According to World Health Organization, breast cancer is the most common cancer in women both in the developed and less developed world. Although breast cancer is thought to be a disease of the developed world, almost 50% of breast cancer cases and 58% of deaths occur in less developed countries
Breast cancer survival rates vary greatly worldwide, ranging from 80% or over in developed world to around 60% in middle-income countries and below 40% in low-income countries. The low survival rates in less developed countries can be explained mainly by the lack of early detection programs, resulting in a high proportion of women presenting with late-stage disease, as well as by the lack of adequate diagnosis and treatment facilities.
Breast cancer is the top cancer in women worldwide and is increasing particularly in developing countries where the majority of cases are diagnosed in late stages.
There is no known single cause of breast cancer, although several factors have been identified to increase one’s risk of suffering from breast cancer. However, for the majority of women presenting with breast cancer it is not possible to identify specific risk factors.
A positive family history of breast cancer increases the risk by a factor of two or three. This is due to some gene mutations that can lead to development of breast cancer. However, these mutations are rare and account for a small portion of the total breast cancer burdenwith less than 10 percent of all breast cancers associated with inherited genetic mutations.
Reproductive factors associated with prolonged exposure to estrogens (female hormone), such as early menarche (periods before the age of 12), late menopause (after the age of 55), late age at first childbirth (older than 30 years) are known risk factors for breast cancer. Oral contraceptive and hormone replacement therapy users are at higher risk than non-users. Breastfeeding has a protective effect
Various modifiable risk factors contribute to about 21% of all breast cancer deaths worldwide and these include: alcohol use, overweight and obesity, and physical inactivity. This proportion is higher in high-income countries (27%), and the most important contributor is overweight and obesity. In low- and middle-income countries, the proportion of breast cancers attributable to these modifiable risk factors is about 18%, and physical inactivity is the most important determinant (10%).
Measures to control specific modifiable breast cancer risk factors (through increased physical activity and control of alcohol intake, overweight and obesity) and breast cancer screening are cornerstone to breast cancer control.
Breast cancer is usually discovered when individuals coincidentally feel swellings within their breasts and at times these swellings are ignored for a long time since they rarely cause symptoms initially. Other symptoms might include skin changes of the breast, inversion or retraction of a nipple that was previously averted (inside-out), bloody discharge from the nipple.
If these swellings are cancerous and ignored, they grow and spread to the surrounding tissues and at times to distant organs and by the time the individual goes to hospital for checkup, the cancer is advanced and this makes the treatment outcome poor.
Previously, and to a great extent presently, proper medical equipment for early detection of these breast cancers were not accessible in low to middle income settings. Medical equipment such a mammogram which is the main recognized screening test for reducing the risk of dying from breast cancer were not easily accessible due to less availability, and cost implications.
Currently, the investigation equipment are becoming more accessible to us Rwandans and this coupled with the availability of various health insurance schemes country-wide, including Mutuelles de Sante, RAMA, MMI and other private insurance schemes which help in cost sharing and making these facilities more affordable to the citizens in need of them.
Some hospitals and medical centers in Rwanda run breast screening programs routinely. Rwanda Military Hospital runs a breast clinic every Wednesday of the week, where patients get to be reviewed and assessed for any suspicion or presence of breast cancer by a breast specialist surgeon and a Cancer specialist. All these health care interventions have led to early detection of breast cancer leading to early medical intervention with the overall total reduction in death of breast cancer in the country at large.
A mammography is a specific type of breast imaging that uses a low dose X-rays to detect cancer early, before women experience any symptoms when it is most treatable. A breast lump which is too small for the doctor to detect on physical examination can be seen during a routine mammography and this can be taken out during the procedure (called stereotactic breast biopsy) which is then taken to the laboratory for further testing to look out for possibility of a cancer.
Screening with mammogram is recommended at the age of 45 years and to done annually until the age of 54 years, after which it is done after every 2 years. In women at higher risk of breast cancer, mammogram screening can begin at 40 years.
There are other screening techniques such as self-breast examinations and clinical breast examinations to look out for any breast masses. The clinician might ask for a breast ultrasound scan to rule out other conditions which can present with breast lumps.
Once the diagnosis of breast cancer has been made, treatment depends on the stage of the cancer at time of detection. Treatment can involve radiation, surgery, chemotherapy but usually involves a combination of two of these.
Radiation therapy is still limited countrywide although hospitals such as Rwanda Military Hospital is in the process of installing a fully functional radiotherapy center where we shall soon have many different forms of cancer, including early breast cancer being treated with radiation from Rwanda.
Dr. Ian Shyaka is a
General Practitioner at Rwanda Military Hospital