
material. Liposuction may be done either from the
lower abdomen, thighs, flanks or buttocks. The fat
is prepared and injected into the desired area by
small, precise injections. The liposuction area may be
strapped post operatively to maintain compression.
One would have to stay in the hospital for a day post
surgery. Antibiotics and pain tables will be given
to take home. Recovering from fat filling is mostly
swift and uneventful as an isolated fat fill is a minor
procedure. There may be some oozing of clear fluids
from the liposuction areas.
WHAT YOU SHOULD KNOW
The most common complications seen in fat grafting
is prolonged swelling and bruising at the injection
site. The swelling is less of a problem in the breast
but may cause significant distress if facial swelling
remains for a long time.
The amount of fat that survives is unpredictable. The
current estimation is that 40% of the fat volume will be
lost. The volume deficit depends on numerous, not as
yet openly identifiable factors, e.g. increase metabolic
rate, medication, etc.
ANOTHER, PERHAPS LESS KNOWN
COMPLICATION OF FAT GRAFTING IS
THE TENDENCY OF THE FAT VOLUME TO
INCREASE AS BODY WEIGHT INCREASES.
ONCE AGAIN THE DIFFICULTY IS
MOST TROUBLESOME IN THE FACE AS
LOCALIZED FAT POCKETS MAY ARISE
RESULTING IN, E.G. BAGS UNDER THE
EYES. THE FAT COLLECTIONS CAN
BE MANAGED BY FAT REMOVAL OR
LIPODISSOLVE.
As the use of fat grafting is increasing, numerous
added effects of fat grafting are becoming evident.
Fat grafting has shown to decrease fine lines and
wrinkles, improve skin texture, lighten pigmentation
and forms new collagen and elastin, thus delaying
the aging process.
DR MARISSE VENTER: Plastic and Reconstructive Surgeon at Netcare Milpark Hospital. She has a special interest in breast
reconstruction and cosmetic surgery. Correspondence: dr.mventer@gmail.com
37 *
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
THE LOW DOWN
HEALTH AND LIFESTYLE
Inge Kriel
VACCINATION RATES HAVE DECREASED IN RECENT YEARS,
LARGELY IN RESPONSE TO THE ANTI-VAXXER MOVEMENT.
accination rates have decreased in recent
years, largely in response to the anti-vaxxer
movement. Social media has contributed
to fear mongering in the general
population, with patients reporting vaccine-related
side-effects on a variety of social media platforms
and encouraging other parents not to vaccinate
their children.
DR ANDREW WAKEFIELD, THE INFAMOUS
MEDICAL GASTRO-ENTEROLOGIST
WHO PUBLISHED HIS FINDINGS IN THE
THE LANCET THAT THE MMR VACCINE
IS RELATED TO AUTISM, HAS SINCE
BEEN STRUCK OFF THE ROLL AS HIS
METHODOLOGY WAS QUESTIONABLE
AND HE DID NOT DECLARE A POTENTIAL
CONFLICT OF INTEREST. HIS ARTICLE
WAS WITHDRAWN FROM THE JOURNAL
AS HE WAS WIDELY DISCREDITED.
Unfortunately, the damage has been done – his article
has fuelled the anti-vaxxer movement to the point
that the MMR vaccine is no longer in production in
some areas due to lack of demand. There have been
recent outbreaks of measles and diphtheria in South
Africa, most likely due to poor uptake of vaccinations.
Patients place their trust in health care professionals
– they trust us to guide them in making decisions
regarding their health. However, when one of our own
publish their unverified findings in an eminent medical
journal, patients are left bewildered and confused as
to whom to trust.
If a medical doctor is telling
them not to vaccinate, then
they trust that it would be in
their best interests to follow
this advice.
Furthermore, patients have
access to scientific journals
without the requisite
training in interpretation of
Inge Kriel
statistics. This creates a very
dangerous situation in which patients make ill-advised
decisions based on dodgy statistics.
All health care practitioners, whether generalists or
specialists, should be doing more to promote uptake
of vaccinations. Vaccinations should be discussed at
every consultation. A balanced approach should be
taken when discussing vaccines – the benefits and the
potential adverse effects both deserve equal attention.
SO WHAT SHOULD WE BE FOCUSING ON
DURING CONSULTATIONS WITH REGARDS TO
VACCINATIONS?
Firstly, we should be reassuring patients that multiple
large randomised controlled trials have failed to
demonstrate a causal relationship between the MMR
vaccine and autism.
