03-01-2014 00:00 By Chukwuma Muanya
Many Nigerian women are dying needlessly from breast cancer. They either wish it away or blame it on the witch next door. The hospital is always the last port of call. They first prefer spiritual help and only turn up in a clinic when the disease has eaten them up, when nothing can be done to save them. However, experts insist that early detection in order to improve breast cancer outcome and survival remains the cornerstone of breast cancer control. Especially, in this month of World Breast Cancer awareness.
BOLA was 25 when she noticed a lump in her left breast. Bola got married later that year to a banker. The lump was painless; it did not bother Bola and her husband, Gboyega. But the lump increased over the years. Ten years later after four children, the husband insisted that they saw a doctor.
After medical examination, the lump was found to be malignant, that is cancerous. The cancer had spread. The doctor recommended mastectomy, the cutting off of the left breast, to check the spread of the malignant tissues to other parts of the body.
Bola refused. “If they cut off my breast my husband will go for other women,” she insisted. “My God will heal me. I wont allow them to cut off my breast,” Bola added.
The cancer spread and consumed Bola. She died two years later. Bola’s family accused the husband of killing her through diabolic ways. The husband remarried within two year of Bola’s death.
She is one of the 75 per cent of Nigerian women that present late for diagnosis and treatment of breast cancer with no chance of survival.
But Betty Anyanwu-Akeredolu has a different story. She survived breast cancer and founded the Breast Cancer Association of Nigeria (BRECAN), a not-for-profit and non-governmental organisation galvanizing action against breast cancer in Nigeria.
She said: “My experience of shattering loneliness, unavailability of information and group support coupled with ‘tight-lip syndrome’ and indifference surrounding the disease so stirred me that I was inspired to do something that will bring about a positive and lasting change in the attitude of breast cancer victims themselves and the Nigerian society toward breast cancer and suffering.”
The Guardian investigation revealed that the hallmark of breast cancer in Nigerian women is late presentation of patients when little or no benefit can be derived from any form of therapy.
Why are most Nigerian women presenting late to hospitals with breast cancer?
Head of Radiotherapy and Oncology Department of the Lagos University Teaching Hospital, Idi-Araba, Lagos, Dr. Remi Ajekigbe, said: “Breast cancer is still the number one in Nigeria; 25 per cent of the cases are reported early while 75 per cent are reported late. They come late because we believe that everything that happens to us was caused by somebody; by a witch or wizard.
“The hospital is always not the first port of call. The patients must have gone to all sorts of places before coming to the hospital. The pastors are not helping issues by claiming miracle cure for cancer. It is wrong. The Whiteman that brought Christianity came along also with medicine and hospital care. Pastors should tell them to come for medical care while they continue praying for them.
“Another reason is that people fear mastectomy. It is one of the major reasons why breast cancer cases are being presented late here. Also, the outrageous claims by alternative and natural medicine practitioners. If somebody presents early the breast will not be removed. The breast will be enhanced.”
Reacting to recent studies linking mammography to breast cancer, Ajekigbe said: “Nobody will tell a 16 or 20-year-old girl to go for mammography. It is advised that women should go for mammography from age 40 to 50. People from age 40 should go for mammography every two years but from 50 it should be yearly.
“Mammogram is X-ray of breast tissue which may cause cancer of the breast about 20 years after. But the good news is that if it is detected early it can be treated and the breast enhanced, not cut off.”
The professor of oncology advised that women should always examine their breasts. “Press the nipples and if anything comes out, go to the doctor. We run cancer clinic three times a week - Mondays, Tuesdays and Thursdays. If we see 10 new cases today, seven will be breast cancer in stages three and four,” he advised.
According to the National Cancer Control Programme (NCCP), cancer incidence in Nigeria is rising.
Recent data from NCCP showed that 60 per cent of cancers occur in women and 39.8 per cent in men. Breast cancer incidence has gone up at least four times over the decade and in 2010, it accounted for 40 per cent of women cancers, closely followed by cervical cancer, 17.9 per cent, lymphomas and ovarian cancers are next.
