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.
Prevalence.
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.”
Reasons
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.”
CAUSES.
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.”
PREVENTION.
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.”
Palliative care
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.
Gaps
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.”
Going forward
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.”
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