Secondly, while we are obliged to discuss potential
side-effects of vaccines, we should spend an equal
amount of time discussing the potential negative
consequences of not being vaccinated.
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 38

FOCUS ON
I WAS IN ICU FOR A WEEK AFTER
CONTRACTING MENINGOCOCCAL
SEPTICAEMIA DURING MY DAYS AS A
MEDICAL STUDENT. MENINGOCOCCAL
SEPTICAEMIA HAS A MORTALITY OF
100% IF LEFT UNTREATED, WITH A
MORTALITY RATE APPROACHING 50%
EVEN IF APPROPRIATE TREATMENT
IS TIMEOUSLY COMMENCED. THE
INFECTIOUS DISEASE SPECIALIST
MANAGING MY CASE TOLD MY FAMILY
THAT ONLY TWO OUT OF THE FIFTY
PATIENTS WITH MENINGOCOCCAL
SEPTICAEMIA THAT HE HAD TREATED,
SURVIVED. I WAS ONE OF THEM.
Meningococcal septicaemia is a vaccine-preventable
illness. Menactra, the vaccine recently launched,
protects against four of the most common strains of
Neisseria meningitides. However, when I did a quick
survey amongst parents at my son’s day-care, only
one or two parents even knew that Menactra existed.
FURTHERMORE, I HAVE NOTICED IN
GENERAL PRACTICE THAT PATIENTS (AS
WELL AS HEALTH CARE PROFESSIONALS)
ARE MISINFORMED ABOUT HOW AND
WHEN VACCINATIONS CAN BE GIVEN.
Vaccines should be delayed in moderate to severe
acute infectious conditions (with or without fever),
but there is no contraindication to vaccination in the
presence of mild illness (even with fever). Mild acute
illnesses include upper respiratory tract infections,
colds, otitis media and mild diarrhoea. Delay in
vaccination of patients with mild illness may hamper
vaccination uptake.
Other conditions incorrectly perceived as vaccination
contra-indications include: previous erythema/
oedema at injection site or low-grade/moderate
fever after previous immunisation, current antibiotic
therapy, and history of non-vaccine allergies.
Administration of the varicella vaccine is not contraindicated
for individuals who have a family member
or household contact with immunodeficiency, or in
the setting of HIV infection where the patient only has
mild symptoms. Hepatitis B can safely be given during
pregnancy and in the setting of auto-immune disease.
Confusion arises with regards to co-administration
of vaccines. Vaccinations may be inappropriately
delayed due to lack of knowledge regarding which
vaccinations can safely be given at the same visit.
As a general rule, most vaccines can safely be coadministered.
An exception to this rule is that the
pneumococcal vaccine (PCV13) should not coadministered
with Menactra in patients with functional
or anatomic asplenia. PCV13/DTP should not be coadministered
with influenza vaccination as there is
an increased risk of febrile seizures. Live parenteral
vaccines (MMR, MMRV, Varicella, Zoster, and yellow
fever) may be administered simultaneously. If not
administered on the same day, they should be given
at least four weeks apart in order to eliminate potential
interference (the first vaccine may interfere with the
antibody response of the second vaccine). Every
opportunity should be taken to ensure simultaneous
administration of vaccinations, especially in children,
as this increases the likelihood that patients will be
fully immunised according to schedule.
Combination vaccinations are preferred over single
component vaccines. One notable exception is the
MMRV vaccine in children 12 to 47 months of age. In
this subset, simultaneous administration of the single
component vaccinations is preferred because of the
increased risk of febrile convulsions with the MMRV
vaccine. HPV vaccines are recommended in girls
and boys from the age of 9. These vaccines confer
protection against the oncological HPV serotypes
(namely 6, 11, 16, 18), and help to prevent cervical,
vaginal, vulval and anal cancers, and genital warts.
HPV infection may also play a role in throat and
penile cancers.
Women planning to fall pregnant should receive the
MMR vaccine (if immunity is insufficient), one or two
months before falling pregnant, as this vaccine is
not safe to administer during pregnancy. Ante-natal
Rubella is particularly dangerous to the foetus – it
may result in serious birth defects or even pregnancy
loss. Inactivated influenza vaccine can safely be
administered during pregnancy. This is particularly
important as pregnant patients are at an increased
risk of influenza-related complications.