However, in men, the commonest reported is prostate cancer accounting for 29.2 per cent of male cancers, closely followed by colorectal cancer and lymphomas.
According to the World Health Organisation (WHO), about 24.6 million people live with cancer worldwide. Some 12.5 per cent of all deaths are attributable to cancer and if the trend continues it is estimated that by 2020, 16 million new cases will be diagnosed yearly out of which 70 per cent will be in developing countries.
But a professor of Anatomic Pathology at the College of Medicine, University of Lagos, Fatimah Abdulkareem, in a paper titled: “Epidemiology and incidence of common cancers in Nigeria,” said the burden of cancer in Nigeria is unknown; mainly because of lack of statistics or under-reporting.
Abdulkareem noted: “This is not peculiar to Nigeria but most parts of Africa. In a study of cancer registry literature update from all over the world, only one per cent of the literature emanated from Africa compared to 34 per cent from Europe and 42 per cent, Asia. This is partly due to inaccurate population statistics which makes age specific incidence rates impossible or if available inaccurate. Large proportion of the population still never seek orthodox medical care and so are not recorded.”
According to Prof. O. Olopade, a breast cancer specialist and director of the Cancer Risk Clinic in the Department of Medicine and Human Genetics, University of Chicago Hospitals, United States, “the five-year survival rate for breast cancer patients in the United States exceeds 85 per cent, in Nigeria it is a dismal 10 per cent. Cancer awareness, even among physicians, and much more so among women at risk, needs an enormous boost in Nigeria.”
According to a recent study published in The Lancet medical journal, nearly 170 million years of healthy life were lost worldwide due to cancer in 2008.
Researchers analyzed cancer registries worldwide and used a measure called disability-adjusted life-years (DALYs) to assess not only the impact of fatal cancer, but also the effects of disabilities among cancer survivors, such as breast loss due to breast cancer or infertility due to cervical cancer.
Along with findings that 169.3 million years of healthy life were lost due to cancer in 2008, the researchers also determined that men in eastern Europe had the largest cancer burden worldwide (3,146 age-adjusted DALYs lost per 100,000 men). Among women, the highest burden was in sub-Saharan Africa (2,749 age-adjusted DALYs lost per 100,000 women).
Colorectal, lung, breast and prostate cancers were the main contributors to total DALYs in most areas, accounting for 18-50 per cent of total cancer burden. Infection-related cancers such as liver, stomach and cervical accounted for a larger part of overall DALYs in eastern Asia (27 per cent of all cancers) and in sub-Saharan Africa (25 per cent of all cancers) than in other regions.
In addition, the study revealed that improved access to high-quality treatment has not improved survival for a number of common cancers associated with poor outcomes, especially lung, stomach, liver and pancreatic cancers. This points to the crucial role that prevention needs to play if the worldwide cancer burden is to be reduced, said Dr. Isabelle Soerjomataram, of the International Agency for Research on Cancer (IARC) in Lyon, France, and colleagues.
The researchers also found higher average levels of premature death due to cancer in lower-income countries and higher average levels of cancer-related disability and impairment in higher-income countries.
Study co-author, Dr. Freddy Bay, deputy head of IARC’s Section of Cancer Information, said in a journal news release: “Our findings illustrate quite starkly how cancer is already a barrier to sustainable development in many of the poorest countries across the world and this will only be exacerbated in the coming years if cancer control is neglected.”
Dr. Ahmedin Jemal of the American Cancer Society, wrote in an accompanying commentary: “Tackling the growing cancer burden in low- and middle-income countries will require a major coordinated effort by many public and private sector partners, “including national and international public health agencies, health industries, philanthropic and government donors, and local and regional policymakers.”
National Coordinator of NCCP, Dr. Patience Osinubi, said that the increase in cancer cases in Nigeria can be attributed to varying reasons, the commonest being relative longevity which is increased life expectancy, changing lifestyles and increased access to screening and diagnostic facilities.”
She explained: “More people now go to hospitals at the slightest suspicion of lumps in their body. So we now have down staging, that is more people present in earlier stages as against the situation a few years ago when they presented in the very late stages.”
