A diagram showing cancer-affected parts of the breast
By EMMA P
VALENCIA, MD
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
• Exercise
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.)