Patients also need to be made aware of the concept
of herd immunity. Live-attenuated vaccinations are
contra-indicated in severely immunocompromised
patients. These patients rely on herd immunity to
protect them from communicable diseases, but if
vaccination rates are not maintained in a patient
population, then these individuals are at risk. The antivaxxer
movement has compromised herd immunity in
certain areas, due to inadequate vaccination rates.
The benefit of vaccination far outweighs the
risks. Health care professionals should take every
opportunity to vaccinate individuals, and vaccinations
should not be delayed unless clear contra-indications
exist. We need to do more to educate patients on
the dangers of not vaccinating, in order to improve
herd immunity and eradicate vaccine-preventable
contagious diseases, and ultimately protect those
individuals who are unable to receive vaccinations
due to medical reasons.
Inge Kriel: Oncology Care Physician, Milpark Breast Care Centre of Excellence. Correspondence: ingekriel84@gmail.com
39 * SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
IZZY’S
STORY
Kyara Bergstrom
The anti-vaxxer movement has upset me so much. People often get
shocked at my reaction until they hear about my little girl Isabella, and
then they understand why.
Izzy has been ill since the day she was born. It
was only at the age of 3 that she was diagnosed
with Common Variable Immune Deficiency
(CVID). Like most people I hadn’t heard about
this. Let’s be honest - when most people think of
immune system problems, we think of cancer and
chemotherapy, or HIV. There are many more primary
immune deficiencies. Think of the movie “Boy in the
Bubble”.
Izzy can’t fight infections on her own. She has a
T-Cell defect, as well as a mannose binding lectin
deficiency. One of the ways doctors diagnosed her is
that she had no antibodies from her vaccines. I have
vaccinated my kids with every single vaccine. I never
used to believe in the flu vaccine until I saw my eldest
get H1N1 (swine flu) when it was making the rounds.
Have you ever seen your child crying and screaming
in pain? You can’t comfort her because her body
hurts so badly and she has a fever so high you don’t
want to leave her for a minute in case she has a
febrile seizure? Well that’s the year I started believing
in the flu vaccine and now we all get vaccinated
every year to protect ourselves, as well to protect Izzy
as much as we can.
Izzy relies on something called immunoglobins.
When people donate blood, they only think of red
blood cells and plasma for
accident victims, surgery,
cancer etc. What they don’t
normally think about is the
immunoglobins from these
transfusions that are taken
and given to people like Izzy.
It takes a lot of transfusions
to make one treatment
and doesn’t rely on blood
type. So I’m always on a
Kyara Bergstrom
campaign to get people to
donate blood. She gets these immunoglobins every
four weeks. Without this she will not be able to fight
the infections like the rest of us. Even when she gets
sick she’s placed on adult dosages of antibiotics and
most of the time she has to be hospitalised when she’s
sick.
SO THIS BRINGS ME BACK TO VACCINES.
PEOPLE OFTEN ASK ME “HOW IS MY
UNVACCINATED CHILD DANGEROUS
TO YOUR VACCINATED CHILD?”.
I UNDERSTAND HOW THIS CAN BE
CONFUSING AS MOST PEOPLE DON’T
UNDERSTAND THE CONCEPT OF HERD
IMMUNITY.
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 40

FOCUS ON
HERD
IMMUNITY
IF ENOUGH PEOPLE ARE VACCINATED,
THEN THEY PROTECT THE PEOPLE THAT
ARE UNABLE TO BE VACCINATED.
IT’S NOT ONLY PEOPLE LIKE IZZY
WHO RELY ON HERD IMMUNITY.
ADULTS AND CHILDREN RECEIVING
CANCER TREATMENT, PEOPLE ON
IMMUNE SUPPRESSANTS FOR ORGAN
TRANSPLANTS, HIV POSITIVE PATIENTS,
AND PATIENTS WITH AUTO-IMMUNE
DISEASES ALSO RELY ON HERD
IMMUNITY. THEY DON’T HAVE A CHOICE
AND THEY RELY ON OTHERS TO BE
VACCINATED. HERD IMMUNITY ALSO
PROTECTS THE YOUNG BABIES WHO ARE
STILL TOO SMALL TO RECEIVE SOME OF
THE VACCINES OR THE ELDERLY WHO
CAN’T GET BOOSTERS ETC.
Imagine a new born getting measles? If enough
people are not vaccinated then the virus finds more
ways to travel and infect the weak. If the virus mutates
then even the vaccinated are more at risk. When
there is another outbreak people like Izzy and other
immune compromised people can’t receive boosters.
They can’t protect themselves from the outbreaks.
