Education to breast health promotes early diagnosis of cancer

Women living in the developing countries have a higher probability of dying from breast cancer as compared to those of the high income western world. According to the Globocan/IARC data  the number of deaths as a percentage of incident cases in 2008 was 48% in the former and 24% in the latter. Exactly twofold.  Available evidence on stage at diagnosis indicate that a much higher proportion of cases in the developing world are detected in late stages thus the potential of survival is poorer. Many reasons are given to explain these data: the stigma of breast cancer and the associated societal implications of its treatments (especially mastectomy) discourage women from seeking care early on; lack of knowledge about breast health; scant options for early detection due to limited access to routine care and examinations; and lack of access to mammography and to affordable, high-quality treatment options. In summary, lack of education to breast health awareness and complex cultural barriers do play a significant role in delaying breast cancer detection in developing countries. Increased awareness of breast cancer symptoms and potential of successful treatment of the tumor in early stages would be of great help to improve survival even without widespread use of mammography, advanced surgical procedures, and adjuvant therapies. In fact, if we examine the reasons for the remarkable improvements in the probability of survival for women diagnosed with breast cancer in the USA as compared to 60 years ago it is possible to realize that a significant result had been achieved also prior to the introduction of massive screening of the tumor simply by means of education to improve breast health awareness and to breast self examination. In the low-income developing world, the provision of better education is bound to provide a solid foundation for reducing stigma and fear that will make more effective the introduction of complex technologies for early diagnosis and the use of highly expensive drugs for adjuvant therapy.

too little benefit from regular mammogram in women in their 40s

Screening by routine mammogram is intended to catch breast cancer in women while it is still small and presumably easier to treat. So far, annual or biennial mammography has been advised to women starting from the age of 40. Some recently collected data have shown, however, that regular mammogram provides very modest benefit in terms of reducing death for breast cancer in women aged 40 to 49.  In fact, without screening, 3.5 out of every 1,000 women in this age group will die of breast cancer in the next 10 years but regular mammography reduces that number to 3, i.e. the benefit derived from screening is only 0.5 per 1000 women!.  Indeed, it has also been calculated that to save one life  in this age group, 1,900 women must be screened annually for 10 years. The other 1,899 women will receive no benefit from mammography over that period, though they will field 1,330 call-backs for reassessment and 665 breast biopsies, and eight of them will be diagnosed with cancers whose prognosis will not be altered by detection via mammogram — either because they would never become dangerous or because they are so aggressive that there's little to be done. Data reported in recently published studies wherein women were randomly assigned to either a screening and a non screening group seem to confirm this contention. The U.S. Preventative Services Task Force thus decided in November 2009 that whether the benefits are worth the risks is a value judgment each woman should make for herself. Regular mammogram is instead highly reccomended after the age of 50 due to a significantly increased risk of breast cancer.  In developing countries the incidence of breast cancer is significantly lower than in high income developed world but mortality due to the tumor is much higher. Even if the chance of detecting breast cancer in women younger than 50 is rather remote, the higher risk of dying of the disease may suggest that regular mammogram in women of developing countries in their 40s should still be encouraged .

breast cancer and passive smoking

Smoking is associated with an increase in breast cancer risk among postmenopausal women but there seems to be a definite increase also in non smoker women who have been extensively exposed  to second hand smoke.  These data were recently reported in the British Medical Journal. The study was based on the observation of nearly 80,000 women aged between 50 and 79 years  enrolled in the Women’s Health Initiative Observational Study from 1993 to 1998. Invasive breast cancer appeared in 3,250 women during 10 years of follow-up. Smokers had a 16% increased risk of developing breast cancer after the menopause as compared to non smokers.  For ex-smokers the risk was 9% and continued for up to 20 years after an individual had stopped smoking. The highest breast cancer risk was found among women who had smoked for over 50 years or more. What about non smokers? women who had never smoked but had lived or worked with smokers for prolonged times also appeared to be at increased risk for breast cancer. In particular, over 10 years’ exposure in childhood, over 20 years’ exposure as an adult at home and over 10 years’ exposure as an adult at work, increased the risk by 32% compared with those who had never been exposed to passive smoking. In low income and developing countries large declines in mortality are projected to occur in the near future for all of the principal communicable disease, maternal, peri-natal and nutritional causes, with the exception of HIV/AIDS. Meanwhile, the aging of the global population will result in significant increases in the total number of deaths caused by most non-communicable diseases  such as cancer. In particular, increases in the prevalence of tobacco consumption and significant lifestyle changes in the population are bound to produce an increased risk of breast cancer in African women.  Thus, efficient screening procedures for early detection of the disease need urgently to be implemented.

