Saturday, 21 April 2012

Breast cancer and Filipino women

 A diagram showing cancer-affected parts of the breast


I HAD the opportunity to be part of a team that studied the profile of women with breast cancer, as gathered from registry data (ie data as reported by hospitals).

We found that women as young as 25 and as old as 80 could get cancer, but majority of breast cancer cases were in their 50’s .  

Median survival, or the survival of 50% of the women, was highest when the woman was less than 65 yrs old, had early stage cancer (meaning, the cancer is confined to the breast only), with epithelial type of cancer, and when she had  surgery as one of the modalities of treatment . 

We also found out that women who were diagnosed with cancer in government hospitals  (an indicator of low economic status) had late stage breast cancer, while those diagnosed in private hospitals (i.e. less poor or more economically advantaged) had early stage cancer at presentation. 

And the data also showed that nearly half of the women in the study  did not receive any treatment for the disease. 

Indeed, breast cancer outcome among Filipino women represented in the registry data seemed to be in large measure, determined by economic status.

Health apparently takes a back seat among the poor, the daily needs of food and education of children taking higher priority among these women.

Until the disease presents with symptoms, and they usually manifest in the late stage, women procrastinate in seeking medical counsel.

Thus when diagnosed, these economically disadvantaged women find themselves already in the late stage of the disease. 

And even if treatment may improve survival, majority did not receive treatment because they can’t afford it.

So how can we help in the early diagnosis of breast cancer, and help women seek treatment when necessary?  

Our answer for early diagnosis was mass screening.

To do this, our project recruited as many women as possible and used a cost-effective screening tool.  

In most advanced economies, mammography is the screening test used. But in low-resource countries such as the Philippines, this tool is not cost-effective  and widely available, and its even intimidating. 

So, clinical breast examination, conducted by trained nurses stationed in various health centers in our pilot area, was the screening tool we adopted.

Volunteer women and barangay workers and  took advantage of  personal relationships (kumare,  kumpare, etc)  to get women  to go to the health center for screening. 

The recruiters went “house to house”, and came back several times if the woman was not available at the initial visit. This intensive recruitment strategy yielded a high 70% screening rate in our pilot area.

If a subject was found to be positive for breast mass, she was referred to a designated government hospital for further work-up.

All costs of work-up procedures-lab, X-ray, ultrasound, etc, were shouldered by the project.

After work-up and if found positive for breast cancer, definitive treatment procedures such as surgery and/or chemotherapy/or radiation and other treatment modalities as recommended by the physician were also shouldered or borne by the project. 

The objective was to find out if removing the financial barrier would increase the work-up and treatment rates of women found with breast cancer.

The results of our study showed that 2/3  of those screened and found positive for breast mass underwent work-up while about 1/3 did not show up or failed to undergo further work – even though the cost of work-up was to be borne by the project. 

And among those whose work-up showed positive breast cancer another 2/3 underwent treatment and  1/3  refused treatment, even though the cost of treatment was, again,  to be shouldered by the project. 

So what else, aside from the financial barrier, hinder women from seeking diagnosis and treatment?

When we did a survey, we found that knowledge about the benefits of early diagnosis and treatment were well known to both compliers and non-compliers so this could not be possibly a significant factor in their decision to complete work-up and treatment. 

We found personal and institution-related reasons for non-compliance: personal reasons - fear that the treatment - surgery, chemotherapy will prevent them form carrying out their responsibilities as mother, caregiver, wife and even  their role as bread winner.

Some women apparently just put the welfare of their family over and above their own. And some are just put off by the  attitudes of doctors and nurses in government hospitals  as well as the perceived poor facilities of government hospitals. 

So, our study demonstrated that it is possible to increase the screening rate for breast cancer, even at the barangay level.

We also demonstrated that removing the financial barrier can improve compliance to diagnosis and treatment in the majority.

But since we cannot expect government to shoulder the cost of work-up and treatment for all women, perhaps a second option is to  conduct free breast cancer screening, using cost-effective screening tools once a year, perhaps in the month of March (Women’ Month) , and mandate  discounts on anti-cancer drugs for women and  laboratory and surgical  procedures when done during the month of March. 

All year round, though, health centers and government hospitals should conduct information campaigns on the factors that have been proven to reduce the risk for breast cancer, among others.
          breastfeeding among mothers
          Weight reduction or maintaining ideal weight for age
          A diet with lots of fruits and vegetables

Needless to say,  national policies  and executive actions that improve the general living conditions of  women are needed.  Thus strategies to reduce poverty which subject and expose  Filipinos and women in particular to unhealthy environments, poor diet and unhealthy lifestyles, and prevent them from seeking early diagnosis and treatment due to low purchasing power, should be more vigorously pursued.

Improving the level of education, particularly of women, would enable them to  process more scientific information and make rational decisions about their health, and free them from superstition and reliance on   unproven and even dangerous   measures. Improving the education of women will also help them get out of the poverty cycle. 

To date, the Philippines is ranked, in Southeast Asia, as having one of the highest  breast cancer rates.  If we don’t do something now, next time, we may see our own mothers, sisters and friends  being afflicted by the disease.

Time to get off our complacent butts. Better yet, time to kick ass.  

(Dr EMMA P Valencia, MD, is a Health Policy analyst, writer, poet and journalist, who shuttles between Manila and California. She once worked with Senator Eduardo J Angara to assist him on important health policy legislations.)

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