WITH SOCIAL MEDIA THE ANTI-VAXXER
MOVEMENT HAS CAUSED MORE
AND MORE OUTBREAKS. PEOPLE
ARE BELIEVING MORE AND MORE
“FACEBOOK MEDICAL PAGES” OR
“FALSE LINKS AND STORIES”.
I often urge people to do relevant research
on more reputable sites. Think of journalistic
sensationalism - everyone loves a dramatic story.
You get people that love creating this drama and
seeing how far their links go.
PEOPLE BELIEVE THINGS THEY READ
ESPECIALLY IF IT CONTAINS WORDS
LIKE “SCIENTIFIC” OR “MEDICAL”, BUT
THEY NEVER CHECK THE AUTHENTICITY
OF THE DATA OR LINKS. I’VE HEARD
AMAZING THINGS LIKE “POISONS IN
VACCINES” AND “PHARMACEUTICAL
GAIN”. THINK ABOUT IT; IF THE POISONS
LINK HAD ANY TRUTH IN IT DO YOU
THINK DOCTORS AND SCIENTISTS
WOULD VACCINATE THEIR CHILDREN?
The autism link that was published all those years
ago has been proven to be false and the paper was
removed from the medical journals after the doctor
admitted to lying and he was stripped of his medical
license. But the damage was done and parents
believed it to be true and stopped vaccinating.
Some natural doctors jumped on the bandwagon
and many started selling their natural vaccines, books
and remedies.
People like my Izzy can’t fight these diseases and rely
on the healthy population to be vaccinated. When
there are outbreaks, I sit with so much fear and anger,
praying my little girl will be safe.
SHE NEEDS OTHER CHILDREN AND
ADULTS TO BE VACCINATED TO KEEP
HER, AND OTHERS LIKE HER, SAFE.
Mrs. Kyara Bergstrom: Head of Research and Complementary Health at the Netcare Breast Care Centre of Excellence as well as
C.O.O of The Pink Parasol Project (www.pinkparasol.co.za) Correspondence: Kyara.Bergstrom@netcare.co.za
41 * SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
CHILDHOOD
OBESITY
AND WHY IT MATTERS WHAT
CHILDREN EAT AT SCHOOL
Francette Bekker
School-aged children spend a large part of their day in the school
environment and consume about a third of their daily energy
requirements while at school.
n an effort to manage and prevent childhood
obesity, schools have become the focus of many
nutrition interventions. Worldwide the obesity
trends are increasing, and in South Africa one
in almost every four school-aged children is either
overweight or obese. The prediction is that these
numbers will continue to rise at alarming rates. The
risk is that an overweight or obese child will more
often than not grow up to be an overweight or
obese adult.
OBESITY, AS WE KNOW, GOES HAND-
IN-HAND WITH MANY LIFESTYLE
ILLNESSES INCLUDING DIABETES,
HEART DISEASE, AND CANCER. THE KEY
IS TO TARGET CHILDREN WHILE THEY
ARE STILL YOUNG AND DEVELOPING
THEIR EATING HABITS.
Registered dietitian, Francette Bekker was the
principal researcher in a South African study about
school tuck shops that was published in the Public
Health Nutrition journal in May 2017. The study
compared the eating habits of children in a school
with a healthy tuck shop to the eating habits of
children in a school with a regular tuck shop. The
healthy tuck shop offered a variety of items with
no added sugar, low in salt, low in saturated fat
and where possible high in fibre including slushies
(fruit juice with crushed ice), iced lollies (frozen
diluted fruit juice), small chicken sandwiches, sliced
fruit, nuts, popcorn (air-popped) and oven-baked
samoosas, while the regular tuck shop offered
sweets, hamburgers, pies, pizza, potato crisps and
carbonated cold drinks. The study had a number
of interesting findings.
Children in a school with a healthy tuck shop
brought significantly more healthy items to school in
their lunchboxes (such as fruit and water) compared
to children in a school with a regular tuck shop.
In the school with the healthy tuck shop children
also had a more positive attitude towards fruits
and vegetables. The younger children were more
favorable towards the concept of having a healthy
tuck shop at school, but despite that, children from
all age groups supported and bought items at the
healthy tuck shop.
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 1 2017 * 42

FOCUS ON
LUNCHBOXES
When asked to make suggestions children had
many ideas about what else they would like to have
available at their healthy tuck shop - including South
African favorites like biltong and braaivleis.
