Professor of Radiation Oncology at the College of Medicine, Adeniyi Adenipekun, whose research covers breast cancer, head and neck cancer, colorectal cancer and cervical cancers asserts in this interview with SADE OGUNTOLA that most patients that face the diagnosis of breast cancer squarely and seek treatment promptly without fear of the disease nor stigmatisation tend to respond better to treatment with many of them being disease-free and are alive and well even two decades afterwards.
WHAT is the prevalent rate of breast cancer in Nigeria?
The prevalence of breast cancer in Nigeria currently ranges between 27 percent and 33 percent. In other words, between 27 and 30 out of 100,000 women in Nigeria have breast cancer. Various epidemiological studies are saying that the incidence of breast cancer is on the rise. This could be for two reasons: there is increased awareness about breast cancer. Hence, more women are coming out to be screened. Secondly, there is an actual increase in the number of people developing breast cancer due to our lifestyle among other epidemiological factors. Unfortunately, the age at which women develop breast cancer is lowered. Some years ago, it used to be a disease of women in their 60s, 70s, and 80s. But now, we are detecting this disease in younger women in their early 30s.
From epidemiological studies, what is responsible specifically for its increase in Nigerian women?
There are multifactorial reasons. Aside from the increase in awareness about breast cancer, uncontrolled environmental pollution is on the rise. Other factors include smoking, even by young girls, excessive alcohol intake, and increasing use of hormone replacement therapy by menopausal women. Tobacco in any form, like the intake of alcohol in any amount, is not safe.
Breastfeeding has been traditionally protective against breast cancer; this has been established through research. Our women are not breastfeeding, hence prone to developing breast cancer. Meanwhile, there’s a lower incidence of breast cancer among those who breastfed for over a year.
A family history of breast cancer can increase the risk of developing the disease, especially if a first-degree relative (mother, sister, or daughter) has been diagnosed. A woman’s risk of developing breast cancer is almost doubled if a first-degree relative has been diagnosed. A woman’s risk of developing breast cancer is increased by about 3-fold if two first-degree relatives have been diagnosed. There are ways to make sure they go through genetic testing so that they can pick it up on time for management.
What can people do to prevent breast cancer?
Let’s start with our lifestyle. It is important to avoid smoking, alcohol use, and a sedentary lifestyle. Technology has increased sedentary lifestyles, both at home and at work. For example, your printout can be done through your phone, and TVs and air conditioners are switched on with the press of a button while lying down on the sofa. That is making people accumulate so much weight, especially in women. As such, the hip is now wider than the waist. Studies have shown that an abnormal hip-waist ratio predisposes to breast cancer.
And there’s also diet; if you are more into carbohydrates and animal products, you are more prone to having breast cancer. Diets rich in vegetables, fruits, and plant-based foods high in fibre are better than refined carbohydrates.
Also, those that have familiar tendencies should make sure to go through genetic counseling and testing. But it is important that all women regularly have self-breast examinations done. First, it helps the woman to be familiar with her breast. Any strange thing that is happening can be easily detected and reported quickly to the doctor. I always joke with women by telling them their husbands can do it for them. It is free of charge, and I’m sure they would love to do it. Of course, individuals should embrace routine general medical examinations. This can be done twice a year. During that time, the breasts would be checked, too. This is aside from the self-breast examination that is supposed to be done daily.
What are those things that you’re supposed to look for?
When performing breast self-examination, things to look out for include changes in the skin that look like an orange peel, changes in the shape or size of the breasts, if the nipples are turned inward or there is any nipple discharge or if there are any lumps or swelling in the breast. This can be done while standing in front of a mirror. Also, if you observe that it seems one breast is sagging more than the other or that one is obviously bigger than the other, you need to quickly alert your doctor.
How do you rate screening facilities for breast cancer in Nigeria?
We have a serious challenge about screening for cancers in Nigeria, even though the government is doing everything to encourage screening. We have a national cancer control programme, whose policies are geared towards screening. But again, this needs to be backed up with the provision of facilities and manpower that will carry out cancer screening. Remember, the majority of Nigerians are in rural areas, so cancer screening should start in primary health centers. Nurses can be trained to examine the breasts of patients, and if they notice any lumps, inform the doctor, the lumps can be removed. This does not excuse everybody from starting their self-breast examination.
Let me quickly add that it’s not every lump that is cancerous. People tend to get agitated and afraid when a lump is found in their breast. It is also a reason people avoid screening. Regardless, eight out of 10 lumps are not cancerous. So, they should not be scared to embrace screening.
Screening should start at the PHC level. If that is done regularly and a lump is found, we always advise that such a lump must be removed. The lumps after they are removed must be tested in the laboratory in what is called histology to make sure that it is not malignant. But the fact is, the majority of lumps are not malignant. Women therefore should please come out in large numbers so that they can really be screened.