What are the causes of breast cancer? Dr. Taiwo O. Fasoranti explained: “There are many risk factors that have been associated with breast cancer. Being a female is one of the factors we really cannot do much about, the chance of getting it increases with the age of the woman, the older women get the more chances of getting breast cancer.
“As with any other genetic diseases, a history of breast cancer in close relatives especially in mothers and siblings has been associated with the risks of getting breast cancer, early onset of menstrual periods before the age of 12 years or reaching menopause after the age of 55 years has both been associated with risks of developing breast cancer. These can be explained by prolong period of estrogen exposure in females. Other risks include being overweight, using hormone replacement therapy, taking birth control pills, drinking alcohol, not having children or having your first child after age 35 or having dense breasts.”
Dr. Temidayo O. Ogundiran of the Division of Oncology, Department of Surgery, College of Medicine, University of Ibadan and University College Hospital, Ibadan; and Dr. Emmanuel R. Ezeome of the Department of Surgery, University of Nigeria and Multidisciplinary Oncology Unit, University of Nigeria Teaching Hospital, Enugu, in a paper titled: “Epidemiology, clinical presentation and management of advanced breast cancer in Nigeria,” noted that much of the burden of cancer incidence, morbidity, and mortality will occur in the developing world due to: Increasing life expectancy; part of a larger ‘epidemiological transition;’ increasing risks associated with diet, tobacco, alcohol, obesity, and industrial exposures; and already burdened by cancers some of which are attributable to infectious diseases.”
They estimated 500,000 new cases of cancer are diagnosis yearly in Nigeria. “Breast cancer presents a typical picture of the enormity of cancer burden on the Nigerian nation due to: Increasing prevalence; afflicts relatively young women – runs an aggressive course; late presentation to hospital; and bulky and scirrhous tumour,” they wrote.
Also, several studies have linked exposure to plastic chemicals to breast cancer. Research suggests that all plastics may leach chemicals if they are scratched or heated. Research also strongly suggests that at certain exposure levels, some of the chemicals in these products, such as bisphenol A (BPA), may cause cancer in people.
Signs and symptoms
What are the signs and symptoms? “It is troubling to know that majority of our females largely ignore changes they might notice around their breasts; this is indeed very common in our country. Some common signs seen in breast cancer such as breast lump which is usually painless, and change in size or shape of the breast or discharge from a nipple are largely ignored. It is however important to know that early detection and prompt treatment is the key to surviving this deadly disease.”
Until now, several studies have shown that most of these cancers can be prevented by healthy lifestyles, increased physical exercises for at least 15 minutes daily, reduced fatty food, sugar and alcohol consumption and of course avoiding tobacco products - cigars, cigarettes, snuff, tobacco leaf chewing - completely.
How can cancer be prevented? Osinubi said: “Be exercise-conscious. Experts would say do 20-minute exercise a day. Also, eat less fatty food, avoid excessive alcohol, and do not smoke. Eat fruits and vegetables. And then, get screened for cancer regularly. It’s essentially the same risk factors for all forms of cancer. The Federal Ministry of Health (FMOH) strongly believes these are inexpensive things to do to prevent cancer.”
What is the FMOH doing through NCCP to address the situation? “Over the past year, the Minister of Health, Prof. Onyebuchi Chukwu has increased cancer awareness and prevention particularly among the electronic and print media professionals to facilitate better reporting. This has been through cancer awareness workshops and free breast, cervical and prostate cancer screening campaigns. Over 3,000 women and 2,300 men have been screened in collaboration with Non-Governmental Organisations (NGOs),” Osinubi said.
She added: “In 2011, the Minister of Health launched the cervical cancer prevention vaccination, Human Papilloma Virus Vaccine, and since then 1,390 young girls have been successfully immunized free with the three doses of the vaccine in the first phase. This is the first time it has been done in Nigeria.
“In 2009, in collaboration with the Institute of Human Virology Nigeria (IHVN) a National System of Cancer Registries was conceived to collect and collate accurate data from 21 Federal tertiary hospital cancer registries. Based on data collected from 11 hospitals, 7,000 new cases of cancer were documented. This tallies with the average estimated 100,000 new cases of cancer reported in Nigeria.”