Overall the results suggested that children’s eating
behaviours at school can be positively influenced
when they are exposed to healthy food and
beverages from a young age. But unfortunately, the
researchers had another unexpected yet fascinating
finding. Children in the school with a healthy tuck shop
did not only bring more healthy items to school in their
lunchboxes but compared to children in a school with
a regular tuck shop, their lunchboxes also contained
significantly more unhealthy items (like sweets and
potato crisps).
This was possible because they could not buy these
items while at school. So, in this case, the many positive
influences of the healthy tuck shop was counteracted
by additional unhealthy items in lunchboxes
brought from home.
HAVING A SCHOOL FOOD POLICY IN
PLACE THAT ENCOURAGES CHILDREN
TO BRING HEALTHY FOOD TO SCHOOL IS
AN OPTION, BUT THAT IS NOT THE ONLY
ANSWER. PARENTS WHO ARE PACKING
LUNCHBOXES, BUYING GROCERIES
AND PREPARING MEALS AT HOME ARE
CHILDREN’S ROLE MODELS, & THEY NEED
TO BECOME MORE INVOLVED IN THE
FIGHT AGAINST CHILDHOOD OBESITY.
Parents must realise the importance of providing
healthy food and beverages and know the risks
involved of having an overweight or obese child.
ALTHOUGH CHILDREN LIKE TO
HAVE A CHOICE IN WHAT THEY EAT,
MANY CHILDREN IN BEKKER’S STUDY
PREFERRED A BALANCE AND TREATS
PER OCCASION ONLY, BECAUSE THEY
WERE SCARED OF BECOMING FAT. BY
LIMITING THE VARIETY ON DISPLAY IN
TUCK SHOPS AND MARKETING HEALTHY
FOOD FOR SALE, CHILDREN MAY BE
ENCOURAGED TO MAKE HEALTHIER
FOOD CHOICES.
The same applies at
home – when there is a
wide variety available,
children tend to make
unhealthy choices.
Involve children and
teach them about
food, listen to their
suggestions and then
also guide them to
make better food and
beverage choices at
school and home.
Having healthy tuck shops at schools may not be
the full solution to the obesity epidemic, but it is an
excellent place to start.
PARENTS AND SCHOOLS WHO ARE SEEKING ADVICE CAN USE
THE ASSOCIATION FOR DIETETICS IN SOUTH AFRICA (ADSA)
WEBSITE TO SEARCH FOR A REGISTERED DIETITIAN IN THEIR
AREA. THERE ARE ALSO ORGANISATIONS THAT GIVE GUIDANCE
AND HAVE ONLINE TOOLS FOR SETTING UP HEALTHY TUCK
SHOPS AT SCHOOLS. THESE INCLUDE THE DISCOVERY VITALITY
SCHOOLS PROGRAMME HEALTHY TUCK SHOP GUIDELINES &
THE WOOLWORTHS HEALTHY TUCK SHOP GUIDE.
Francette Bekker: Registered Dietitian (SA). Correspondence: Please contact the relevant sub-editor as well as cc the
Editor-in-Chief for more information.
43 *
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
PROGNOSTIC &
ONCOLOGY
PREDICTIVE
MARKERS IN
BREAST CANCER
Georgia Demetriou
Biomarkers can be determined in numerous
ways, some are identified in easily obtained
body fluids such as plasma, serum, and urine,
but many biomarkers can only be identified
on tumour tissue from immunohistochemical stains,
DNA and RNA. In many cases biomarkers are
initially identified without being placed in either the
prognostic or predictive biomarker category, over
time the prognostic value of the biomarker may
become apparent and in many cases, therapeutic
options are subsequently developed to target the
prognostic marker making it a predictive marker too.
A predictive marker may be able to define the
benefit of a therapeutic intervention or its potential
futility, allowing for far more personalized and patientspecific
interventions. Some serum biomarkers can be
used to monitor treatment response. The utility of a
particular biomarker may be particular to a single
tumour site or be of value in more than one cancer.
OESTROGEN(ER) AND PROGESTERONE
(PR) RECEPTOR EXPRESSION IS AN
INDEPENDENT PROGNOSTIC FACTOR
IN BREAST CANCER. PATIENTS WITH ER
AND/OR PR POSITIVE TUMOURS HAVE
A BETTER SURVIVAL THAN HORMONE
RECEPTOR NEGATIVE TUMOURS. THE FIVE
YEAR SURVIVAL (ALL STAGES) OF BREAST
CANCER IS IN THE REGION OF 83% IN THE
ER+/PR+ GROUP VERSUS 69% IN PATIENTS
WITH “DOUBLE NEGATIVE” DISEASE.