Also, those between age 18 and 40 can have breast ultrasound scans yearly to pick up any abnormality on time. After age 40, we recommend mammography, which is a radiological examination of the breast that is more detailed than ultrasound. But by the time you are 40, we recommend a yearly mammogram for women. Mammography is a radiological examination of the breast that will show greater detail than ultrasound. That’s why internationally, October is called a pink month when women do mammography. And usually, during that time, mammography is subsidised in most centres. You may be wondering, why 40 years. It involves some form of radiation. That’s why it is for women after they have passed the childbearing age.
How do you rate Nigerian screening facilities in terms of 1 to 10?
Oh, I would say we are maybe around three. We are far from what it should be; there are things that need to be done differently. Apart from increasing the awareness, we must ensure enough personnel, not only in the teaching hospitals but right through to the PHC level. The teaching hospital is not meant for screening. It should start right from the PHC level. And we need to ensure that screening at that primary healthcare level is free. If you are still telling people to come and pay, they won’t come. If they pick anything during the screening, they should then send it to the secondary healthcare level, where histology and everything can be done.
Apart from screening, the government must ensure arrangements for treatment and that must be highly subsidised. If you screen and find a disease and there’s nothing you are going to do for them, I don’t think that is right.
What does it mean to be diagnosed with maybe stage 1, 2, 3, or 4 breast cancers? What does it infer in terms of one’s survival rate?
We classify all cancers into four broad stages. Stage one, stage two, stage three, and stage four. Stage one is when the lump is less than two centimetres, which is a little bigger than the rice grain. Then, the cancer has not spread to the nodes or nearby breast tissues. Stage two, it has gone to about four centimetres; Stage three, it has gone beyond that and it has gone into the nodes in the armpit. By the time an individual has stage four breast cancer, it means the disease has gone beyond the breast. It has already spread through the blood and lymphatic system to other parts of the body.
So, stage one breast cancer is curable when surgery, chemotherapy, and radiotherapy are promptly offered. If it is stage one in which you are able to get everything out and the margin shows that there is no disease about five centimetres away from margin of lump from histology report, possibly what the patient will require are only chemotherapy and hormonal depending on type. There may not even be the need to offer radiotherapy. It is when the margin is compromised that we insist on radiotherapy. And in terms of survivor for stage one breast cancer, survival can be as close as 80 percent in five years. Survival rates keep coming down from stage two breast cancer. Survival from stage four breast cancers can be less than 30 percent in five years.
Unfortunately, 70 percent of our women in Nigeria present in the late stage i.e. stage 3 and stage 4 combined. This has been so for over 10 years now. Studies done last year still show that they still come in late stages.
What is the cost of treating breast cancer like in Nigeria?
The cost of treating breast cancer is dependent on what stage of cancer it is, its classification (immunochemistry), the naira to dollar exchange rate because the drugs are all imported, and whether it will entail surgery, chemotherapy, and radiotherapy. For instance, if it is in its early stage, surgery will be done to remove the lump, and investigations will be done to determine its classification and the best treatment option.
Immunochemistry tells the kind of proteins that are on the surface of the cancer cells whether it is a human epithelial receptor positive that is called HER2. Its treatment will be expensive, far more than if it were just oestrogen receptor, progesterone receptor positive ones, and HER2 negative. If the individual has HER2 receptor-positive, that patient will pay quite a bit because the target drug meant for that is in the range of N450,000 per month, and that patient would take it for at least a year. So regardless of the classification, the cost of treating breast cancer cannot be less than N2 million. The ones that may possibly be cheap are those advanced cases, because in advanced cases, sometimes surgery may not even be feasible, and all we’ll go for is chemotherapy, some radiotherapy and more of palliative care.
What are those cultural and social barriers that are contributing to the problem of breast cancer in Nigeria and why are there delays in seeking treatment for breast cancer in Nigeria?
The delays are multifactorial. Let’s take it from the cultural aspect. People assume that breast cancer is caused by witches and wizards, and therefore, most people now want to seek a solution through non-medical means. Those who are traditionalists will go to the alternate medicine, the babalawo’s, for the treatment. Those who are of faith, whatever religion, will go to their spiritual leaders for prayers, and that tends to cause a delay in presentation.
I remember a traditional healer who brought his wife in stage four, and he asked me to help him because he claimed “we are together in this business.” I told him I was sorry and that I’m a medical doctor and not a traditional healer. He delayed because he was busy trying all kinds of herbs and things on his wife. By the time she presented, the two breasts had already been greatly affected. Of course, we lost her. So, the cultural beliefs tend to cause a delay in presentation.
And then, as for the religious aspects I’ve mentioned, some just believe that it is possibly because they offended God, and all they need to do is pray to God, and when they are forgiven, I will be okay. But the Bible says my people perish for lack of knowledge, medical knowledge was given by God to doctors to cure people. So, they should know that the wisdom doctors have is from God to make them live better. God can perform miracles through the hands of the health professionals. It is not a sin to seek medical treatment.
The other aspect of it is fear. People just don’t want to go for screening because of the fear of the unknown. What if there is a lump and it turns out to be cancer? The fear of the diagnosis makes them go down quickly. I must tell you from experience that the majority of all my patients that faced the diagnosis squarely said, ‘Look, doctor, continue what you want to do. I’m not going to die of this disease.’ They eventually tend to survive and I can tell you, we have people that are 27 years post-treatment for breast cancer; they are alive and well. We have many that post treatment that are alive and well 10 to 15 years afterwards. They just come for follow up once a year.