What is the Federal Government doing to help those who are already living with cancer? “For those that have developed cancer, the FMOH has equipped several hospitals to be able to diagnose the disease. Mammography services for breast cancer screening and diagnosis are spread out in all the six geo-political zones. In addition to these machines many hospitals have been given culposcopes, ultrasound scans, electrosurgical machines, cryoprobe systems, ELIZA machines and Prostate Seminal Antigen (PSA) kits to be able to run comprehensive breast, cervical and prostate cancer screening services in each of the geo-political zones,” Osinubi said.
She said these ongoing efforts are in partnership with the International Atomic Energy Agency (IAEA) to upscale 10 more teaching hospitals to offer radiotherapy and nuclear medicine services in addition with the five existing ones.
Another issue is the dearth of trained personnel in the management of cancer. Is there any conscious effort by the FMOH to reverse the trend? “Human capacity is being enhanced. The Minister has established expert committees to train the much needed medical physicists, dosimetrists, therapy radiography locally in response to the dearth of these professionals,” the NCCP boss said.
She added: “Currently, IAEA is partnering to train resident doctors, nurses, pharmacists in health institutions abroad in readiness for these cancer treatment machines. Radiotherapy services are available at LUTH, University of Nigeria Teaching Hospital (UNTH), Enugu; UCH, Ibadan; National Hospital (NH), Abuja; Ahmadu Bello University Teaching Hospital (ABUTH), Zaria; Usman Danfodio University Teaching Hospital (UDUTH), Sokoto and Federal Medical Centre (FMC) Gombe.”
Are there plans for those who present in the hospitals at the very late or terminal stages?
Osinubi said: “Palliative care services have been upgraded to care for them. Twenty-nine doctors, 42 nurses, two social workers have been trained in palliative care so that these patients get good quality of life at the terminal stage.”
She said key to palliative care is pain control and the FMOH has increased the importation of morphine for the production of liquid morphine at the Federal Manufacturing Laboratory in Yaba to increase access to pain control at an affordable cost
Osinubi said the NCCP is currently in talks with cancer drug manufacturers as to strategies to bring down the cost of cancer treatment and will continue to make giant strides until the cancer scourge is brought under control.
But the Pink Pearl Foundation disagrees: “Nigeria is ill equipped to deal with the complexities of cancer care. A wobbly health care infrastructure makes clinical services hard to come by and inadequately distributed. Only a few health centers have functioning radiotherapy equipment and the cost of care remains out of reach for most Nigerians who have received a cancer diagnosis.
“What is the poor widow with little or no income to do after she’s been diagnosed of cancer? Should she spend her last kobo to buy her own coffin seeing as there seems to be no hope for her? Forbid it Almighty God! Let us join hands together to fight cancer in Nigeria. Together we can provide hope and reduce the suffering of cancer patients all over the country. Let us help them know that their fight to stay alive is not in vain. Let us help them win.”
Dr. Taiwo O. Fasoranti in a paper titled: “Combating breast cancer in Nigeria; the need for comprehensive screening programmes,” concluded: “Breast cancer treatment and management is a big challenge in Nigeria largely due to limited resources as discussed earlier on. It is high time our government focused on these largely treatable diseases by providing the necessary funds that will make the establishment of screening centres nationwide a priority.
“On our part as citizens, I am appealing to us all; call your sisters, mothers, cousins, aunties, nieces, friends on this breast cancer awareness month and ask them if they have been screened for breast cancer. You might have saved a life and contributed your own part as we try to defeat ‘this biggest cancer killer of Nigerian women.’”
According to the WHO, “recommended early detection strategies for low- and middle-income countries are awareness of early signs and symptoms and screening by clinical breast examination in demonstration areas. Mammography screening is very costly and is recommended for countries with good health infrastructure that can afford a long-term programme.
“Many low- and middle-income countries that face the double burden of cervical and breast cancer need to implement combined cost-effective and affordable interventions to tackle these highly preventable diseases.”