A high cellular expression of
ER and PR predicts for benefit
from endocrine blockade in
the adjuvant and metastatic
setting. Tumour hormone
receptors can change during
the course of disease with the
ER status of metastatic disease
differing from the primary in
Georgia Demetriou 20% of cases. The PR expression
can be lost in up to 40% of metastatic lesions when
compared to the primary lesion. This information
has resulted in a change in practice where the
reassessment of a metastatic lesions hormone
receptors by repeated biopsy is advised on the
diagnosis of a metastasis if the lesion is amenable to
sampling without creating undue risk from procedural
complications, in some cases, it may influence
treatment planning.
Her2 gene amplification leads to overexpression of
its receptor on the cell membrane. Over expression
of Her2 results in increased proliferation, angiogenesis
and inhibition of apoptosis. Overall Her2 positive
tumours are more aggressive and have a worse
prognosis compared to those that are negative.
ASSESSMENT OF HER2 STATUS IS
ESSENTIAL IN ALL BREAST CANCER
PATIENTS TO DETERMINE PATIENT
ELIGIBILITY FOR HER2-TARGETED
THERAPY.
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017 * 44

FOCUS ON
HER2
HER2 STATUS PREDICTS OUTCOMES
IN BREAST CANCER, INCLUDING
A RESPONSE TO TRASTUZUMAB,
PERTUZUMAB, AND TDM-1, IT ALSO
PREDICTS THE RESPONSE TO VARIOUS
TYROSINE KINASE INHIBITORS, TAXANE
AND ANTHRACYCLINE CHEMOTHERAPY
AND A RELATIVE RESISTANCE TO
TAMOXIFEN.
Four phase III clinical trials enrolled more than 13 000
pts, these studies (HERA, Combined B31 & N9831
analysis and the BCIRG006) established the benefit
of a year’s trastuzumab in the adjuvant treatment
of Her2 positive breast cancer. To date studies of a
shorter trastuzumab duration have been unable to
demonstrate noninferiority when compared to a
year’s treatment.
Lapatinib is a small molecule tyrosine kinase inhibitor
that, like trastuzumab, blocks the activity of the Her2
protein, but it does so by a different mechanism.
Lapatinib binds to the intracellular part of the Her2
protein and is a potent, reversible inhibitor of ErbB1
and ErbB2, which are members of a receptor tyrosine
kinase family.
Like ER and PR expression Her2 expression can change
over time and can vary between lesions requiring
repeat biopsy when metastasis occurs if feasible or
if there is a progression of the disease. Both primary
and secondary resistance to trastuzumab can occur
with the expansion of tyrosine kinase inhibitors in the
second line metastatic setting and beyond.
Ki 67 a nonhistone protein which is universally
expressed among proliferating cells is expressed in G1,
S and G2 phases of the cell cycle with a peak during
mitosis. Ki 67 usually has a low proliferative activity in
ER-positive tumours, with high levels of ki 67 at baseline
indicating an aggressive tumour.
A high pre-treatment score is associated with
a good chance of achieving a complete
pathological response to chemotherapy and
thus paradoxically a good long-term outcome.
Post neoadjuvant chemotherapy measurement
of ki 67 is a strong predictor of recurrence-free and
overall survival.
Cyclin D1 is localized on chromosome 11q23 and
has been identified in 20% of breast cancers, it
has a strong correlation with ER and PR expression
levels and has predictive value in hormone
receptor positive patients as its co-amplification
and overexpression is a predictor of inadequate
response to anti-estrogen treatments.
THE ONCOLOGICAL AGE OF
PERSONALIZED AND MOLECULAR
MEDICINE HAS MOVED FROM
THE LAB TO OUR CLINICS AND IS
RELEVANT IN EVERYDAY PRACTICE.
STRONG PROGNOSTIC AND
PREDICTIVE MARKERS HAVE
IMPROVED PATIENT OUTCOMES AND
WILL HOPEFULLY CONTINUE TO IN
THE FUTURE.