HPV vaccination and cervical cancer

Cervical cancer is the second most common cancer in women worldwide and it is linked to persistent infection by human papilloma virus (HPV). Vaccination against HPV represents an important tool to obtain a primary prevention of the tumor. There are many strains of the virus but only a small number of them causes cancer. An international team of researchers has recently identified eight strains of the HPV responsible for more than 90% of cervical cancer cases. The study, which was published in the prestigious medical journal The Lancet, examined 60 years of data from 10575 cases of invasive cervical cancer in 38 countries. HPV was found in about 85% of cancer samples.  More than 90% of these cases were caused by  HPV types 16, 18, 45, 33, 31, 51, 58 and 35, in descending order of frequency. Only 1% of cases worldwide were linked to the infection by HPV types 26, 30, 61, 67, 69, 82 and 91. The former group of eight strains will represent the target for the next generation of HPV vaccines. Currently two vaccines are available in the market, Cervarix and Gardasil, which cover the infection by HPV strains 16 and 18. Gardasil covers 11 additional non oncogenic HPV strains which are responsible for genital warts.  Prophilactic efficacy of the two HPV vaccines is almost 100% and they can prevent cancer cases directly linked to infection by HPV strains 16 and 18. Efficacy of the vaccination is obviously dependent upon the recipient not having been already infected with that type of HPV.  Cancer cases due to 16 and 18 HPV strains represent about 60%-70% of total cases. Future efforts will focus on the production of second generation vaccines covering in addition the other six HPV strains (45, 33, 31, 51, 58 and 35) in order to prevent more than 90% of cases.

breast cancer risk factors and triggers

The genetic risk factors for breast cancer to develop are age, being a female, and having a family history of the tumor. In developed countries the risk of breast cancer in women at the age of 29, 39, and 49, is, respectively, one in 2000, one in 215, and one in 50. The lifetime risk of breast cancer reaches the highest values in women 70 and older: one in eight !. In the latter age group the incidence has progressively increased in the last fifteen years as it was one in ten in 1997 and one in nine in 2003. Why is it happening?  Cancer is a genetic disease but it needs some triggers to develop. There is now a good evidence that triggers of breast cancer can be found in lifestyle and environment and most probably are the followings: having fewer children and in later life; reduced breastfeeding; widespread hormone replacement therapy  (administered to contrast the debilitating symptoms of the menopause); increased alcohol consumption, and excess of weight (especially after menopause).  Oestrogen and other hormones are strongly implicated in breast cancer, and both pregnancy and breastfeeding reduce the amount of circulating hormone. Each birth decreases the risk of breast cancer by 7%. Every year of breastfeeding cuts the risk by 4.3%.

Women in developing countries have lower rates of breast cancer mainly because they start to have babies at a much younger age  and have higher parity. In Sub-Saharan Africa, higher incidence rates and relative frequencies of breast cancer have been reported in association with urban than with rural residence but, in any case, the incidence of the disease is much higher among white women in Africa than among black African women. Notice that this is just the opposite of what has been reported for afroamerican women as compared to white women in the USA (see my previous post on the topic).   In the future decade a progressive change in women’s lifestyle (on the model of western women) will probably take place also in many countries of the African continent and this will parallel a rise in breast cancer incidence. We should get prepared: the fight against breast cancer can be successful only if local health systems provide early diagnosis and proper treatment facilities.

Village health workers’ role in primary prevention of diseases

plumeria (frangipani)

Villagers in many developing countries rarely see doctors or nurses. In fact, a fraction of medical graduates and nurses of English speaking parts of Africa or southern Asia, often emigrate to wealthy countries (Canada, USA, UK and Australia) as they are attracted by better pay and working conditions. Those doctors who, instead, remain in their home country tend to stay in the cities and not in rural areas.  Similarly, nurses are rarely tempted by rural villages. Doctors and nurses, however, are not necessary to improve rural health in developing countries. Two very successful programs in desperately poor parts of India’s Maharashtra State which were described in an interesting report appeared in the New York Times show that people with no or little formal medical training do successfully substitute for doctors and nurses. Once properly trained, these ordinary women and men help prevent most rural sickness by teaching people very simple acts such as the use of clean water, waste-disposal systems and more diverse farming. As a matter of fact, village health workers do have a huge impact on the health and prosperity of the community they serve. They visit pregnant women repeatedly, attend births, teach mothers about how to keep their babies healthy and check in on the children often.  They teach new mothers how to feed and care for their babies and how to treat diarrhea and fever. Children get regular immunizations, and tuberculosis,  scabies and leprosy are properly and effectively prevented. The main role of these health rural workers is teaching the community some essential preventive measures. Their potential role also in the prevention of HIV infection and cancer of the cervix uteri in young women should be properly and adequately stressed. They can really induce a major behavioral change in sex habits of the population by means of interpersonal communication activities. Health workers should be trained on this topic too and prevention of tumors should become a novel goal of these programs.

AIDS prevention in Zimbabwe

tropical nymphaea

According to the United Nations, about 33.3 million people worldwide are infected with HIV and the majority of those live in sub-Saharan Africa. The virus can be controlled with cocktails of drugs, but there is no cure and nearly 30 million people have died of HIV-related causes since the disease first emerged in the 1980s. The good news is however that the disease has taken a dramatic downturn in Zimbabwe, a country where its incidence was among the highest in the world. In fact, people infected with HIV were 29% in 1997 but ten years later, in 2007, they were 16%. How was it possible? The answer is: primary prevention. Zimbabweans have primarily been motivated to change their sexual behavior because of increased awareness about AIDS deaths which heightened their fears of catching the human immunodeficiency virus that causes it. The behavioral changes associated with HIV reduction consisted mainly in reductions in extramarital, commercial, and casual sexual relations, and associated reductions in partner concurrency. These changes were probably aided by prevention programs utilizing both mass media and church-based, workplace-based, and other interpersonal communication activities. The main lesson emerging from these data which were published in the PloS medical journal online is that, unless prevention efforts can be made more effective, there will ultimately be no victory in the fight against HIV/AIDS. This lesson is for all countries worldwide.