But those who are already afraid, jittery, and shaking are psychologically defeated and tend to go down quickly. And of course, that fear also affects their immune system, too. So, the fear of the disease, the fear of its diagnosis, and the fear of the unknown tend to make people delay screening for breast cancer.
Another one is finance. They’ve heard that breast cancer is a very expensive disease. So, they initially take alternative medicine. We’ve heard of urine therapy; they collect all their urine and will be drinking it. We’ve had water therapy where people drink water and think it will go away. Social media is another problem now; it is misleading our patients terribly. For instance, they will tell them that all they need to do is avoid sugar. When you don’t have a single sugar in your body, you will not have breast cancer. That’s a lie. Without sugar in your body, you can’t even be standing, you won’t be conscious. Your brain needs sugar to function. So, all kinds of misinformation tend to add to delays in treatment. Likewise, finance can be an issue, too. So, they want to stay away from having treatment.
Looking at the state of the country’s healthcare delivery system and gross infrastructure deficiency, coupled with the dwindling number of personnel, how are you coping with the challenges of delivering quality healthcare services to persons with cancer, including breast cancer?
Honestly, that is a great challenge facing healthcare now. You’re aware of the emigration of doctors and other health professionals in large numbers. That has put so much stress on those that are left behind. The number of oncologists in Nigeria cannot cope with the number of people having breast cancer. And that’s why sometimes patients are given a long appointment when they go to a health facility; it takes some months before they are seen by an expert.
But mind you, this is not happening only in Nigeria, it is so even in the UK. It’s evidence of a gross deficiency in the workforce. And that cuts across all workers in radiation oncology: nursing oncologists, therapy radiographers, radiation oncologists, and medical physicists; very few are available. Most medical physicists are getting retired, so we have very few of them. Their job is to calculate the dose that the machine will deliver and how the machine will deliver it. Again, therapy radiographers who are the ones that will operate the machine are getting very few in the country. We must have two per machine. Right now, because of a dearth of personnel, sometimes we have to keep one operating the machine. That is not right.
Right now, we cannot boast of 70 radiation oncologists in Nigeria. We used to talk of 100 radiation oncologists, but the majority of them have gone. In those days, senior doctors were those that used to go out to look for work. But right now, even house officers want to go.
So we need to train more radiographers, medical physicists, nursing oncologists, radiation oncologists, and surgical oncologists. Not every surgeon can operate on cancer cases, and that is why we see some funny scars in some cancer patients because their surgeries were done by general surgeons and not surgical oncologists. Surgical oncology is a speciality on its own, not that because you are a general surgeon, you a surgical oncologist. So we have very few of them in the country.
When a surgical oncologist does the surgery, you will know. You will see the scar that’s not so big and not the type that will run like one kilometre to the other. You will see the fineness in the operation. They are very few.
Also, not all the centres are well equipped. Machines of most of the long-standing centres that have been at the forefront of cancer treatment are down. The federal government, I know, is doing everything possible to make sure they get new machines and establish new centres to try and mitigate against this lack of facilities, but it is nothing to write home about.
The World Health Organisation recommends one single radiotherapy machine for a 250,000 population. For the low-income, they recommend one radiotherapy machine to one million. If we put Nigeria’s population at 200 million, for a low-income country, we are supposed to have at least 200 functional radiotherapy machines. Nigeria today has less than ten functional machines and therefore, those centres that are functioning now are overworked. I was in a tertiary hospital recently as the chief examiner for radiation oncology for the National Postgraduate Medical College and also to accredit radiotherapy at the hospital. Yes, they have functioning machines, but the work force is so short. They don’t even have time for a break; they work late into the night, and all that is not right. Due to the heavy workload, starting fresh patients treatment is delayed for months while the cancer is progressing; The disease does not wait for anybody.
The federal government is doing something; I must give them that credit, but the machine for the radiotherapy treatment is very expensive. A cancer health fund was established, in which a patient can have one million naira at the start, and if it finishes, it can be reloaded with another one million naira. But that is only meant for treatment of breast, cervix, and prostate cancers. We are appealing to them to increase the number of cases that can benefit from the fund and that it should include children with cancers. We also observe that to get registered and be funded takes about five months. But we’ve had some discussion with the Nigerian Institute for Cancer Research and Treatment (NICRAT) to have it shortened. Now, it has been shortened to less than two months. But if the patient applies within a month, he should be able to pick up that facility. So available machines and workforce must increase, so must increase in awareness for cancer screening. All of these things together will help in the cancer management.
Can men have breast cancer? And do you see them often?
Yes, men can have breast cancer. Men have breasts too, only that our breasts are not as developed as those in women. However, it’s just about 1 to 1.5% of all breast cancer cases that occur in men. It’s also commoner among men that have first-degree relatives with breast cancer. Breast cancer in men is treated the same way we treat the women.
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