DEFINITIONS:
BIOMARKER
A CHARACTERISTIC THAT CAN BE OBJECTIVELY
MEASURED AND EVALUATED IN A PATHOLOGIC
PROCESS OR A TUMOUR
PROGNOSTIC MARKER
A BIOMARKER THAT PROVIDES INFORMATION ABOUT
A PATIENT’S OVERALL OUTCOME REGARDLESS OF THE
TREATMENT A PATIENT RECEIVES
PREDICTIVE MARKER
A BIOMARKER THAT PROVIDES INFORMATION ABOUT
THE THERAPEUTIC EFFECT OF AN INTERVENTION
Georgia Demetriou: Senior Consultant in the Division of Medical Oncology at the University of Witwatersrand Faculty of Health
Sciences and Charlotte Maxeke Johannesburg Academic Hospital since 2004. She is Head of a General Medicine Undergraduate
Academic teaching unit for the Department of Internal Medicine at Charlotte Maxeke Johannesburg Academic Hospital.
Correspondence: georgiademetriou@hotmail.com
45 *
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 2 2017

FOCUS ON
SOUTH AFRICA’S
CULTURAL OBSESSION WITH FOOD &
THE PSCYHOLOGY OF WEIGHT LOSS
HOW GASTRIC BYPASS PATIENTS
‘LEARN TO EAT AGAIN’
Martina Nicholson
Obesity is a growing concern in South Africa, particularly because
of the lifestyle diseases associated with it, including type 2 diabetes,
hypertension and heart disease.
SURGERY, OBESITY & METABOLISM
Gastric bypass surgery is an increasingly
popular treatment option for appropriate
patients, however surgery alone cannot
address the unhealthy relationship with
food that frequently leads to obesity.
“OFTEN PEOPLE REWARD OR COMFORT
THEMSELVES WITH FOOD, WHICH IS
EATING FOR PSYCHOLOGICAL RATHER
THAN NUTRITIONAL REASONS, AND,
OVER TIME, THIS CAN BECOME DEEPLY
INGRAINED AND MAY LEAD TO OBESITY,”
EXPLAINS CHARLENE MCINTOSH,
ONE OF THE PSYCHOLOGISTS IN THE
MULTIDISCIPLINARY TEAM SUPPORTING
GASTRIC BYPASS PATIENTS OF GENERAL
SURGEON, DR GERT DU TOIT, AND HIS
SURGICAL PARTNER DR IVOR FUNNELL,
WHO HEAD UP THE BARIATRIC SURGERY
CENTRE AT NETCARE ST AUGUSTINE’S
HOSPITAL.”
“Another aspect that appears to be driving obesity
is the central role of food in South African culture, by
which I mean that many of our social interactions
tend to revolve around eating,” she explains.
“We often meet friends and family for a meal, tea
and cake, shisinyama or a braai. For people who are
grappling with their weight, this can make it even
harder for them to exercise self-control, particularly if
they feel social pressure to eat,” says McIntosh.
Dr Du Toit, who specialises in complex digestive
laparoscopic procedures, says that gastric bypass
surgery is not to be undertaken lightly and is not
appropriate for all patients with obesity and related
conditions.
“We are committed to helping patients achieve
positive health outcomes, and there is a growing
body of evidence to suggest that conditions such
as type 2 diabetes and hypertension can be well
controlled, if not fully alleviated, with gastric bypass
surgery and behavioural change,” Dr Du Toit notes.
In line with the protocols of the South African Society
for Surgery, Obesity and Metabolism (SASSO),
prospective patients must be assessed for suitability
and supported through the surgery and afterwards by
a multidisciplinary team of healthcare professionals.
“Patients must be dedicated and committed to
making a lifelong change, otherwise the surgical
intervention will be far less likely to help the individual
achieve better health over the long term. For
this reason, it is sometimes advisable for patients
to prepare for a few additional months to make
absolutely certain that they are ready for the
significant lifestyle changes to ensure that they get
the best out of the treatment,” explains Dr Du Toit.
Dr Du Toit likens the preparation for gastric bypass
surgery to that of climbing a mountain. “If you consider
people who climb Mount Everest, it is the ones who
never look back who are most likely to make it to the
summit. Our team needs to ensure that the surgical
SOUTH AFRICAN PSYCHIATRY ISSUE 2 2017 * 46

FOCUS ON
candidates have a similar mindset and commitment
before the gastric bypass is performed.”
A vital aspect of preparation for the surgery is dealing
with the emotional aspects, as McIntosh explains: “The
role of the psychologist is to identify and address
underlying emotional trauma that may be at the
root of some people’s compulsion to eat. This is a vital
aspect of the holistic treatment for patients undergoing
gastric bypass surgery, because the operation can
change the body but the person’s mindset also needs
to change to achieve lasting outcomes.”
