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.”
TheGuardian
The
Nigerian National Petroleum Corporation (NNPC) has redeployed some key
officials in a shakeup meant to achieve a new strategic fit for the
state-owned oil giant.