“WE EMPHASISE THAT THERE IS A
DISTINCTION BETWEEN EATING
BECAUSE YOU ARE HUNGRY AND
EATING FOR PSYCHOLOGICAL OR
SOCIAL REASONS. PEOPLE NEED TO
REDEFINE THEIR RELATIONSHIP WITH
FOOD, AND IN THE CASE OF OBESE
PATIENTS WE ESSENTIALLY HAVE TO
TEACH THEM TO EAT AGAIN.”
Addressing the social pressures around eating often
requires the individual’s support base, including family
and friends, to develop greater awareness. “Instead of
organising time together around food, as in ‘let’s meet
for lunch’, it is a good idea to sensitise the person’s social
circle to rather meet for a walk or other activities that do
not centre around eating,” she advises.
This is one of the messages conveyed in the monthly
meeting of the support group for people who have
either had or are considering gastric bypass surgery,
hosted by dietitian Mandy Read, who is also part of
the multidisciplinary team at the bariatric surgery
centre. The meetings are also open to the family and
friends supporting patients through their journey.
“A key aspect of changing people’s emotional
reliance on food is replacing comfort eating or reward
eating with another pleasurable activity, such as
going for a massage, having a relaxing bubble bath
or learning to play a musical instrument. Interestingly,
we have found that people who replace emotional
eating with a creative outlet, such as painting,
photography, music or gardening, tend to have better
outcomes in general,” McIntosh observes.
“Perhaps the most important factor is for the person to
realise that they can shape their future and have real
belief that their lives can be different. If a person has
been morbidly obese for many years, sadly they often
become used to sitting at home and feeling isolated,
and cannot imagine a life beyond that.”
“Imagine clothes shopping, and being so limited in
your choice because you are trying to find something
that is large enough to fit you, rather than shopping for
clothing that makes you look and feel good. We try to
help people realise that there is a life beyond obesity
and help them to get to the stage where they can
get full enjoyment out of life without an overreliance
on food,” she adds.
According to McIntosh people who have lost a
lot of weight may have some difficulty reconciling
the changes in their bodies with the way they see
themselves. “Some patients have managed to get
down to a healthy weight but will still turn sideways
to go through doors as they had to when they were
morbidly obese. Often there is a process of re-building
a person’s self-esteem so that they can make the best
of the physical transformation they have achieved,”
she concludes.
CENTRES OF EXCELLENCE FOR METABOLIC
MEDICINE AND SURGERY
There are currently five centres of excellence for
metabolic medicine and surgery at Netcare hospitals,
offering patients access to specialised bariatric
surgery, including gastric bypass procedures.
These centres of excellence are located at Netcare
Sunward Park Hospital in Boksburg, Netcare St
Augustine’s Hospital in Durban, Netcare Greenacres
Hospital in Port Elizabeth, Netcare N1 City Hospital in
Cape Town, and Netcare Waterfall City Hospital in
Midrand, Gauteng. The centre at Netcare Waterfall
City Hospital is the only internationally accredited
centre for the treatment of bariatric and metabolic
conditions in South Africa, and is the principal centre
for the four other locally accredited centres of
excellence located at Netcare hospitals.
The dedicated multi-disciplinary teams at these
centres are comprised of surgeons, endocrinologists,
psychiatrists, psychologists and dietitians, among
others, in line with the protocols advocated by
the South African Society for Surgery, Obesity and
Metabolism (SASSO), which is chaired by endocrinologist,
Professor Tess van der Merwe. As director of the Centres
of Excellence for Metabolic Medicine and Surgery of
South Africa (CEMMS)(SA), Prof van der Merwe oversees
the work of the centres of excellence, including those
based at Netcare hospitals.
The centres adhere to international practices to
create a safe environment and to support obese
patients with empathy and care. To comply with
international standards, a database with statistics on
each patient is maintained. Strict rules and regulations
with regard to patients’ dietary environment, as
well as care in ICU and wards are followed. Training
facilities with specialised technology and equipment
are also incorporated in the centres.
Martina Nicholson Associates (MNA): on behalf of Netcare St Augustine’s Hospital Correspondence: martina@mnapr.co.za,
graeme@mnapr.co.za
47 *
SOUTH AFRICAN WOMEN'S HEALTH ISSUE 1 2017

40 SOUTH AFRICAN PSYCHIATRY ISSUE 4 2015
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